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As suggested on page 40, problems exist in that there are conflicting assumptions around approaches and methodologies appropriate to the researching of clinical supervision. It is for this reason that, before considering the research literature, some words are included regarding the context and rigour of research into supervision in health and the consequent problems with most, if not all, published reviews on the literature around supervision.

Context

The impact of professional, cultural and contextual differences between studies reported in the literature has not been adequately articulated. Internationally, there are a number of active researchers consistently publishing in the area of clinical supervision, each with its own particular focus. In the broadest of terms these include writers from Scandinavia, Australia, the United States and the UK:

Scandinavia

A large body of literature derives from a Scandinavian context including a number of authors who often publish collaboratively from Finland. These authors’ interests focus around the ways in which clinical supervision relates to issues of leadership and management as well as conceptions of clinical supervision itself (Hyrkas, Koivula and Paunonen 1999; Hyrkas, Appelqvist-Schmidlecher and Paunonen-Ilmonen 2002; Hyrkas and Appelqvist-Schmidlecher 2003; Hyrkas 2005; Hyrkäs 2006; Hyrkas, Appelqvist-Schmidlecher and Haataja 2006; Sirola-Karvinen and Hykas 2006) and another group, also often publishing together, from Norway and Sweden

(Severinsson 1996; Severinsson and Hallberg 1996; Severinsson and

Borgenhammar 1997; Berg and Hallberg 1999; 2000; Arvidsson, Lofgren and Fridlund 2001; Berggren and Severinsson 2003; Arvidsson and Fridlund 2005; Berggren, Barbosa da Silva and Severinsson 2005; Bégat and Severinsson 2006; Berggren and Severinsson 2006; Berg and Kisthinios 2007).

Australia

Much smaller numbers of researchers from Australia publish work on some of the difficulties with implementation of clinical supervision (Walsh, Nicholson, Kedugh, Pridham, Kramer and Jeffrey 2003; Hancox, Lynch, Happell and Biondon 2004; Cleary and Freeman 2005; White and Winstanley 2006).

United States

Writers from the United States, whose approach to research tends to favour a positivistic paradigm, focus almost exclusively on the supervision of trainees, given that very little post-qualifying supervision takes place in the US(Holloway and Neufeldt 1995; Holloway and Poulin 1995; Holloway and Carroll 1996).

United Kingdom

A number of researchers from the UK have tended to be more open to a post-

modern turn in their studies and their interests include the role of reflective practice in clinical supervision as well as the recurring problems with implementation and

development. Authors in the UK have also produced some evaluative studies and proposed developments on alternative, less hierarchical formats (Butterworth, Bishop and Carson 1996; Butterworth, Carson and White 1997; Butterworth and Faugier 1998; Jones 1998; 2000; Milne and James 2000; Stevenson and Jackson 2000; Gilbert 2001; Johns 2001; Davy 2002; Grant 2003; Wheeler 2003; Stevenson 2005; Townend 2005; Jones 2006; Stevenson and Cutcliffe 2006; Grant and

Townend 2007; Milne 2007; Wheeler and Richards 2007; Butterworth 2008; Townend 2008).

In addition, each of these groups is located almost exclusively within the nursing profession, with the exception of some of the UK literature around reflective practice which include some of the allied health professions in the discussions. There are very few individual researchers who routinely publish on the subject from other mental health professions though there are examples in counselling e.g. Wheeler and psychology e.g. Milne, both of whom have published reviews of the literature on clinical supervision for their respective professions (Milne and James 2000; Wheeler 2003; Wheeler and Richards 2007).

Given the relatively small literature on clinical supervision overall, there is a

regrettable tendency for researchers to refer liberally, and too often indiscriminately, from any or all of these groups, cultures and disciplines, often with no reference to the potential impact the contextual differences may have on any individual study.

This is a critical issue and is taken up in the conclusion on page 227.

Rigour

The quality of research into clinical supervision has been the subject of some debate, largely in respect of a perceived lack of rigour in the qualitative approaches used (Ellis, Ladany and Krengel 1996). In addition to this review undertaken by Ellis and colleagues, an overview of clinical supervision in nursing was undertaken by Hyrkas Koivula and Paunonen which concluded that research into supervisory effectiveness is still in its infancy (Hyrkas, Koivula and Paunonen 1999). The problem with this review, however, is that the authors chose to use the evaluation criteria identified by Ellis, Ladany and Krengel, whose approach is strongly influenced by what Holloway and Carroll have described as a post-positivistic paradigm (Ellis, Ladany and Krengel 1996); the problem with this is that the vast majority of the studies under review by both Ellis et al. and by Hyrkäs and colleagues site themselves within an increasingly interpretive paradigm (Holloway and Carroll 1996). This imposition of evaluative criteria from one paradigm (post-positivistic) onto research carried out in another paradigm (interpretive) seriously undermines the rigour of the conclusions of both reviews, rather like evaluating oranges using the characteristics of an apple. It unsurprising that Hyrkäs et al conclude: “our examination has exposed many problems and factors reducing the reliability of the results…” (Hyrkas, Koivula and Paunonen 1999 p183), arguing as they do for a clarification of concepts, an increase in scientific rigour of research and the development of theory. “To do this,

supervision studies should have large samples and use reliable instruments” (Hyrkas, Koivula and Paunonen 1999 p184). Whilst I recognise there is a valuable place for such studies, I strongly contest that only these kinds of studies produce reliable results. Holloway and Carroll, in their own review of supervision research, refer to this as “the tension between field relevancy and methodological rigor” (Holloway and Carroll 1996 p51). Their response to the earlier review by Ellis and colleagues stresses the need to contextualise supervision research and address the distinctives of the British approach. Whilst I support these aims, the issue over what counts as evidence remains largely unresolved. Meanwhile the positivistic paradigm continues to assert its historical dominance over newer methodologies.

As will be demonstrated in the discursive frame chapter (chapter six), therapeutic approaches have informed much of the practice of supervision, due to the influence of counselling and psychotherapy on the origins of supervision, Of all the therapeutic approaches within which clinical supervision has been practised, it is the cognitive behavioural approach (CBT) that has gained the most credibility through evidence- based research in recent years (Milne and James 2000; Sloan, White and Coit 2000; Waskett and Shone 2006; Townend 2008). This may well be attributable to this same hegemony of the post-positivist research paradigm as suggested in the paragraph above, leading to the devaluing of those more pluralistic research methodologies often utilised by other therapeutic traditions such as the psychodynamic or humanistic. See, for example the recent Improving Access to Psychological Therapies (IAPT) programme, a joint Department of Health and Care Services Improvement Partnership (CSIP) pilot project, which was launched by the then Health Secretary, Patricia Hewitt, in 2006 which recommends CBT as the only approach to receive funding under this initiative.

An example of the tautological consequences of this lack of clarity can be identified in the similar foregrounding of the cognitive behavioural approach (CBT) as being the only approach supported by evidence of effectiveness within the practice of clinical supervision. It is self-evidently true that an approach, such as CBT, which itself derives from, and is structured around, quantitative, measurable forms of analysis is going to emerge as being more effective than similar analyses being applied to approaches which are not so easily measured, such as the person-centred or psychodynamic approaches. If review authors’ rejection of such studies is due only to the definitions of their own inclusion criteria, then this predetermines the outcome in terms of recommendations of their effectiveness. Despite longstanding and robust theoretical arguments for research methodologies that more congruently reflect the holistic, personalised and intimate nature of nursing practice (Leininger 1985; Traynor 1996), including more recent feminist research (Hagell 1989), these

arguments do not appear to have translated into a wide scale academic acceptance of such methodologies. In the current climate in UK healthcare practice where so- called evidence-based practice is seen as the gold standard, then a diversity of practice within clinical supervision is unlikely unless this status quo is robustly challenged.

Taken together, these two concerns in respect of context and rigour risk jeopardising the credibility of much supervision research. It is for this reason that this study makes a genuine and serious attempt consistently to identify and articulate

contextual factors and to provide a transparent account of the research process, in order that it can go some way to counter these risks. The first step towards

achieving this is to review the literature on the use of discourse analysis as an

appropriate methodology for researching health in general, and clinical supervision in particular.

Review section one: discourse analysis as a methodology for