Impact of clinical supervision on healthcare organisational outcomes: A mixed methods systematic review.

OBJECTIVE: To review the impact of clinical supervision of post-registration/qualification healthcare professionals on healthcare organisational outcomes.
BACKGROUND: Clinical supervision is a professional support mechanism that benefits patients, healthcare professionals and healthcare organisations. Whilst evidence is growing on the impact of clinical supervision on patient and healthcare professional outcomes, the evidence base for the impact of clinical supervision on organisational outcomes remains weak.
METHODS: This review used a convergent segregated approach to synthesise and integrate quantitative and qualitative research findings, as per the Joanna Briggs Institute's recommendations for mixed methods systematic reviews. Databases searched included CINAHL, Embase, PubMed, PschINFO, and Scopus. Whilst a narrative synthesis was performed to present the findings of the quantitative and qualitative studies, the evidence from both quantitative and qualitative studies was subsequently integrated for a combined presentation. The review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
RESULTS: Thirty-two studies including 27 quantitative, two qualitative and three mixed methods studies, were included in the review. The results of the quantitative analysis showed that effective clinical supervision was associated with lower burnout and greater staff retention, and effective supervisor was associated with lower burnout and greater job satisfaction. Qualitative findings showed that healthcare professionals believed that adequate clinical supervision could mitigate the risk of burnout, facilitate staff retention, and improve the work environment, while inadequate clinical supervision can lead to stress and burnout. The evidence from quantitative and qualitative studies were complementary of each other.
CONCLUSION: Clinical supervision can have a variable effect on healthcare organisational outcomes. The direction of this effect appears to be influenced by the effectiveness of both the clinical supervision provided and that of the clinical supervisor. This highlights the need for organisations to invest in high quality supervision practices if maximal gains from clinical supervision are to be attained.

Introduction

Clinical supervision is widely practiced in health and social care professions across the globe owing to its beneficial effects to patients, health professionals and organisations [1, 2]. Operationally, clinical supervision, for post-qualification health professionals, is viewed as a process that provides quarantined time and an opportunity to further develop the supervisee’s skills and knowledge, within the context of an ongoing professional relationship, usually with an experienced practitioner (one-to-one supervision), or with peers (peer group supervision). The aim of clinical supervision is for the supervisee to engage in guided reflection on current practice in ways designed to develop and enhance that practice in the future [1, 2]. This type of supervision involves reflective thinking, and discussion regarding professional development issues, caseload, clinical issues, and staff interpersonal issues. Issues in clinical supervision definition and terminologies are widely prevalent [2]. In this review, the following definition of clinical supervision has been adopted:

“The formal provision, by approved supervisors, of relationship-based education and training that is work-focused, and which manages, supports, develops and evaluates the work of colleague/s” [1].

Whilst efforts are growing to strengthen the evidence for clinical supervision, there is also criticism about a vast majority of evidence on supervision, as being proof by association or tentative [3]. While there is a growing evidence base for the impact of clinical supervision on patient outcomes such as reduced risk of mortality, reduced risk of complications and more effective care [4-7], and health professional outcomes such as being better supported in their roles [8], there remains a need to systematically review the evidence for the impact of clinical supervision of post-qualification health professionals, on organisational outcomes, to further strengthen the evidence base on clinical supervision.

Determining the impact of clinical supervision on healthcare organisations, however, is difficult given the challenges in defining organisational outcomes and the overlapping nature of patient, health professional and organisational outcomes. For example, improved patient outcomes (e.g. improved morbidity and mortality) can satisfy multiple targets for healthcare organisations, as can health professional outcomes (e.g. reduction in stress and burnout), which can reduce staff sick leave, a usual key performance indicator for organisations. In determining the organisational outcomes of interest for this review, we undertook a scan of the broader literature. A recent systematic review of leadership styles and outcome patterns for the nursing workforce and work environment, grouped the outcomes into six categories: staff satisfaction and job factors, staff relationships with work, staff health and wellbeing, relations among staff, organisational environment factors and productivity and effectiveness [9]. Another systematic review on the relationship between governance mechanisms in healthcare and health workforce outcomes considered staff turnover and job satisfaction [10]. Other organisational outcomes cited in the clinical supervision literature include improved teamwork [11] and job satisfaction [12]. In considering all this, organisational outcomes in the current review will reflect the well-being of health professionals resulting from clinical supervision, that lead to better outcomes for the organisations such as recruitment and retention, intent-to-stay, intent-to-leave, job satisfaction and quality of work life, burnout and absenteeism. Furthermore, despite the benefits of supervision, to date, no review has explored health professionals’ perspectives of, and the impact from, clinical supervision on organisational outcomes.

Therefore, as means of addressing these knowledge gaps, using a mixed methods design, this review aims to answer the following research questions:

What are the effects of clinical supervision of healthcare professionals on organisational outcomes?

What are healthcare professionals’ experiences, views, and opinions regarding clinical supervision as it relates to organisational processes and outcomes?

What can be inferred from the qualitative synthesis of healthcare professionals’ experiences/ views that can explain the effects of clinical supervision or inform its appropriateness and acceptability for health professionals?

Methods

This systematic review was conducted using Joanna Briggs Institute (JBI) methodology for mixed methods systematic review, specifically the convergent segregated approach to synthesis and integration [13]. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline [14] and was based on an a-priori published protocol [15].

Eligibility criteria

The review protocol indicated the inclusion of studies that focused on one-to-one clinical supervision rather than group supervision. However, during the screening of studies, it became apparent that there was a prevalence of studies that investigated both one-to-one and group supervision (which was facilitated by a supervisor, as opposed to peer supervision), and studies that did not specify the type of clinical supervision investigated. Given this challenge, and to reflect the reality of healthcare organisations utilising both these types of supervision regularly, the review team agreed to include any study on clinical supervision, regardless of the type (i.e. one-to-one or group). To be eligible, studies had to meet the following criteria: (1) investigated clinical supervision of qualified or registered health professionals (i.e. clinical supervision of post-qualified health professionals, where they engage in one-to-one or group supervision sessions that happen over a period of time); (2) used qualitative, quantitative or mixed-methods study design; (3) if a quantitative study, examined the effects of clinical supervision on organisational outcomes, such as staff retention and recruitment, intent to stay, intent to leave, job satisfaction and quality of work life, burnout, and absenteeism; (4) if a qualitative study, explored health professionals’ experiences, views, or opinions regarding clinical supervision as they relate to organisational outcomes.

Search strategy

As means of avoiding publication and location bias, the search strategy was developed to identify black (commercially published) and grey literature. Search terms were identified based on the key concepts relating to the intervention/phenomenon of interest, i.e. clinical supervision and outcomes of interest, i.e. organisational outcomes.

An initial limited search of PubMed and CINAHL was undertaken followed by analysis of text words contained in the title and abstract and the index terms used to describe the articles. The search strategy, including all identified keywords and index terms, was then adapted for each database. The search for published studies was performed from the date of inception until May 2020 in the following databases: CINAHL, Embase, PubMed, PsycINFO, and Scopus. These databases were chosen as they commonly include literature from health disciplines, a combination of discipline specific (e.g. CINAHL includes nursing and allied health literature) and multi-disciplinary (e.g. Scopus) and are routinely used in systematic reviews. The search for grey literature was undertaken in ProQuest Dissertations and Theses, Google Scholar and WorldWideScience.org. Reference lists of relevant studies were reviewed to identify additional publications. The search strategy for each database is shown in S1 Appendix.

Study selection

Following the search, all identified citations were collated and uploaded into EndNote X8.2 (Clarivate Analytics, PA, USA) [16] and duplicates removed. Two reviewers independently screened the titles and abstracts (LL and DS) against the inclusion criteria for the review. Potentially relevant articles were retrieved in full and assessed independently for eligibility by two other reviewers (PM and SK). Disagreements were resolved through discussion and consensus. Studies that did not meet the inclusion criteria were excluded and reasons for their exclusion are provided in S2 Appendix. Abstracts and full text articles did not require translation to another language to determine their eligibility. All full text articles reviewed contained sufficient information to determine their eligibility without the need for further clarification from authors. The PRISMA flow diagram of included studies is available in Fig 1.

Fig 1

Flow diagram of included studies.

Quality assessment

All eligible studies were assessed for methodological quality by two independent reviewers (PM and DS for quantitative studies; PM and LL for qualitative studies using the relevant JBI critical appraisal tools [17]. These tools were chosen as they assist in assessing the trustworthiness, relevance and results of published studies and are widely used. Any disagreements that arose between the reviewers were resolved through discussion. All studies, regardless of the results of their methodological quality, underwent data extraction and synthesis.

Data collection

For the quantitative component, data were extracted from quantitative and mixed methods studies (quantitative component only) and included specific details about the supervisee and supervisor characteristics (sample size, profession), characteristics of the supervision (type, frequency, duration), study design, setting, clinical supervision characteristics, outcomes measured, and results related to the organisational outcomes. For the qualitative component, data were extracted from qualitative and mixed methods studies (qualitative component only) and included specific details about the supervisee and supervisor characteristics (sample size, profession, work experience), study design and methods, setting, and findings which included participants’ experiences of clinical supervision as they relate to organisational outcomes. Findings extracted from individual studies consisted of themes or subthemes reported by the authors. These findings were accompanied by a direct quotation representing a participant’s voice (i.e. illustration). Findings were also assigned one of three levels of credibility according to the following criteria: (1) unequivocal: findings accompanied by an illustration that is beyond reasonable doubt and therefore not open to challenge, (2) credible: findings accompanied by an illustration lacking clear association with it and therefore open to challenge, and (3) not supported: findings are not supported by data. The review team discussed the data extraction process, established standards and consistencies on how this should occur, and those with quantitative expertise (DS) and qualitative expertise (LL) lead the extraction process, with the primary reviewer (PM) acting as the additional reviewer for validation purposes.

Data synthesis and integration

A convergent segregated approach to synthesis and integration was applied [13]. This involved an initial independent synthesis of the quantitative studies and qualitative studies followed by the integration of findings from such syntheses using configurative analysis.

Quantitative data were analysed descriptively; meta-analyses were deemed not appropriate due to heterogeneity between studies in terms of clinical supervision interventions and participants. Odds ratios (OR) of dichotomous events and standardised mean differences (SMD) for continuous measures were calculated. For experimental studies OR were converted to SMD using an online calculator [18], to assist with interpretation of effect size. For observational analytical studies the correlational coefficient (r) was calculated in addition to OR and SMD. Effect size was determined using the following reference values for SMD: small 0.2, medium 0.5, large 0.8 [19]; OR: small 1.68, medium 3.47, large 6.71 [20]; and r: small 0.1, moderate 0.3, large 0.5 [19].

Qualitative synthesis was conducted using the meta-aggregative approach [21]. Meta-aggregation is aligned with the philosophy of pragmatism, focusing on the practicality and usability of the synthesised findings and generation of statements that are useful for informing actions in clinical practice [21]. This involved assembling and aggregating the extracted findings from individual studies, based on similarity in meaning, to generate a set of statements (i.e. categories) that represented that aggregation. These categories were then subjected to meta-synthesis to produce a set of synthesised findings. The development of categories and synthesised findings was conducted via a consensus process between the reviewers (LL and PM).

The findings of each single method synthesis were juxtaposed and examined for convergence/divergence and complementarity. To explore the relationship across individual syntheses, the findings were reviewed to determine whether they were supportive or contradictory and identify which aspects of the quantitative evidence were not explored in the qualitative studies and vice-versa. The clinical supervision interventions which had been investigated in the quantitative studies were further analysed in line with the experiences of participants in the qualitative studies to explain the impact of clinical supervision on the different organisational outcomes. However, due to the heterogeneity of the quantitative studies and the lack of well-conducted trials, and the limited qualitative studies, no clear cause and effect relationships can be determined, nor in-depth analysis can be made to explain the impact of clinical supervision.

Results

The database search yielded 1266 records. Eighty-five articles were retrieved for full text review following application of the eligibility criteria to title and abstract. Thirty-four fulfilled the inclusion criteria when applied to full texts. Three of these articles were duplicate publications, resulting in a yield of 31 studies. One article was identified through pearling of references in the included studies; hence the final yield was 32 studies (Fig 1).

Study characteristics

Twenty-seven quantitative [22-48], two qualitative [49, 50] and three mixed methods studies [51-53] were included in the review. Fifteen studies used a randomised controlled (n = 1) [22] or quasi-experimental design (n = 14) [23–35, 51] to establish the effect of clinical supervision on organisational outcomes. Eight studies investigated the association between effectiveness of clinical supervision and organisational outcomes [37–43, 52]. Eight studies investigated the association between the effectiveness of the supervisor and organisational outcomes [32, 36, 39, 41, 43, 45, 46, 48]. Two studies used a cross sectional survey study design to measure perceptions of effect of clinical supervision on organisational outcomes [44, 47]. Four studies [49-52] used a qualitative descriptive design, with either individual [49-51] or focus group [52], semi structured interviews as the method of data collection. The qualitative component of one study [53] applied the grounded theory methodology, using a qualitative questionnaire for data collection. Ten studies were published in the 1990s [23, 25, 26, 30, 34, 45–49], six studies were published in the 2000s [24, 28, 35, 39, 41, 43], and 16 studies were published in the 2010s [22, 27, 29, 31, 32, 33, 36–38, 40, 42, 44, 50–53] with seven of these published in the last 5 years [27, 37, 40, 50–53].

Studies were conducted in hospital (n = 15) [22–26, 29–31, 34, 37, 40, 41, 44, 47, 53], community healthcare settings (n = 6) [32, 36, 38, 39, 48, 52] and a combination of hospital and community healthcare settings (n = 11) [27, 28, 33, 35, 42, 43, 45, 46, 49–51]. Most studies were conducted in the mental health setting (n = 15) [25–28, 30, 34, 37, 39, 42–44, 46–48, 53]. Health professionals who received clinical supervision included nursing (n = 23) [22–26, 30–35, 37, 39–42, 44, 46–49, 51, 53], social work/psychology/counselling professionals (n = 10) [27, 32, 36, 38, 43, 45, 46, 48, 52], other allied health professionals (n = 4) [28, 29, 50, 52] and medical professionals (n = 3) [22, 33, 48]. Seven studies were conducted in Sweden, [23, 25, 26, 28, 30, 34, 47] seven in Australia [32, 38, 40, 43, 50–52], seven in the United Kingdom [22, 35, 37, 39, 44, 49, 53], four in the United States of America [27, 45, 46, 48], two in Finland [31, 41] and one each in Norway [24], Israel [36], Africa [33], Denmark [42] and Italy [29]. Eight studies investigated only group supervision [23–26, 30, 31, 42, 47] four studies investigated only individual (one-to-one) supervision [22, 27, 38, 50], 12 studies investigated both group and individual supervision [29, 32, 35, 39, 41, 43–46, 49, 51, 52] and eight studies did not state whether the supervision they investigated was group or individual [28, 33, 34, 36, 37, 40, 48, 53]. The frequency and duration of supervision sessions were variable between studies, ranging from weekly to every three months, and 30 to 480 minutes. Frequency and duration of supervision were not reported in 16 [22, 28, 29, 33–37, 40, 45, 48–53] and 18 studies [24, 28, 29, 33–38, 40, 44, 45, 48–53], respectively.

Five studies (two qualitative [49, 50] and three mixed methods studies [51-53]) explored the clinical supervision experiences of healthcare professionals including its impact on clinical practice. Fifteen studies investigated the effect of supervision on burnout [22, 25, 27–32, 35–37, 39, 41, 42, 48, 52], 9 studies on other measures of well-being [22, 24–26, 30–32, 42, 44], 13 studies on job satisfaction [25–28, 30, 32, 33, 41–43, 45, 46, 51], 9 studies on the work environment [23–26, 31, 34, 35, 38, 47], and 3 studies on job retention [32, 33, 40]. There was a large diversity of outcome measures used with only four measures used in more than one study; the Maslach Burnout Inventory was used in 13 studies [25, 27, 29–32, 35, 37, 39, 41, 42, 48, 52], and the Creative Climate Questionnaire [25, 26], Tedium Measure [25, 30] and Satisfaction with Nursing Care questionnaire [25, 30] each used in two studies. Study characteristics can be found in Table 1.

Table 1

Study characteristics.

Study	Design	Setting	Participants		Supervision			Outcomes (Quantitative) OR Interview questions (Qualitative)
		(country)	Supervisee	Supervisor	Type	Frequency	Duration
			Profession	Profession
			Work Experience, mean
			n
Begat 1997	Quantitative Quasi-experimental pre/post	Acute hospital medical wards (Sweden)	Nursing	Nursing	Group	Weekly—Fortnightly	90 minutes	Work environment a
			11 to 18 years
			n = 34
Begat 2005	Quantitative Quasi-experimental cross sectional	Acute hospital medical wards (Norway)	Nursing	N/S	Group	Fortnightly	N/S	Well-Being a
			9 years					Work Environment
			n = 71					WEQ
Ben-Porat 2011	Quantitative Cross sectional	Domestic violence and women’s shelters (Israel)	Social Work	N/S	N/S	N/S	N/S	Burnout
			11 years					Burnout Questionnaire
			n = 143
Berg 1994	Quantitative Quasi-experimental pre/post	Psychogeriatric hospital (Sweden)	Nursing	Nursing	Group	Fortnightly–every third week	120 minutes	Burnout
			11 years					MBI
			n = 39					Job Satisfaction
								Satisfaction with Nursing Care
								Well-being
								Tedium Measure
								Work Environment CCQ
Berg 1999	Quantitative Quasi-experimental pre/post	Psychiatric hospital (Sweden)	Nursing	Nursing	Group	Fortnightly	180 minutes	Job Satisfaction
			14 years					SNCW
			n = 22					Well-being
								SOC
								WRSI
								Work Environment
								CCQ
Berry 2019	Quantitative Cross sectional	Psychiatric hospital (UK)	Nursing	N/S	N/S	N/S	N/S	Burnout MBI
			N/S
			n = 137
Best 2014	Quantitative Cross sectional	Alcohol and drug community service (Australia)	Social Work/Psychology/Counselling	N/S	Individual	Fortnightly–monthly	N/S	Work Environment
			56% > 10 years					Organizational Readiness for Change Assessment
			n = 43
Cooper-Nurse 2018	Quantitative Quasi-experimental cross sectional	Mental health settings (USA)	Social Work/Psychology/ Counselling	N/S	Individual face-to-face +/- over phone/online	55% less than once per week	82% >30 minutes	Burnout
								MBI
			N/S					Job Satisfaction
			n = 60					AJDI
Ducat 2016	Qualitative Qualitative descriptive	Rural and regional areas (Australia)	Social work/Nutrition/Dietetics/ Occupational Therapy/Physiotherapy/Speech pathology/Medical radiation/Psychology	N/S	Individual	N/S	N/S	Interview question
			N/S					What effect has CS had on your practice (if any)?
			n = 42
Edwards 2006	Quantitative Cross sectional	Community mental health (UK)	Nursing	N/S	Individual, group or combination	57% monthly	32% >60 minutes	Burnout
			52% <5 years					MBI
			n = 260
Eklund 2000	Quantitative Quasi-experimental cross sectional	Acute and community psychiatric care (Sweden)	Occupational Therapy	Occupational Therapy/Social Work/Psychology Nursing/Medical	N/S	N/S	N/S	Job Satisfaction
			N/S					Job Satisfaction Questionnaire
			n = 291
Fischer 2013	Quantitative Quasi-experimental cross sectional	Acute Hospital (Italy)	Physiotherapy	N/S	Individual or group	N/S	N/S	Burnout
			13 years					MBI
			n = 132
Gonge 2011	Quantitative Cross sectional	Psychiatric hospital wards and community mental health centres (Denmark)	Nursing	Psychiatry/ Psychology	Group	Every two months	90 minutes	Burnout
								MBI
								Job Satisfaction
			N/S					CPQ
								Well-being
								CPQ
			n = 145					SF-36
Hallberg 1994	Quantitative Quasi-experimental pre/post	Paediatric psychiatric ward (Sweden)	Nursing	Nursing	Group	Every third week	120 minutes	Burnout
								MBI
								Job Satisfaction
			15 years					Satisfaction with Nursing Care
			n = 11					Well-being
								Tedium Measure
Hussein 2019	Quantitative Cross sectional	Acute hospital (Australia)	Nursing	N/S	N/S	N/S	N/S	Job Retention
			1 year					Modified Nurse Retention Index
			n = 87
Hyrkäs 2005	Quantitative Cross sectional	Acute hospitals (Finland)	Nursing	Nursing/Psychology	Individual or group	67% every three weeks or monthly	34% 60 minutes duration	Burnout
			57% > 10 years					MBI
			n = 569					Job Satisfaction
								Minnesota Job Satisfaction Scale
Kavanagh 2003	Quantitative Cross sectional	Hospital and community mental health settings (Australia)	Social Work/ Psychology/Occupational Therapy/ Speech Therapy	N/S	Individual, group or combination	Monthly	120 minutes	Job Satisfaction
			8 years					Hoppock Job Satisfaction Measure
			n = 199
Koivu 2012	Quantitative Quasi-experimental cross sectional	Acute hospital medical and surgical wards (Finland)	Nursing	N/S	Group	Every 3 or 4 weeks	90 minutes	Burnout
			15 to 17 years					MBI-GS
			n = 304					Well-being
								GHQ-12
								Work Environment
								QPSNordic
Livini 2012	Quantitative Quasi-experimental pre/post	Drug and alcohol service (Australia)	Nursing/Psychology/Social Work/Counselling	Nursing/Psychology	Individual, group or combination	2 to 8 sessions over 6 months	70 to 480 minutes	Burnout
								MBI
								Job Satisfaction
			N/S					IJSS
			n = 42					Well-being
								Scales of psychological well-being
Long 2014	Quantitative Cross sectional	Mental Health Hospital (UK)	Nursing	N/S	Individual, group or combination	23% monthly	N/S	Well-being
			28% > 7 years					BCS
			n = 128
Love 2017	Quantitative Quasi-experimental cross sectional Qualitative Qualitative descriptive	Hospital and community maternity services (Australia)	Nursing	N/S	Individual, group or combination	N/S	N/S	Job Satisfaction NSWQ
			17 years
								Interview questions
			n = 108
								What can you tell me about your overall experience of CS?What, if any, benefits have you gained from CS?Has CS been of use to you in your practice and personal life?
McAuliffe 2013	Quantitative Quasi-experimental cross sectional	Obstetric care settings (Africa)	Nursing/Medical	N/S	N/S	N/S	N/S	Job Retention a
			N/S					Job Satisfaction
			Cohort 1 n = 540					Job Satisfaction Scale
			Cohort 2 n = 541
			Cohort 3 n = 480
McCarron 2017	Quantitative (Not included in the review) Qualitative Grounded theory	Psychiatric hospital (UK)	Nursing	N/S	N/S	N/S	N/S	No relevant outcomes
			Cohort 1, 8.5 years n = 20
			Cohort 2, 6.5 years n = 30					Interview questions
								What has your experience of CS been?If you feel that your level of CS is inadequate, how do you think this impacts on you, your ability to do your job and patient care?
Nathanson 1992	Quantitative	Hospital and community services (USA)	Social work	Social work	Individual or group	N/S	N/S	Job Satisfaction a
			50% ≤ 3 years
			n = 196
Saxby 2016	Quantitative Cross sectional Qualitative Qualitative descriptive	Community health service (Australia)	Dietetics/Social Work/ Physiotherapy/Podiatry/ Occupational Therapy/ Psychology/Speech Therapy	N/S	Individual or group	N/S	N/S	Burnout
								MBI
								Job Retention
								Intention to Leave Scale
			57% > 10 years
								Interview questions
								How would you describe your experience of CS?What makes a CS effective?Any factors that reduce the effectiveness of CS?Can you give examples where CS has made a difference to: how services are delivered to clients? How workers cope with stresses in their job? how workers feel about where they work?
			n = 82
Schroffel 1999	Quantitative Cross sectional	Mental health service (USA)	Social Work/Counselling/Nursing/ Psychology	N/S	Individual or group	Weekly	71% > 30 minutes	Job Satisfaction
			16 years					JDI
			n = 84					JIG
Severinsson 1996	Quantitative Cross sectional	Psychiatric hospital (Sweden)	Nursing	Nursing	Group	Weekly	90 minutes	Work Environment a
			10 years
			n = 26
Severinsson 1999	Quantitative Quasi-experimental cross sectional	Acute hospital (Sweden)	Nursing	N/S	N/S	N/S	N/S	Work Environment
			N/S					Work Environment Measure
			n = 158
Teasdale 2001	Quantitative Quasi-experimental cross sectional	Acute hospital and community health settings (UK)	Nursing	N/S	Individual, group or combination	N/S	N/S	Burnout
			14 years					MBI
			n = 211					Work Environment
								Nursing in Context Questionnaire
Wallbank 2010	Quantitative Randomised controlled trial	Acute hospital obstetrics and gynaecology (UK)	Nursing/Medical	Psychology	Individual	N/S	60 minutes	Burnout
			N/S					ProQol
			n = 30					Well-being
								IES
								ProQol
Webster 1999	Quantitative Cross sectional	Community mental health services (USA)	Social Work/Medical/Psychology/ Counselling/Nursing	N/S	N/S	N/S	N/S	Burnout
			N/S					MBI
			n = 151
White 1998	Qualitative Qualitative descriptive	Community, medical ward, paediatric ward, management, School of Nursing, A&E department, gynaecology ward, GP unit, residential care (UK)	Nursing	Nursing	Individual or group	N/S	N/S	Interview
			N/S					Questions
			N = 12					N/S

a–outcome measure not validated; AJDI–Abridged Job Descriptive Index; BCS–Bradford Clinical Supervision Scale; CCQ–Creative Climate Questionnaire; CPQ–Copenhagen Psychosocial Questionnaire; GHQ–General Health Questionnaire; IES–Impact of Event Scale; IJSS–Intrinsic Job Satisfaction Scale; JDI–Job Descriptive Index; JIG–Job in General Index; MBI–Maslach Burnout Inventory; MBI-GS–Maslach Burnout Inventory-General Survey; SNCW–Satisfaction with Nursing Care and Work; NSWQ–Nursing Workplace Satisfaction Questionnaire; SF-36–36-Item Short Form Survey; ProQol–Professional Quality of Life Scale; QPSNordic–The Nordic Questionnaire for Psychological and Social Factors at Work; SOC–Sense of Coherence Scale; WEQ–Work Environment Questionnaire; WRSI–Work-related Strain Scale.

N/S–Not stated.

Methodological quality

The predominant methodological risk of bias for analytical cross-sectional cohort studies (n = 14) was the absence of strategies to deal with confounding factors [36, 39, 41, 45, 46, 48, 52]. For quasi-experimental studies (n = 14) it was unclear if participants received similar support interventions other than clinical supervision in 12 studies [23–29, 31, 33–35, 51], outcome measurement was not performed both pre and post intervention (i.e. multiple time points) in nine studies [24, 27–29, 31, 33–35, 51], and it was unclear if participants were similar at baseline in seven studies [24, 27–29, 33, 34, 51]. The single randomised controlled trial [22] only met five of the 13 items; notably the method of randomisation was unclear and there was no between group statistical comparison. JBI Critical Appraisal Checklists can be found in S1–S3 Tables.

The methodological quality of the five qualitative studies (including the qualitative component of mixed methods studies) was generally high. Two studies [51, 52] scored 10 out of 10, while two other studies [49, 50] scored eight out of 10, failing to account for the potential influence of the researcher on the research findings. One study [53] did not demonstrate congruity between their stated philosophical perspective and the research methodology used, nor was there congruence between their research methodology and their research question/objectives, methods of data collection and analysis and interpretation of results. The JBI Critical Appraisal Checklist can be found in S4 Table.

Impact of clinical supervision on organisational outcomes (quantitative findings)

1. Clinical supervision compared to control

Eleven studies, including 2,965 participants, evaluated the effect of clinical supervision on organisational outcomes by comparison to a control group that did not receive clinical supervision [22, 24, 25, 27–29, 31, 33–35, 51]. Eight studies included nursing professionals [22, 24, 25, 31, 33–35, 51], one study included social work/psychology/counselling professionals [27], two studies included other allied health professionals [28, 29] and two studies included medical professionals [22, 33]. While individual studies found clinical supervision had a positive effect on organisational outcomes, there were variable results across studies for burnout (six studies, n = 776 participants) (Fig 2A–2D), job satisfaction (four studies, n = 2,020 participants), well-being (four studies, n = 444 participants), and workplace environment (five studies, n = 783 participants). Notably, a single randomised controlled trial (n = 30 participants) found that clinical supervision had a large effect on burnout (Fig 2D) and well-being [22]. Results from individual studies can be found in S5 Table.

Fig 2

A. Supervision vs. control: emotional exhaustion (burnout) SMD 95%CI. B: Supervision vs. control: depersonalisation (burnout) SMD 95%CI. C: Supervision vs. control: personal accomplishment (burnout) SMD 95%CI. D: Supervision vs. control: overall burnout SMD 95%CI.

2. Clinical supervision compared to within-group historical control (pre/post implementation)

Six studies, including 178 participants, evaluated the effect of clinical supervision on organisational outcomes by comparing post-implementation with pre-implementation [22, 23, 25, 26, 30, 32]. Six studies included nursing professionals [22, 23, 25, 26, 30, 32], one study included social work/psychology/counselling professionals [32] and one study included medical professionals [22]. While individual studies found clinical supervision had a positive effect on organisational outcomes, there were variable results across studies for burnout (four studies, n = 122 participants) (Fig 3A–3D), job satisfaction (four studies, n = 114 participants), well-being (five studies, n = 144 participants), and workplace environment (three studies, n = 95 participants). Results from individual studies can be found in S6 Table.

Fig 3

A: Pre- vs. post-supervision implementation: emotional exhaustion (burnout) SMD 95%CI. B: Pre- vs. post-supervision implementation: depersonalisation (burnout) SMD 95%CI. C: Pre- vs. post-supervision implementation: personal accomplishment (burnout) SMD 95%CI. D: Pre- vs. post-supervision implementation: overall burnout SMD 95%CI.

3. Association between effective clinical supervision and organisational outcomes

Eight studies, including 1,376 participants, investigated the association between effective clinical supervision and organisational outcomes [37, 38–43, 52]. Five studies included nursing professionals [37, 39–42], three studies included social work/psychology/counselling professionals [38, 43, 52] and one study included other allied health professions [52]. There was preliminary evidence to suggest that effectiveness of clinical supervision may be negatively associated with burnout and positively associated with job retention (Table 2). The association between effective clinical supervision and job satisfaction was unclear.

Table 2

Synthesis of studies investigating association between effectiveness of clinical supervision and organisational outcomes.

Outcome	Number of studies	Number of participants	Direction of association within study (number of studies)			Effect size
			-	o	+
Burnout–Emotional Exhaustion	5 [37, 39, 41, 42, 52]	1,046	3	2	1	Small to moderate
Burnout–Depersonalisation	5 [37, 39, 41, 42, 52]	1,046	4	1	0	Small
Burnout–Personal Accomplishment	5 [37, 39, 41, 42, 52]	1,046	1	3	1	Moderate
Job Retention	2 [40, 52]	152	0	0	2	Moderate
Job Satisfaction	3 [41–43]	836	1	0	2	Small
Well-being	1 [42]	136	0	0	1	U/A

N/A–not applicable; U/A–Unable to calculate.

Positive association for job retention, job satisfaction, and well-being indicates effectiveness of supervision is associated with better outcome.

Negative association for burnout indicates effectiveness of supervision is associated with better outcome.

Synthesis of five studies [37, 39, 41, 42, 52], including 1,046 participants, indicated that effectiveness of clinical supervision may be negatively associated with emotional exhaustion and depersonalisation, but not associated with personal accomplishment. Three studies found a small to moderate association with emotional exhaustion [39, 42, 52] and four studies found small association with depersonalisation [37, 39, 41, 42].

Synthesis of two studies [40, 52], including 152 participants, indicated that effectiveness of clinical supervision may be positively associated with job retention. Both studies found a moderate association with job retention.

Synthesis of three studies [41-43], including 836 participants, indicated that the association between effectiveness of clinical supervision and job satisfaction was unclear. Two studies [41, 42] found a small positive association and one study [43] found a small negative association. Results from individual studies are available in S7 Table.

4. Association between effective supervisor and organisational outcomes

Eight studies, including 1,600 participants, investigated the association between effectiveness of the supervisor and organisational outcomes [32, 36, 39, 41, 43, 45, 46, 48]. Five studies included nursing professionals [32, 39, 41, 46, 48], seven studies included social work/psychology/counselling professionals [32, 36, 43, 45, 46, 48, 52] and one study included medical professionals [48]. There was preliminary evidence to suggest that an effective supervisor may be negatively associated with burnout, and positively associated with job satisfaction (Table 3).

Table 3

Synthesis of results: Association between an effective supervisor and organisational outcomes.

Outcome	Number of studies	Number of participants	Direction of association within study (number of studies)							Effect size
			-		o			+
Effectiveness of Supervisor
Burnout–Emotional Exhaustion	3 [39, 41, 48]	901	2		0			1		Small
Burnout–Depersonalisation	3 [39, 41, 48]	901	2		1			1		Small
Burnout–Personal Accomplishment	3 [39, 41, 48]	901	0		3			0		U/A
Burnout–Overall	2 [32, 36]	150	1		1			0		Large
Job Satisfaction	5 [32, 41, 43, 45, 46]	1128	0		0			5		Small to Large
Well-being	2 [32, 36]	180	0		1			1		Large

U/A–Unable to calculate.

Positive association for job satisfaction, role competence and well-being indicates effectiveness of supervision is associated with better outcome.

Negative association for burnout indicates effectiveness of supervision is associated with better outcome.

Synthesis of three studies, [39, 41, 48] including 901 participants, indicated that an effective supervisor may be negatively associated with depersonalisation but not associated with personal accomplishment. Two studies found a small association with depersonalisation [39, 48]. The association between an effective supervisor and emotional exhaustion was unclear, with two studies finding a small negative association [39, 48] and one study finding a small positive association [41].

Synthesis of five studies [32, 41, 43, 45, 46], including 1128 participants, indicated that an effective supervisor may be positively associated with job satisfaction. Studies found a small to large association with job satisfaction. Results from individual studies are available in S8 Table.

Healthcare professionals’ experiences of clinical supervision as it relates to organizational processes and outcomes (qualitative findings)

Five studies, including two qualitative [49, 50] and three mixed methods studies [51-53], explored the experiences of healthcare professional supervisees on clinical supervision as it relates to organisational outcomes. A total of 16 findings and their illustrations were extracted. Of the 16 findings, 14 were unequivocal and two were credible. The 16 findings were organised into four categories which were further deduced to two synthesised findings. Table 4 shows a summary of the qualitative findings.

Table 4

Summary of qualitative findings.

Synthesised Findings	Categories	Findings	Illustrations
Synthesised Finding 1	Category 1.1	Some respondents felt that inadequate supervision had no impact; however, others identified personal consequences in terms of stress and burnout, feeling unsupported and there being an impact on their work, the ward and clients. (UNEQUIVOCAL)	‘I feel my confidence is affected.’ (RN 2016) (McCarron et al 2017, p. 153)
		Supervision assisted them to manage the workplace stress and hence, reduce their risk of burnout. (UNEQUIVOCAL)	‘When I first started with my supervisor I was in a really bad place. . . . and I was sort of at the point of no return, so getting my clinical supervision organized and constantly every month, that gave me back my confidence.’ (Saxby 2016, p. 175)
Adequate clinical supervision mitigates the risk of burn out and facilitates staff retention, while inadequate clinical supervision can lead to stress and burnout.	Adequate CS mitigates the risk of burn-out, while inadequate CS can lead to stress and burnout
		Supervision was helpful for the worker to gain a greater understanding of the dynamics operating in the client interaction to ensure there were no negative impacts for the worker or the client. (UNEQUIVOCAL)	‘We’re exploring. . . . the impact of that particular case on myself as a worker. . . .. it seems to make it clearer and give me insight into different ways of looking at that particular person.’ (Saxby 2016, p. 175)
		Opportunity to debrief challenging events provided supervisees with validation of their feelings and consideration of different management strategies to reduce their distress. (UNEQUIVOCAL)	‘I was absolutely gob-smacked with this new reform that could be coming in and potentially what could happen to me in terms of where I’m going to be going or that type of thing, you know, it’s quite unsettling. . .. . . but just having that opportunity to debrief and face my concerns has been helpful.’ (Saxby 2016, p. 175–176)
	Category 1.2	The implementation of clinical supervision as evidence that the health service management ‘cared about’ her and her colleagues and valued and wished to retain their workers. (UNEQUIVOCAL)	‘Yeah, it’s supportive and I guess it’s an indication the organization does care about us enough to push that. . . .. and they want to keep their staff.’ (Saxby 2016, p. 173)
		Supervisees’ responses illustrated that supervision did enhance job satisfaction and reduce workers’ intention to leave. (UNEQUIVOCAL)	‘Now I feel like I can still cope with what’s going on and that to me was worth it because otherwise I would probably be packing shelves at Coles or something. So it’s given me back my self worth, just from supervision.’ (Saxby 2016, p. 174)
	Implementation of effective CS facilitates staff retention and reduces their intention to leave
		The supervisor played an active role in encouraging staff to undertake career developing activities. (UNEQUIVOCAL)	‘I guess, encouragement, being encouraged to do something, maybe something that you didn’t think you were capable of. . . . Yes, my supervisor. . .she’s suggested I become a supervisor, so I’ve done that and I’m going to start doing that. Yes, she makes suggestions like that from a professional development point of view.’ (Saxby 2016, p. 173)
Synthesised Finding 2	Category 2.1	Midwives felt the structure of a safe space for regular reflection offered them continual opportunities for self-development especially in terms of enhanced communication and improved working relationships. (UNEQUIVOCAL)	‘For me personally it has helped with dealing with conflict stuff, and people, or my own personal issues with other people without ever having to involve them, because it was me that was able to adjust things.’ (Midwife 6) (Love et al 2017, p.278)
	CS enhances team relationships through improved communication
		Midwives used words such as ‘courage’, ‘confidence’ and ‘strength’ to describe how their CS sessions had fostered in them an improved ability to engage in difficult conversations at work. (UNEQUIVOCAL)	‘I would have just been left in limbo with that situation and that person I think. So it enabled me to actually look at the situation and address it with that person.’ (Midwife 2) (Love et al 2017, p.278)
CS improves the work environment through boosting staff morale, motivation to work, staff well-being and team relationships
	Category 2.2	Midwives described feeling more positive about the work environment with an increased desire to ‘give back’ to the unit. (CREDIBLE)	‘It really boosted morale and got people motivated.’ (Midwife 3) (Love et al 2017, p.278)
		Prominent valuable outcomes of clinical supervision at the level of organization were the strengthened relationships with work colleagues, which on occasion was reported as a challenge for senior staff, and increased staff morale. (CREDIBLE)	‘I think if you affect staff morale, that in turn has got to affect patient morale, because the staff has such a strong influence over the patients. . . If the staff member feels supported, feels as if they’ve got somewhere to go, feel that they are not on their own and not isolated, which is how I think people do feel perhaps without the [clinical supervision] session, then you can sometimes unwittingly take it out on patients, I think. So I think it definitely affects patient care.’ (Staff Nurse) (White et al 1998, p. 190)
	CS promotes staff morale, motivation to work and well-being
		Enthusiasm, growth and organisational commitment were identified by supervisors and supervisees. (UNEQUIVOCAL)	‘... we did an evaluation just when we had our face to face meeting, she said that she’s more enthusiastic about her position, she’s more motivated, she’s more organised and she’s been encouraged to do more skills development activities.’ (Ducat et al 2016, p. 32)
		Supervision kept workers motivated, interested and engaged in their roles of delivering health care services. These features of supervision increased allied health workers’ sense of connection to the employing organisation and decreased their intention to leave. (UNEQUIVOCAL)	‘It’s made such a difference to me as a practitioner. It helps you stay really focused on why am I here and it helps you stay focused on the positives that you are getting all the time because they are easy to forget about.’ (Saxby 2016, p. 171)
		Receiving positive feedback was particularly valuable for workers (at the time of data collection) as they were experiencing high uncertainty in many areas including changes to their roles and the focus of the service. Feedback from supervisors provided reassurance, as well as a sense of stability amid the evolving occupational landscape. (UNEQUIVOCAL)	‘It’s quite a supportive relationship, so your skills and your experience are recognised and that’s quite important in the current environment when everything else is being questioned and changed all the time.’ (Saxby 2016, p. 172)
		Supervision increased staffs’ sense of connection to the employing organisation, enabling supervisees to feel that they individually had a place within the organisation and therefore a sense of belonging to something greater than their immediate and often atomized local environment. (UNEQUIVOCAL)	‘What it does bring is a sense of being connected to the broader organisation. To feel connected, it’s just to feel connected to, that somebody has a clue what I do, that somebody thinks it’s ok, that it’s not just me floating around here hoping like crazy, I’m doing something useful. . . .. like I’m out there and nobody knows where I am or what I’m doing and that total sense of no one having you back almost. . . .. That feeling for me, the word is connected, to something bigger.’ (Saxby 2016, p. 173)
		Improved evidence-based practice, best practice, patient safety and clinical governance were identified by managers, supervisors and clinicians. (UNEQUIVOCAL)	‘... and, we really do need to ensure that our clinicians are doing the best practice, that they are supported to develop the skills they need for the role they do, and to have someone to support them to do that, not just measure them against it. . .’ (Ducat et al 2016, p.32)

Synthesised finding 1: Adequate clinical supervision mitigates the risk of burnout and facilitates staff retention, while inadequate clinical supervision can lead to stress and burnout

Health professionals indicated that if clinical supervision was adequate or if they felt supported the risk of experiencing burnout or leaving the workplace was less likely. Conversely, health professionals, who felt that their supervision was inadequate, reported that clinical supervision had no positive impact or can lead to stress and burnout if they felt unsupported. This synthesised finding was developed from two categories comprising of seven unequivocal findings.

○ Category 1.1 Adequate clinical supervision mitigates the risk of burnout, while inadequate clinical supervision can lead to stress and burnout.

Adequate supervision meant that health professionals experienced the opportunity to debrief challenging events with their supervisor and gain a better understanding of patient interactions which can be stressful, and cause burnout for some staff. However, participants who felt unsupported identified stress and burnout as the negative consequences. This category was supported by four findings:

Some respondents felt that inadequate supervision had no impact; however, others identified personal consequences in terms of stress and burnout, feeling unsupported and there being an impact on their work, the ward, and clients. (Unequivocal)

Supervision assisted them to manage the workplace stress and hence, reduce their risk of burnout. (Unequivocal)

Supervision was helpful for the worker to gain a greater understanding of the dynamics operating in the client interaction to ensure there were no negative impacts for the worker or the client. (Unequivocal)

Opportunity to debrief challenging events provided supervisees with validation of their feelings and consideration of different management strategies to reduce their distress. (Unequivocal)

○ Category 1.2 Implementation of effective clinical supervision facilitates staff retention and reduces their intention to leave.

Participants reported that clinical supervision was a reflection that the health organisation valued their staff. Participants also indicated that supervisors encouraged staff to pursue career developments. These experiences enhanced job satisfaction and reduced staffs’ intention to leave the healthcare organisation. This category was supported by three findings:

The implementation of clinical supervision as evidence that the health service management ‘cared about’ her and her colleagues and valued and wished to retain their workers. (Unequivocal)

Supervisees’ responses illustrated that supervision did enhance job satisfaction and reduce workers’ intention to leave. (Unequivocal)

The supervisor played an active role in encouraging staff to undertake career developing activities. (Unequivocal)

Synthesised finding 2: Clinical supervision improves the work environment through boosting of staff morale, motivation to work, staff well-being and team relationships

Health professionals indicated that clinical supervision was valuable, led to increased motivation and enthusiasm at work, and provided not only reassurance to staff but also a safe space for improved working relationships. This synthesised finding was developed from two categories comprising of seven unequivocal findings and two credible findings.

○ Category 2.1 Clinical supervision enhances team relationships through improved communication.

Participants (ie. midwives) felt that clinical supervision offered an opportunity to enhance their ability to engage in difficult conversations with their team which is key in effective working relationships. This category was supported by two findings:

Midwives felt the structure of a safe space for regular reflection offered them continual opportunities for self-development especially in terms of enhanced communication and improved working relationships. (Unequivocal)

Midwives used words such as ‘courage’, ‘confidence’ and ‘strength’ to describe how their clinical supervision sessions had fostered in them an improved ability to engage in difficult conversations at work. (Unequivocal)

○ Category 2.2 Clinical supervision promotes staff morale, motivation to work and well-being.

Participants reported that having a clinical supervisor to support them and provide valuable feedback made them believe that they had a place within their organisation, increased their morale and enthusiasm at work, and improved their overall perception of their work environment. This category was supported by six findings:

Midwives described feeling more positive about the work environment with an increased desire to ‘give back’ to the unit. (Credible)

Prominent valuable outcomes of clinical supervision at the level of organization were the strengthened relationships with work colleagues, which on occasion was reported as a challenge for senior staff, and increased staff morale. (Credible)

Enthusiasm, growth and organisational commitment were identified by supervisors and supervisees. (Unequivocal)

Supervision kept workers motivated, interested, and engaged in their roles of delivering healthcare services. These features of supervision increased allied health workers’ sense of connection to the employing organisation and decreased their intention to leave. (Unequivocal)

Receiving positive feedback was particularly valuable for workers (at the time of data collection) as they were experiencing high uncertainty in many areas including changes to their roles and the focus of the service. Feedback from supervisors provided reassurance, as well as a sense of stability amidst the evolving occupational landscape. (Unequivocal)

Supervision increased health professionals’ sense of connection to the employing organisation, enabling supervisees to feel that they individually had a place within the organisation and therefore a sense of belonging to something greater than their immediate and often atomized local environment. (Unequivocal).

Integration of quantitative and qualitative evidence

Quantitative and qualitative findings in this review have been largely complementary and supportive of each other, especially on the impact of clinical supervision on burnout, staff well-being, job satisfaction, job retention and workplace environment.

Burnout

Quantitative findings have provided preliminary evidence that effective clinical supervision and effective supervisor may be negatively associated with burnout. This was also supported by qualitative findings that showed that adequate clinical supervision mitigated the risk of burnout, and that inadequate clinical supervision lead to stress and burnout.

Staff well-being

Quantitative findings from a single randomised controlled trial showed a large effect on reducing burnout and enhancing well-being. Qualitative studies supported this, showing that effective clinical supervision improved staff well-being.

Job satisfaction

Although quantitative evidence from three studies showed that the association between effective clinical supervision and job satisfaction was unclear, evidence from four studies showed a positive association of an effective supervisor with job satisfaction. Qualitative findings supported this showing that effective clinical supervision strengthened team relationships and sense of belonging to the organisation, thereby enhancing job satisfaction. This was particularly true when the supervisor was effective, provided valuable feedback and encouraged staff to pursue career developments.

Job retention

Evidence from two quantitative studies showed a moderate positive association of the effectiveness of clinical supervision with job retention. Similarly, qualitative studies showed that adequate clinical supervision facilitated staff retention.

Workplace environment

Synthesis of quantitative evidence from 11 studies investigating the effect of clinical supervision, and six studies investigating post-implementation of clinical supervision with pre-implementation, showed variable results in regard to its effect on workplace environment. However, qualitative evidence highlighted that effective feedback from supervisors were considered valuable and improved supervisee perceptions of the work environment and their sense of belonging to the organisation.

In summary, both the quantitative and qualitative evidence highlight that effective clinical supervision and effective clinical supervisors may be associated with positive organisational outcomes, whereas, ineffective or inadequate clinical supervision and ineffective supervisors may have a negative impact on the well-being of the supervisee.

Discussion

This systematic review of 32 studies is the first known synthesis of quantitative and qualitative evidence to further our knowledge on the impact from, and experiences of, clinical supervision of post-qualification health professionals, on organisational outcomes. Quantitative findings indicate that clinical supervision can have variable effects on organisational outcomes. The effectiveness of both the clinical supervision and the supervisor appear to influence this effect; effective clinical supervision is associated with lower burnout and greater staff retention, and an effective supervisor is associated with lower burnout and greater job satisfaction. This is supported by the qualitative findings which show that healthcare professionals believe adequate clinical supervision can mitigate the risk of burnout, facilitate staff retention, and improve the work environment, while inadequate clinical supervision can lead to stress and burnout. Overall, qualitative synthesis highlights that the effectiveness of clinical supervision and supervisors can significantly influence the effect of clinical supervision on organisational outcomes.

Effective clinical supervision and effective supervisors may be pre-cursors for the realisation of beneficial effects of clinical supervision by healthcare organisations. This is consistent with a model of clinical supervision, for post-qualification health professionals, proposed by Gonge and Buss [42], where participation in effective clinical supervision (ie. prioritising supervision time) is a pre-requisite to beneficial clinical supervision. While clinical supervision has become increasingly mandated in many healthcare organisations, through standard policies and procedures, the subsequent challenge lies in its effective and consistent implementation and uptake. This can be achieved in several ways. Organisations can adopt/utilise evidence-informed clinical supervision frameworks to guide supervision, such as the one recently developed by Rothwell and colleagues [54]. This review by Rothwell and colleagues, based on evidence from 135 studies, encourages organisations to consider making supervision mandatory to increase the value placed on it, and provide protected time for supervisors and supervisees to engage with it. It also offers several practical strategies such as providing staff with both one-to-one and group supervision options, facilitating a person-centred supervision approach with clear boundaries, tasks, ground rules and record keeping processes, and provision of ongoing training to supervisors and supervisees [54]. Implementation and uptake of clinical supervision can be completed by building a positive organisational culture that supports engagement in and uptake of clinical supervision [54], which could be regularly monitored through routine evaluations. Such evaluations will be critical to identify and respond to what clinical supervision strategies have worked, or not worked, for whom and why. Based on our work in this field, we believe that the organisational context can have an important role, and there is no one-size fits all approach when it comes to supporting the implementation and uptake of clinical supervision within organisations.

Healthcare organisations also need to support clinical supervisors to build and foster positive supervisory relationships with their supervisees. This has commonly been reported to be the single most important factor that influences the effectiveness of clinical supervision [3, 11, 54], and requires investment of both time and resources. Supervisors and supervisees can also be guided by evidence-informed principles that facilitate effective clinical supervision. For example, Martin and colleagues [11] provide several practical recommendations for supervisors and supervisees to enhance the effectiveness of clinical supervision, such as the development of a supervision contract, undertaking sessions at an optimal length and frequency, utilising different modes including telesupervision, evaluating supervision, and working on skills and abilities such as open communication, flexibility, trust and availability to foster a positive supervisory relationship [11]. Health professionals can be provided with continuing professional development opportunities to upskill in evidence-informed supervision practices [3, 55]. There is evidence from a longitudinal, multi-methods study to support the delivery of supervision training in various modes such as videoconference, online and blended modes, thereby catering to those that can’t access face-to-face training. In this study, participants knowledge and confidence in the provision of supervision increased after training, which was also sustained at three-months post-training across all the four modes. This success was attributed to the careful design and delivery of training across different modes, which maximised participant access to training [56].

This review found various methodological concerns across many studies reviewed, which is consistent with findings from a recent survey of 20 systematic reviews on clinical supervision reported between 1995 to 2019 [3]. Methodological concerns include predominance of ex post facto, cross-sectional, correlational designs, small sample sizes, over reliance on self-report measures, lack of psychometrically sound supervision measures, and lack of experimental and longitudinal designs [3]. Incomplete provision of information (on clinical supervision parameters) seems to continue to plague supervision research, as again found in the survey of supervision reviews [3], and in the systematic review reported here, making it hard to judge the full merit of the study or replicate it. There is a need for further rigorous high-quality studies in this area that use pluralistic research approaches where experimental investigation, randomisation, and data-driven case studies are used in conjunction with ex post facto, and cross-sectional designs [3]. Studies also need to better define the specifics of the clinical supervision intervention to allow replication and identification of the clinical supervision practices that are, or are not, effective for improving outcomes.

Limitations

The final review deviated from the protocol to also include group supervision, as many studies did not specify the type of supervision investigated. However, group supervision is commonly practiced in healthcare organisations and including these studies in this review likely improves the generalisability of our findings. Although the qualitative studies included were deemed to be of good quality, there were several shortcomings in the methodologies employed by the quantitative studies, especially the lack of randomised trials and absence of strategies to deal with confounding factors in cross-sectional studies. Although there were a variety of healthcare settings and health professionals represented in this review, the majority of included studies were conducted in mental health settings with nursing and/or mental health disciplines (i.e. psychology, counselling, and social work). This may limit the generalisability of the results to other disciplines and indicates the need for further research beyond mental health settings and nursing/mental health disciplines.

Conclusions

Clinical supervision can have a variable effect on healthcare organisational outcomes. This effect appears to be influenced by the effectiveness of both the clinical supervision provided and that of the clinical supervisor. This highlights the need for organisations to invest in high quality supervision practices if they wish to benefit from clinical supervision. Without such investment, there is a risk of policy-practice gaps in this area (i.e. while there may be policies to support clinical supervision in healthcare organisations, in practice it may not be implemented well). Ongoing further research, which grows the evidence base for high quality clinical supervision and helps to unpack the black box of clinical supervision practices that have the most effect on organisational outcomes, is required.

PRISMA checklist.

(DOC)

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JBI critical appraisal checklist for randomised controlled trials.

(DOCX)

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JBI critical appraisal checklist for quasi-experimental studies.

(DOCX)

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JBI critical appraisal checklist for analytical cross sectional studies.

(DOCX)

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JBI critical appraisal checklist for qualitative studies (including qualitative component of mixed methods studies).

(DOCX)

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Results of studies investigating the effect of clinical supervision on organisational outcomes compared to control (no supervision).

(DOCX)

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Results of studies investigating the effect of clinical supervision on organisational outcomes pre/post implementation.

(DOCX)

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Results of studies investigating the association between effectiveness of clinical supervision and organisational outcomes.

(DOCX)

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Results of studies investigating the association between an effective supervisor and organisational outcomes.

(DOCX)

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Search strategy.

(DOCX)

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Excluded studies.

(DOCX)

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3 Aug 2021

PONE-D-21-20050

Impact of clinical supervision on healthcare organisational outcomes: a mixed methods systematic review

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This comprehensive review explored an important topic. I enjoyed reading this manuscript which clearly synthesised the literature. I have some suggestions to enhance clarity. Thank you for synthesising and contributing to the evidence.

Abstract:

L80 supervisor should be supervision?

Intro:

L93-94 needs reference

L116-130 Rather than reporting each review, can you combine the outcomes and reference accordingly?

Methods:

On the whole the methods were clearly described. It would be beneficial to outline the philosophical framework (ie pragmatism?) for the meta-aggregative approach to help situate the reader at the outset. This reference provides excellent context: Hannes, K. and Lockwood, C., 2011. Pragmatism as the philosophical foundation for the Joanna Briggs meta‐aggregative approach to qualitative evidence synthesis. Journal of advanced nursing, 67(7), pp.1632-1642.

L217 why were 3 levels of credibility assigned, and how was this decided? Quality appraisal was already conducted so it is not clear why there is an additional layer to this.

L241 Reference 21 does not relate to the meta-aggregative approach. This is perhaps why the above point requires clarifying

L241-255 How many authors conducted the qualitative synthesis?

Results:

Quantitative findings were comprehensively reported

L385 How was it determined that findings were credible or unequivocal? This was not described in the methods.

L406-409 Perhaps it is my lack of understanding regarding the “unequivocal” status, but finding 1 seems to indicate that supervision may or may not have an impact. So is the unequivocal finding that there is variability in supervisees’ perceptions of impact?

Discussion:

The discussion reads well and considers important aspects to translate the findings of this review.

L532-534 This sentence is not quite clear – it seems to state the obvious, as how can one experience beneficial supervision without participating in supervision?

L539 Which review?

L526-527 Is it inadequate supervision that leads to stress/burnout? Or the workload itself?

L604-605 Not sure that “The direction of this effect appears to be influenced by the effectiveness of both the clinical supervision provided and that of the clinical supervisor” when these data were not extracted from the study.

A number of interesting and practical points were made. It seems clear that clinical supervision is beneficial but concepts of cost to organisations (or individuals) was not considered. What are the barriers to implementing effective clinical supervision programs when there is clearly much evidence to support their benefits?

Reviewer #2: I have thoroughly enjoyed reading this systematic review. The authors are to be commended for their comprehensive review. I have only minor comments to align the manuscript to the PRISMA 2020 expanded checklist: PRISMA_2020_expanded_checklist.pdf (prisma-statement.org)

Strengths of the manuscript:

Introduction

Clear and logical development of the research questions that underpinned the systematic review.

Methods section

Protocol registration – stated as reference 15 Martin et al (2020) JBI Evid Synth. 2020;18(1):115-120. doi: 10.11124/JBISRIR-D-19-00017. PMID:658 31464853

Eligibility criteria - listed as inclusion criteria. I would recommend changing the sub-title from inclusion criteria and using the term eligibility criteria as per both 2009 and 2020 PRISMA Checklists. Comprehensive table of excluded studies and the respective reason is presented in Appendix 2.

Information sources – presented in Appendix 1 and main body of the manuscript.

Data items - Great clarity is provided regarding extraction of the qual, quant and mixed methods data

Effect measures - the outcomes. Used in the synthesis and presentation of the results, including thresholds, are presented in the manuscript.

Synthesis of results - Data synthesis and integration are comprehensively presented.

Results section:

Study selection & study characteristics are both clearly articulated for the 32 included studies. Table 1 clearly presents the study characteristics. Table 2. Clearly presents the synthesis of studies investigating association between effectiveness of clinical supervision and organisational outcomes.

Results of individual studies – comprehensive review and presentation within the manuscript, tables, and supplementary tables. The authors are commended for such a comprehensive presentation of the qualitative and quantitative review.

Methodological quality results are presented on page 13. Supplementary table four presents the JBI critical analysis for qualitative studies and includes a qualitative component of mixed methods studies.

Results synthesis – Extensive provision of supplementary tables 1-8 illustrate the breadth and depth of data synthesis from the included studies, according to the associations of outcome measures.

Integration of qualitative and quantitative evidence is well constructed and logical.

Discussion section: The findings are interpreted in the context of other evidence, including limitations of the evidence and the review.

Support: No funding was utilised to undertake this systematic review.

Availability of data, code, and other materials: A comprehensive range of supporting documents have been provided.

Areas for consideration:

Search strategy – Comprehensive search strategy provided in Appendix 1. As this is a mixed methods review, it would be ideal to clarify if the search strategy was developed If the search strategy structure adopted a PICO-style approach/SPIDER/SPICER, then describe the final conceptual structure and any explorations that were undertaken to achieve it.

Study selection – reviewer roles during the screening have been specified. Please clarify additional PRISMA 2020 checklist (section 16) reporting recommendations:

• Report any processes used to obtain or confirm relevant information from study investigators.

• If abstracts or articles required translation into another language to determine their eligibility, report how these were translated

Study risk of bias assessment - Quality assessment sub-header is stated, and reviewer involved noted. All studies were reviewed regardless of their methodological quality. It is not clear why the Mixed Methods Assessment Tool (MMAT) was not utilised for example, for the included mixed methods studies. The JBI Qualitative component is presented in supplementary Table 4.

Data extraction sub-heading is used instead of data collection process (PRISMA criteria 10) and Data items (PRISMA Criteria 11). Consider revising the subheadings to align better with the PRISMA 2020 checklist. The role and number of reviewers involved are reported within the manuscript.

Certainty assessment is not overtly covered in the current manuscript (sections 15 and 22 of the PRISMA (2020) expanded checklist

Results: With respect to Supplementary Table 6 the Maslach burnout inventory scores are not individualised with respect to Livini (2012), is this an oversight or where they not separated in the research study. Perhaps worth clarifying.

There is an excellent summary of qualitative findings in Table 4. To enhance the comparison of information in the main body of the manuscript and Table, it would be helpful to indicate the categories: e.g., “Category 1.2 Implementation of effective clinical supervision facilitates staff retention and reduces their intention to leave…” stated on lines 418-419, but the table does not have numbered categories in column 2 of Table 4.

The implications of the results for practice and policy are not overtly presented. Please make explicit recommendations for future research, as per section 23d of the PRISMA (2020) expanded checklist.

Reviewer #3: This manuscript presents a much-needed systematic review of the quantitative, qualitative, and mixed methods supervision literature capturing organizational outcomes in healthcare. The authors have conducted a methodologically sound, comprehensive review which will contribute to the interdisciplinary healthcare and supervision literature, and support practice. Additional information and clarity as noted below would be beneficial.

Introduction

In justifying the need for the study, the authors nicely present the gap in the supervision literature related to reviews of organizational outcomes, noting reviews typically focus on client or practitioner outcomes. An additional comment/value statement related to why reviewing organizational supervision outcomes is important outside of it not being done would highlight the contribution of this manuscript.

Methods:

1. given the definition provided, one would assume “group supervision” was led be a supervisor, and therefore “peer-supervision” only studies were not included. Can this be explicitly noted?

2. clarify “date of inception” pg. 7, line 176;

3. include date range of studies reviewed;

4. a brief definition of “pearling” on page 8 would be helpful.

Results:

5. I very much appreciated the detail presented, however, at times the narrative description is difficult to follow. A statement regarding the presentation (e.g., number of studies in specific categories are not mutually exclusive) would be helpful.

6. The sentence regarding setting is confusing as it seems to be reporting on both setting and profession. I found myself trying to understand if they were connected. Separate sentences per characteristic would make the meaning more clear, unless they are specifically connected in which case outlining the connection would be helpful.

7. In presenting the type of supervision, the total number of studies presented is 30, leaving me curious about the other two studies. Additionally, I was not sure why multi-professional supervision was separated out related to this characteristic?

8. For frequency and duration of supervision, can the number of studies included in the mean be reported explicitly? Or conversely the number that did not?

9. The number of participants represented in the studies as connected to methodological quality is helpful. Including the number of participants included in all categories of impact would be useful (e.g., adding to control, and within-group sections on page 14 and 15).

10. What definitions were used for “effective supervision” and “effective supervisor”?

11. For the synthesized finding, Category 2.1: was the finding about impact on teams specific to group supervision? Can this be noted? Midwives are also specifically noted in this finding, yet other disciplines are not noted at any other point in the Results. This leads to questions related to specifics of this discipline, and homogeneity of findings across the others. Can this please be clarified?

12. In the study protocol, authors identify the range of professions to be covered in this review. Aside from the above results related to midwives, and summary of nurses, psychology, social workers, and counsellors, there is little comment on the professions representation in this literature. Addressing this would be important.

Reviewer #4: Thank you for the opportunity to review this interesting manuscript. Overall I found the work to be coherent and well constructed. My major comment would be clarification in the title and throughout the manuscript that the work focuses on the post-professional clinical supervision literature, rather than the supervision literature as a whole (including pre-professional students). The methods section could also be reduced as much of this is described in the protocol paper but focus on the elements that were modified from the protocol. I have also made other suggestions throughout in the attached document. This will be a useful addition to the literature and thanks for the contribution.

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Reviewer #1: Yes: Simone Gibson

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Brett Vaughan

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Submitted filename: PONE-D-21-20050_reviewer.pdf

Click here for additional data file.

6 Sep 2021

Response letter attached

Submitted filename: Response_Letter_7Sep21.docx

Click here for additional data file.

4 Nov 2021

Impact of clinical supervision on healthcare organisational outcomes: a mixed methods systematic review

PONE-D-21-20050R1

Dear Dr. Martin,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Shane Patman, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I would like to thank you for taking the time to make the adjustments to your manuscript and accompanying files. The reviewers comments have been responded to appropriately and comprehensive information provided if a change was not made.

Reviewer #3: The paper is well-written, the study rigourous, and will make a significant contribution to the literature. I have one outstanding comment related to my earlier review:

• Comment #10: I appreciate the explanation of the reliance on the definitions of effectiveness provided by the authors’ of the studies included in the review. I believe this is important to note in the actual manuscript.

Reviewer #4: Thank you for the opportunity to review the revised version of this manuscript. The authors have satisfactorily addressed the comments on the previous version. This manuscript will be a useful addition to the clinical supervision literature and I look forward to seeing it published.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Brett Vaughan

9 Nov 2021

PONE-D-21-20050R1

Impact of clinical supervision on healthcare organisational outcomes: a mixed methods systematic review

Dear Dr. Martin:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

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on behalf of

Assoc Prof Shane Patman

Academic Editor

PLOS ONE