Copyright © eContent Management Pty Ltd. Contemporary Nurse (2010) 34(2): 258–266.

Superficial supervision: Are we

placing clinicians and clients at risk?
ANDREW GARDNER
School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, City
East Campus, Adelaide, SA, Australia

HELEN MCCUTCHEON
Deputy Head, Department of Clinical Nursing, University of Adelaide, Adelaide, SA, Australia

MARIA FEDORUK
School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, City
East Campus, Adelaide, SA, Australia

ABSTRACT
Mental heath nurses recognise the importance of professional boundaries and therapeutic relation-
ships and understand that clinical supervision is an important component to good clinical practice
and their ongoing professional development. This qualitative constructivist grounded theory research
has uncovered a potential risk in contemporary mental health clinical practice, where the desire
for expedient answers may compromise the outcome of formal structured supervision. The notion
of a new concept ‘superficial supervision’ and its implications for formal structured supervision are
explored.

Keywords: supervision; professional boundaries; mental health; grounded theory; mental health nursing

INTRODUCTION even have restrictions placed on their licence to

M ental health nurses are exposed to intense

levels of emotions in the work place such as
are problems involving therapeutic relationships
and professional boundaries which for many
mental health clinicians are an occupational haz-
ard (Simon, 1999). If a clinician breaches the
professional boundary in their clinical practice,
a vulnerable client may become even more vul-
nerable, feeling emotionally exposed or at risk,
and is likely to require additional counselling.
Furthermore a professional who has compro-
mised their practice by breaching a professional
boundary is likely to face a disciplinary pro-
cess (if the breach is exposed), they may also be
required to seek ongoing counselling and could
practice.
This paper reports on some early themes as
part of an ongoing qualitative study. The focus
of the interviews was how clinicians maintain
the professional boundary and hence protect the
therapeutic relationship, the interview time and
space has become the catalyst for deeper reflection
and structured time to discuss the subtleties of the
interpersonal relationship. Using a constructivist
grounded theory approach, this research exposes
new concepts in the area of therapeutic relation-
ships and professional boundaries that have not
previously been well described, such as: ‘therapeu-
tic friendliness’, which describes how clinicians
engage clients; and ‘superficial supervision’, where

258 CN Volume 34, Issue 2, February/March 2010

 Superficial supervision: Are we placing clinicians and clients at risk?
clinicians may not be engaging in thoughtful
reflective supervision as their perceived difficul-
ties have been resolved through informal conver-
sations with their colleagues.
Whilst these concepts and their associated
problems are being recognized by mental health
nurses it is evident that some of the more subtle
issues are not being discussed in formal clinical
supervision; despite most mental health profes-
sionals identifying that formal clinical supervi-
sion is an important part of their professional
development.
This paper provides some insights into new
emerging concepts from recent interdisciplinary
research and will question whether we practice
superficial supervision that places mental health
nurses and perhaps even clients at risk.
LITERATURE REVIEW
Mental health nurses and other mental health clini-
cians work with a particularly vulnerable group of
clients, and are generally speaking highly regarded
in the community as a group of trusted profes-
sionals (Roy Morgan Research, 2007). However
each year regulators investigate complaints and
in some cases impose sanctions when clinicians
have breached the professional boundary. Table 1
provides a snap shot of complaints made to the
various professional bodies or to the Health and
Community Services Complaints Commission in
Australia during 2006–2007. Information con-
tained in the table was sourced from the various
annual reports.
The different reporting systems used by
each regulatory body uses resulted in very dif-
ferent numbers being represented in the table
above. For example, Health Care Complaints
Commission in NSW received a total of 589
complaints. The aggregated data is not broken
down into discipline specific complaints or the
nature of the complaint for example sexual mis-
conduct or misappropriation of funds for exam-
ple. However, the Nursing and Midwifery Board
of NSW reports data more specifically indicat-
ing that six complaints regarding professional
Volume 34, Issue 2, February/March 2010
CN
boundary issues were received during the report-
ing period 2006–2007.
Social Work is currently not regulated in
any State or Territory of Australia, hence there
are no figures available for this profession. In
addition Occupational Therapists are not regu-
lated in some states and territories in Australia.
Further complicating the data is the fact that the
Health Complaints Commission (vis-à-vis Health
Service Complaints Commissioner, or Health
Care Complaints Commission, or Health Quality
and Complaints Commission, or Human Rights
Commission), often do not separate complaints
into the different professional groups hence there
are gaps in the information and consequently
some data is not available for certain professional
groups.
The issues surrounding the therapeutic rela-
tionship and boundaries are an area of professional
concern for all mental health clinicians including
mental health nurses. Professional boundaries,
therapeutic relationships and the underlying eth-
ics and principles that inform each discipline’s
understanding of the professional boundary are
consistently reported in the literature (Gabbard,
1999; Lamb & Moorman, 1998; Martinez, 2000;
Nadelson & Notman, 2002; Scopelliti et al.,
2004; Strom-Gottfried, 1999; Williams, 1997).
Mental health clinicians recognise that profes-
sional boundaries provide the limit of the thera-
pist/client relationship, as well as providing a ‘safe
space’ for the interaction between the therapist
and the client. However a universal definition of
the concept does not exist (Chadda & Slonim,
1998).
The concept of a professional boundary can
be considered as a psychological space or distance
between individuals. This space helps define the
clinician’s position of anonymity, neutrality and
objectivity (Scopelliti et al., 2004). The estab-
lishment of a boundary is necessary to provide
a foundation for the therapeutic relationship in
which safety and trust can develop (Smith &
Fitzpatrick, 1995). However, this boundary is
clearly not visible, it is in effect a social construct.
CN 259
CN Andrew Gardner, Helen McCutcheon and Maria Fedoruk

TABLE 1: COMPLAINTS AND INVESTIGATIONS AS REPORTED BY THE AUSTRALIAN REGULATION AUTHORITIES ANNUAL
REPORTS 2006–2007, AND HEALTH SERVICES/COMPLAINTS COMMISSIONER REPORTS
Health Medical Nursing & Occupational Psychology
complaints midwifery therapy
commission

Australian 283 complaints 9 complaints 3 boundary Information not Complaints

Capital unethical violation available referred to
Territory improper complaints Human Rights
conduct Commission
New South 589 issues of 17 doctors 6 complaints Information not 71 complaints
Wales professional referred to professional available received about
conduct raised Professional boundary psychologists
in complaints Standards issues
Committee
Northern 94 complaints Do not publish Do not publish Do not publish Do not publish
Territory independent independent independent independent
reports reports reports reports
Queensland 2922 17 11 new formal 1 complaint 17
complaints 38 Investigations investigations under investigations
investigations inappropriate investigation of
conduct/ unprofessional
relationship conduct
South Australia 55 complaints 34 complaints 41 formal 1 formal 3 formal
unprofessional unprofessional proceedings investigation of investigations
conduct nature, sexual unprofessional 1 outstanding
misconduct conduct matter
Tasmania 16 18 31 cases Information not Information not
misconduct 5 unprofessional ‘Management available available
unprofessional 1 sexual of Professional
conduct misconduct Conduct’
complaints complaints
Victoria 63 complaints 23 conduct 4 49 Information not 7 psychologists
formally sex misconduct unprofessional available determined
referred to 2 personal behaviour 5 sex unprofessional
Regulatory conduct misconduct conduct
Boards
Western 1470 153 complaints 31 complaints 1 new 10 cases of
Australia complaints under complaint no unprofessional
investigation further action conduct

Martinez (2000) described these ‘boundaries’, as a
construct that helped facilitate discussions about
clinical and ethical issues in the professional client
relationship.
Boundary maintenance is a significant issue
for all the helping professions including psy-
chology, general medicine, psychiatry, nurs-
ing and social work (Gabbard, 1999; Lamb &
Moorman, 1998; Martinez, 2000; Nadelson
& Notman, 2002; Scopelliti et al., 2004;
Strom-Gottfried, 1999; Williams, 1997). The
uncertainty about boundaries, what they are,
how to create and maintain boundaries, and
the inherent differences in opinion amongst the
professions, expert opinion and regulators as to
what constitutes a boundary crossing only adds
to the confusion.
Boundary maintenance is a complicated
and vexed issue with health professionals who
in general have a lack of understanding about

260 CN Volume 34, Issue 2, February/March 2010

 Superficial supervision: Are we placing clinicians and clients at risk?
boundary theory (Collins, 1989) and the
dynamics involved in boundary negotiation.
Simon (1999) has suggested that problems
involving the professional relationship and the
therapeutic boundary are an occupational haz-
ard for those professionals who work in the area
of mental health. Recent changes to mental
health care practices and a more informed con-
sumer may have also contributed to these prob-
lems (Galletly, 2004).
Over the last 10 years, mental health care in
Australia has undergone a number of changes
most notably being the movement towards rec-
ognising the client as a customer and expert
‘knower and manager’ of their own condition.
Today’s mental healthcare consumers are more
informed of their own healthcare needs; have
unprecedented access to information; are less tol-
erant of the professional as knowledgeable expert,
and are more aware of their rights as consum-
ers. Hence mental healthcare services have had
to adopt a more consumer focussed approach to
care and adapt to consumer expectations about
health care. These changes, combined with time-
poor professionals and consumers who are more
informed and have greater demands of service
providers, may have contributed to some of
the blurring of boundaries between the client
and the professional. Medicine for example has
deliberately become less formal, urging doctors
to foster respectful relationships rather than
adhering to rigid rules (Galletly, 2004). A less
formal approach to the relationship potentially
creates situations that reduce clarity about treat-
ment boundaries for both health professionals
and their clients.
RESEARCH METHODOLOGY
This research project utilised a constructivist
grounded theory approach informed by Charmaz
(2006). Grounded theory as a methodology is a
research approach derived from social construc-
tivism and symbolic interactionism (Blumer,
1969; Bowers, 1988; Denzin & Lincoln, 1994;
Mead, 1932). Symbolic interactionists view
Volume 34, Issue 2, February/March 2010
CN
reality as a social construct, that the individual
is a socially constructed being and that we make
sense of our world and develop shared under-
standings through the social process of interac-
tion with others.
When using a constructivist approach the
researcher is required to adopt a position of
mutuality recognising the interrelationship or
partnership between the researcher and the par-
ticipant (Mills, Bonner, & Francis, 2006). Mental
health clinicians recognise that the therapeutic
encounter is based on a similar partnership and
has reciprocal rewards. Whilst the intention of
the relationship is for the therapist to assist the
client back to wellness, there is also the poten-
tial through every therapeutic encounter for the
therapist to learn more about their craft and
through reflection to learn more about himself
or herself as a therapist. Charmaz’s perspective
(2006) shares this view, in that she recognises
that the researcher cannot be distanced from the
participants, acknowledging that the researcher
is connected and develops more understanding
of the phenomenon under study with each per-
son being interviewed.
METHOD
The researcher initially met with discipline seniors
to seek support for the research endeavour. Once
this was achieved the researcher arranged to meet
with the various rehabilitation teams at the local
work sites during the usual team meetings to dis-
cuss the research in more detail. If teams were
interested in participating in the research a future
date was arranged when the researcher would
be present with the team and would conduct
interviews throughout the day. Written material
(including electronic versions), explaining the
research aims and an invitation to be interviewed
was also left with the team managers for further
distribution in case other team members were not
present.
Interview participants (n = 15) self selected
(volunteered to be interviewed), and approached
the researcher to negotiate a time and place
CN 261
CN Andrew Gardner, Helen McCutcheon and Maria Fedoruk
for the interview. Data collection involved
face-to-face intensive interviews (Charmaz,
2006), over about 1 h. Interviews were recorded
using an MP3 recorder and later transcribed.
Field notes were written during the interviews
to record the researcher’s thoughts and impres-
sions during the interviewing process, and as
a reminder to follow-up on certain points for
further clarification. Transcriptions were coded
with the assistance of NVIVO for data manage-
ment purposes. The researchers own memos
also formed part of the data for analysis due to
the reflexive nature of constructivist grounded
theory.
DATA ANALYSIS
Data analysis was conducted throughout the
research using constant comparative analysis. The
process of coding included three phases: initial
coding; focused coding; and theoretical coding.
Data analysis methods used in the grounded
theory approach require the researcher to group
and code pieces of data to assist in further analysis
of the concepts that emerge. Data collection and
analysis were conducted simultaneously with each
interview informing the next set of interviews as
more and more data was analysed. Emerging cat-
egories were analysed and further developed as
more data was collected. Major categories then
emerge and are able to be identified and through
the process of theoretical sampling can be further
explicated.
Throughout the research Memos were
recorded by the researcher to capture analytical
thoughts as codes and categories were considered
and to record initial theoretical ideas. Memo
writing is a continuous process throughout the
research and is considered a pivotal activity in
grounded theory as it prompts the researcher
to consider data and codes early and through-
out the research process. Engaging with the
data at an early stage in order to record memos
also assists in determining which directions
might be useful to pursue in subsequent data
262 CN Volume 34, Issue 2, February/March 2010
collection episodes (Charmaz, 2006). However,
memo writing also assists the researcher to take
time out from data collection to record initial
theoretical ideas and to capture the analytical
thoughts as codes and categories are considered.
Revisiting memos over time and recording new
thoughts and insights is a recognised strategy
in the process of constructing and refining
theoretical perspectives in the grounded theory
approach (Charmaz, 2006).
ETHICS
Human research ethics approval was granted by
the University of South Australia human research
ethics committee. Once this was obtained addi-
tional approval was sought to conduct the
research through the health service research ethics
committee. Interview participants were provided
with information demonstrating the research eth-
ics approval from both the University and the
health service. Although the researcher was a pre-
vious Director of Nursing in the state where the
research was conducted, interview participants
did not have any previous working relationship
with researcher.
EMERGING RESULTS
All interview participants articulated the benefits
of clinical supervision and the belief that super-
vision is an important part of clinical practice
and their ongoing professional development.
Supervision has been broadly described by the
research participants as having two dimensions.
Formal Structured Supervision (FSS), which
occurs on a regular scheduled basis, it is formal
and structured, and most often is a one to one
relationship with a supervisor, that can be of the
same or different discipline, depending on local
policy or perceived need of discipline specific or
specialised knowledge. Other examples of group
supervision have been noted but most often in
the case of this research it was on a one to one
basis. Research participants also described the
value of informal supervision on an ad hoc basis,
 Superficial supervision: Are we placing clinicians and clients at risk?
which seems to take place in the form of corri-
dor conversations, when there is an important
need to ‘check something out’. This practice is
occasionally referred to in the literature as pro-
fessional consultation (Gonsalvez & McLeod,
2008). However professional consultation is
usually more formal than just a casual corridor
conversation.
A quickly and then you need to just reflect on it.
It happens both formally and informally, I
do have a supervisor that I catch up with on
a regular basis, but they don’t work in the
same team as me. So if something happened
like for something like this I would probably
informally go and talk to one of my colleagues
around it, to have a general discussion around
how I might address this.
The above quote elucidates the need for clini-
cians not only to have FSS but to also have access
to a variety staff for professional consultations to
discuss critical issues at various times of day. The
interview participant clearly denotes the differ-
ence between formal supervision with a ‘super-
visor’ and an informal process ‘general discussion’
with colleagues. The informal process is used to
resolve clinical issues by having a general discus-
sion with colleagues.
Formal structured supervision is highly
regarded (Norcross, Hedges, & Castle, 2002) by
professional staff from all disciplines (Muijen,
1997), and is considered to be the most valu-
able in terms of professional growth and devel-
opment. It is seen by clinicians as a structured
space for sorting through some difficult cases or
issues that have arisen in the course of clinical
practice. The following quote further explicates
the need for structured time that is set aside
which allows for ‘time out’ to reflect practice
based issues. This sort of FSS occurs at a pre-
determined time, in a ‘formal setting’, and is
clearly seen as a positive experience by the next
interview participant.
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CN
K1
Being a formal process it is more regular, you
have this structured time, so it falls due at a
certain date, you can sit and reflect on your
practice. Informally it will only come up if
you feel there is a problem of if there is a need
for it. If you see it then you can bring it up.
So being in a formal setting, it comes around
So I think it is more a positive thing.
Research participants reported that sometimes
FSS does not happen it gets cancelled. Or it is
not valued by the organisation, as time is not set
aside to provide supervision during paid time.
Another issue that has been identified is that
organisational policies may exist that enforces
clinical supervision with the line manager. Some
staff do not see this as being the best way to
progress FSS. One clinician in particular stated
that they seek FSS outside of the organisation
for this reason:
R
Most of my supervision in the last few years has
been external to the service with an ex colleague.
This particular clinical supervision relation-
ship was seen as being extremely valuable as there
was no formal management relationship. The
meetings were conducted outside of normal busi-
ness hours so there was no pressure felt to return
to the coal face, and there was a level of mutual
recognition of each other’s needs for continuing
professional and personal development. The rela-
tionship is formal and structured even though the
meetings did not occur strictly within the con-
fines of the organizational setting.
DISCUSSION
Clinical supervision has its history in psy-
choanalysis training with a focus on teaching
and analysis of the trainee (Buckley, Conte,
Plutchick, Karasu, & Wild, 1982). However
there is a lack of empirical evidence (Winstanley
CN 263
CN Andrew Gardner, Helen McCutcheon and Maria Fedoruk
& White, 2002) that supports FSS as necessarily
improving client outcomes. In addition there is a
lack of evaluation of the effectiveness of supervi-
sion practice (Gonsalvez & Freestone, 2007), in
terms of developing an evidence-based approach
to clinical supervision, despite a long history of
its use and a variety of models currently being
used.
There exists an assumption that when clini-
cians do engage in FSS that they are doing so
for the right reasons and that they are not just
doing it because they have to, for example pay-
ing lip service to the process. Additionally there
is also an assumption that allocated supervisors
are skilled and educated in the fine art of clinical
supervision, teaching, consultancy and counsel-
ling (Bernard, 1997) let alone evaluation of the
supervision process it self.
Whilst there are almost as many models of
supervision as there are approaches to psycho-
therapy (Bernard & Goodyear, 2004), the tradi-
tional nature of FSS may pose some additional
problems for the now generation as – we desire
to have answers now and we need to fix it now.
Perhaps this may shed some light on the need for
clinicians to seek instant advice and support, or
to work out the best approach through a profes-
sional consultation. For example, the following
quote acknowledges that professional consulta-
tion is sometimes more valuable than formal
supervision.
R Like I call informal like at the end of the day
So it is a recognition of I am not quite sure
what to do here and I need some advice, some
support, to be able to talk it through to work
out the best approach. I think supervision
is on a continuum, there is a lot of supervi-
sion that happens in the corridors that is very
informal and at times probably more valu-
able than the formal supervision. Informal
supervision is just as important, a good five
minute chat in the corridor is sometimes as
valuable if not more valuable in an immedi-
ate crisis.
264 CN Volume 34, Issue 2, February/March 2010
This type of professional consultation, which
seems to sustain collegial relationships, in that
there is some recognition of mutual support, has
probably existed in some form or another for quite
some time. However, it may be that this practice
is now more influenced by the risk minimisation
movement and the threat of the litigious environ-
ment in which we practice. Or it may be a sign of
the times, where we need instant answers, reassur-
ance and affirmation of our practice. Perhaps the
very nature of contemporary mental health prac-
tice with time poor professionals and greater con-
sumer demands may also be having an impact on
the need for clinicians to seek expedient answers
or assurance from their colleagues. Therefore it is
conceivable that socio-political environment in
which mental health clinicians practice could also
be influencing the nature of both informal, in the
way of professional consultations and FSS.
SUPERFICIAL SUPERVISION
Whilst it is understandable that clinicians utilise
the quick fix professional consultation to ‘check
things out’ to ‘seek advice’ and to ‘debrief ’, there
are implications for the casual corridor conversa-
tions, or supervision on the run as they are tran-
sient and superficial in nature. The following
quote identifies that informal supervision also
includes the end of the day debrief.
K2
or after an issue or something just checking it,
running it past the other staff that were there,
debriefing basically.
This sort of debriefing has its place but it can-
not be seen as quality supervision. Clearly this
interview participant interpreted debriefing as an
informal process. What are the implications of
this informal approach in terms of good clinical
supervision practice? When clinicians engage in
‘informal supervision’ contracts and norms are
not established, it is not a formalised process; it
is without structure and does not allow for deep
 Superficial supervision: Are we placing clinicians and clients at risk?
reflection on practice. In addition a casual con-
sultation does not allow the ‘supervisor’ to assess
and explore subtle cues such as the clinicians use
of specific narrative and body language. There is
the risk of missing important details and nuances
in the therapeutic relationship, perhaps even the
avoidance of some issues, glossing over others
or not covering certain points in more depth as
the need for expedient validation of practice is
required. Hence the term superficial supervision
is used here to describe and name this process as
being superficial in nature.
The expedited resolving of ‘clinical issues’ has
the potential to water down the need to explore
subtle distinctions in the interpersonal (therapeu-
tic) relationship in more detail, which should be
discussed thoroughly in FSS. This then has the
potential to lead to FSS taking on a superficial
nature as the perception is that everything is OK
because crisis have been averted through the use
of convenient answers sourced from obliging
colleagues.
Through the interview process clinicians have
reflected on how they maintain the professional
boundary; they have discovered that they had not
previously thought of some issues and additionally
had not discussed these issues during FSS. As the
focus of the interview was around maintenance of
the professional boundary and protection of the
therapeutic relationship, the interview time and
space has become the catalyst for deeper reflection
and structured time to discuss the subtleties of the
interpersonal relationship, without the complica-
tions of a supervisory relationship.
S Boston: Pearson.
In my own discipline … I don’t think it is
so clearly, it is not emphasized so strongly.
What we are on about is more of a technical
process of change and motivating the client.
Whereas to me support is pretty important
in life and so on. I think I need therapy after
this session.
Whilst these concepts and their associated
problems are being recognized by mental heath
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CN
clinicians it is evident that some of the more sub-
tle issues are not being discussed during clinical
supervision. This interview participant recognized
that there were areas of practice that could be
improved upon and that the process of the inter-
view had stimulated much greater reflection on
certain areas of practice, hence the final comment
about the need to seek therapy after the interview
session was completed.
CONCLUSION AND IMPLICATIONS FOR
PRACTICE
The contemporary nature of mental health nurs-
ing practice may have an influence on the way
mental health clinicians practice and the way they
seek collegial support and advice. However, the
desire for expedient answers must be balanced
with the need for a more formalised approach to
clinical supervision. Whilst professional consulta-
tions with obliging colleagues serve a purpose, we
must not let the expedient nature of contempo-
rary mental health practice water down the need
for and value of quality FSS.
The next time a colleague wants a quick profes-
sional consultation, whilst we might be happy to
indulge and share our wisdom, perhaps we should
also be placing a caveat on our advice, that our
colleague should ensure that whatever the reason
for the professional consultation the issues should
be explored in more detail and greater depth dur-
ing their next FSS session.
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Received 12 March 2009 Accepted 21 January 2010
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