PLOS ONE

RESEARCH ARTICLE

Impact of clinical supervision on healthcare

organisational outcomes: A mixed methods
systematic review
Priya Martin ID1,2*, Lucylynn Lizarondo3, Saravana Kumar4, David Snowdon5,6

1 Senior Research Fellow, Rural Clinical School, Faculty of Medicine, The University of Queensland,
Toowoomba, QLD, Australia, 2 Advanced Clinical Educator Interprofessional, Advance Queensland Industry
Research Fellow, Cunningham Centre, Darling Downs Health, Toowoomba, QLD, Australia, 3 Research
Fellow: Implementation Science, Joanna Briggs Institute, The University of Adelaide, Adelaide, SA, Australia,
4 Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia, 5 Research
a1111111111 Fellow, Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, VIC, Australia,
a1111111111 6 Allied Health Research Lead, Academic Unit, Peninsula Health, Melbourne, VIC, Australia
a1111111111
a1111111111 * Priya.Martin@uq.edu.au
a1111111111

Abstract

OPEN ACCESS Objective

Citation: Martin P, Lizarondo L, Kumar S, To review the impact of clinical supervision of post-registration/qualification healthcare pro-
Snowdon D (2021) Impact of clinical supervision
fessionals on healthcare organisational outcomes.
on healthcare organisational outcomes: A mixed
methods systematic review. PLoS ONE 16(11):
e0260156. https://doi.org/10.1371/journal. Background
pone.0260156
Clinical supervision is a professional support mechanism that benefits patients, healthcare
Editor: Shane Patman, University of Notre Dame professionals and healthcare organisations. Whilst evidence is growing on the impact of
Australia, AUSTRALIA
clinical supervision on patient and healthcare professional outcomes, the evidence base for
Received: June 22, 2021 the impact of clinical supervision on organisational outcomes remains weak.
Accepted: November 3, 2021
Methods
Published: November 19, 2021
This review used a convergent segregated approach to synthesise and integrate quantita-
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review tive and qualitative research findings, as per the Joanna Briggs Institute’s recommendations
process; therefore, we enable the publication of for mixed methods systematic reviews. Databases searched included CINAHL, Embase,
all of the content of peer review and author PubMed, PschINFO, and Scopus. Whilst a narrative synthesis was performed to present
responses alongside final, published articles. The
the findings of the quantitative and qualitative studies, the evidence from both quantitative
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0260156 and qualitative studies was subsequently integrated for a combined presentation. The
review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and
Copyright: © 2021 Martin et al. This is an open
access article distributed under the terms of the Meta-Analyses.
Creative Commons Attribution License, which
permits unrestricted use, distribution, and Results
reproduction in any medium, provided the original
author and source are credited. Thirty-two studies including 27 quantitative, two qualitative and three mixed methods stud-
ies, were included in the review. The results of the quantitative analysis showed that effec-
Data Availability Statement: All relevant data are
within the manuscript and its Supporting tive clinical supervision was associated with lower burnout and greater staff retention, and
Information files. effective supervisor was associated with lower burnout and greater job satisfaction.

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Funding: The authors received no specific funding Qualitative findings showed that healthcare professionals believed that adequate clinical
for this work supervision could mitigate the risk of burnout, facilitate staff retention, and improve the work
Competing interests: The authors have declared environment, while inadequate clinical supervision can lead to stress and burnout. The evi-
that no competing interests exist. dence 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 organi-
sations to invest in high quality supervision practices if maximal gains from clinical supervi-
sion 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]. Opera-
tionally, 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 defi-
nition 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 col-
league/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 ten-
tative [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 dif-
ficult given the challenges in defining organisational outcomes and the overlapping nature of
patient, health professional and organisational outcomes. For example, improved patient out-
comes (e.g. improved morbidity and mortality) can satisfy multiple targets for healthcare orga-
nisations, 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

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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 work-
force outcomes considered staff turnover and job satisfaction [10]. Other organisational out-
comes 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. Further-
more, 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:
1. What are the effects of clinical supervision of healthcare professionals on organisational
outcomes?
2. What are healthcare professionals’ experiences, views, and opinions regarding clinical
supervision as it relates to organisational processes and outcomes?
3. 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 super-
vision 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

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

qualitative study, explored health professionals’ experiences, views, or opinions regarding clin-
ical supervision as they relate to organisational outcomes.

Search strategy
As means of avoiding publication and location bias, the search strategy was developed to iden-
tify 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 Sco-
pus. 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 litera-
ture) 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 iden-
tify 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 con-
sensus. 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 transla-
tion 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.

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 trustworthi-
ness, 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, fre-
quency, duration), study design, setting, clinical supervision characteristics, outcomes mea-
sured, and results related to the organisational outcomes. For the qualitative component, data
were extracted from qualitative and mixed methods studies (qualitative component only) and

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Fig 1. Flow diagram of included studies.

https://doi.org/10.1371/journal.pone.0260156.g001

included specific details about the supervisee and supervisor characteristics (sample size, pro-
fession, 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

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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 accompa-
nied 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 extrac-
tion 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 partici-
pants. 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-aggre-
gation 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. catego-
ries) 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 find-
ings was conducted via a consensus process between the reviewers (LL and PM).
The findings of each single method synthesis were juxtaposed and examined for conver-
gence/divergence and complementarity. To explore the relationship across individual synthe-
ses, 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,

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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 clini-
cal 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], com-
munity 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 stud-
ies 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 supervi-
sion 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 environ-
ment [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.

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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 Acute hospital Nursing Nursing Group Weekly— 90 Work environmenta
Quasi- medical wards 11 to 18 years Fortnightly minutes
experimental (Sweden)
pre/post n = 34
Begat 2005 Quantitative Acute hospital Nursing N/S Group Fortnightly N/S Well-Beinga
Quasi- medical wards 9 years Work Environment
experimental (Norway)
cross sectional n = 71 WEQ

Ben-Porat Quantitative Domestic violence Social Work N/S N/S N/S N/S Burnout
2011 Cross sectional and women’s shelters 11 years Burnout
(Israel) Questionnaire
n = 143
Berg 1994 Quantitative Psychogeriatric Nursing Nursing Group Fortnightly– 120 Burnout
Quasi- hospital (Sweden) 11 years every third minutes MBI
experimental week
pre/post n = 39 Job Satisfaction
Satisfaction with
Nursing Care
Well-being
Tedium Measure
Work Environment
CCQ
Berg 1999 Quantitative Psychiatric hospital Nursing Nursing Group Fortnightly 180 Job Satisfaction
Quasi- (Sweden) 14 years minutes SNCW
experimental
pre/post n = 22 Well-being
SOC
WRSI
Work Environment
CCQ
Berry 2019 Quantitative Psychiatric hospital Nursing N/S N/S N/S N/S Burnout MBI
Cross sectional (UK) N/S
n = 137
Best 2014 Quantitative Alcohol and drug Social Work/ N/S Individual Fortnightly– N/S Work Environment
Cross sectional community service Psychology/ monthly
(Australia) Counselling
56% > 10 years Organizational
n = 43 Readiness for Change
Assessment
Cooper- Quantitative Mental health settings Social Work/ N/S Individual 55% less than 82% >30 Burnout
Nurse 2018 Quasi- (USA) Psychology/ face-to-face once per minutes MBI
experimental Counselling +/- over week
cross sectional N/S phone/online Job Satisfaction
n = 60 AJDI
(Continued )

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Table 1. (Continued)

Study Design Setting Participants Supervision Outcomes

(Quantitative) OR
Interview questions
(Qualitative)
(country) Supervisee Supervisor Type Frequency Duration
Profession Profession
Work Experience,
mean
n
Ducat 2016 Qualitative Rural and regional Social work/ N/S Individual N/S N/S Interview question
Qualitative areas (Australia) Nutrition/Dietetics/
descriptive Occupational
Therapy/
Physiotherapy/
Speech pathology/
Medical radiation/
Psychology
N/S What effect has CS
n = 42 had on your practice
(if any)?
Edwards Quantitative Community mental Nursing N/S Individual, 57% monthly 32% >60 Burnout
2006 Cross sectional health (UK) 52% <5 years group or minutes MBI
combination
n = 260
Eklund 2000 Quantitative Acute and Occupational Occupational N/S N/S N/S Job Satisfaction
Quasi- community Therapy Therapy/Social
experimental psychiatric care N/S Work/ Job Satisfaction
cross sectional (Sweden) Psychology Questionnaire
n = 291 Nursing/
Medical
Fischer 2013 Quantitative Acute Hospital (Italy) Physiotherapy N/S Individual or N/S N/S Burnout
Quasi- 13 years group MBI
experimental
cross sectional n = 132
Gonge 2011 Quantitative Psychiatric hospital Nursing Psychiatry/ Group Every two 90 Burnout
Cross sectional wards and Psychology months minutes MBI
community mental
health centres Job Satisfaction
(Denmark) N/S CPQ
Well-being
CPQ
n = 145 SF-36
Hallberg Quantitative Paediatric psychiatric Nursing Nursing Group Every third 120 Burnout
1994 Quasi- ward (Sweden) week minutes MBI
experimental
pre/post Job Satisfaction
15 years Satisfaction with
Nursing Care
n = 11 Well-being
Tedium Measure
Hussein Quantitative Acute hospital Nursing N/S N/S N/S N/S Job Retention
2019 Cross sectional (Australia) 1 year Modified Nurse
n = 87 Retention Index

(Continued )

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Table 1. (Continued)

Study Design Setting Participants Supervision Outcomes

(Quantitative) OR
Interview questions
(Qualitative)
(country) Supervisee Supervisor Type Frequency Duration
Profession Profession
Work Experience,
mean
n
Hyrkäs 2005 Quantitative Acute hospitals Nursing Nursing/ Individual or 67% every 34% 60 Burnout
Cross sectional (Finland) 57% > 10 years Psychology group three weeks minutes MBI
or monthly duration
n = 569 Job Satisfaction
Minnesota Job
Satisfaction Scale
Kavanagh Quantitative Hospital and Social Work/ N/S Individual, Monthly 120 Job Satisfaction
2003 Cross sectional community mental Psychology/ group or minutes
health settings Occupational combination
(Australia) Therapy/ Speech
Therapy
8 years Hoppock Job
n = 199 Satisfaction Measure
Koivu 2012 Quantitative Acute hospital Nursing N/S Group Every 3 or 4 90 Burnout
Quasi- medical and surgical 15 to 17 years weeks minutes MBI-GS
experimental wards (Finland)
cross sectional n = 304 Well-being
GHQ-12
Work Environment
QPSNordic
Livini 2012 Quantitative Drug and alcohol Nursing/ Nursing/ Individual, 2 to 8 70 to 480 Burnout
Quasi- service (Australia) Psychology/Social Psychology group or sessions over minutes MBI
experimental Work/Counselling combination 6 months
pre/post Job Satisfaction
N/S IJSS
n = 42 Well-being
Scales of psychological
well-being
Long 2014 Quantitative Mental Health Nursing N/S Individual, 23% monthly N/S Well-being
Cross sectional Hospital (UK) 28% > 7 years group or BCS
combination
n = 128
Love 2017 Quantitative Hospital and Nursing N/S Individual, N/S N/S Job Satisfaction
Quasi- community maternity 17 years group or NSWQ
experimental services (Australia) combination Interview questions
cross sectional n = 108
Qualitative What can you tell me
Qualitative about your overall
descriptive 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?
(Continued )

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Table 1. (Continued)

Study Design Setting Participants Supervision Outcomes

(Quantitative) OR
Interview questions
(Qualitative)
(country) Supervisee Supervisor Type Frequency Duration
Profession Profession
Work Experience,
mean
n
McAuliffe Quantitative Obstetric care settings Nursing/Medical N/S N/S N/S N/S Job Retentiona
2013 Quasi- (Africa) N/S Job Satisfaction
experimental
cross sectional Cohort 1 n = 540 Job Satisfaction Scale
Cohort 2 n = 541
Cohort 3 n = 480
McCarron Quantitative Psychiatric hospital Nursing N/S N/S N/S N/S No relevant outcomes
2017 (Not included in (UK) Cohort 1, 8.5 years
the review) n = 20
Qualitative
Grounded Cohort 2, 6.5 years Interview questions
theory n = 30 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 Quantitative Hospital and Social work Social work Individual or N/S N/S Job Satisfactiona
1992 community services 50% � 3 years group
(USA)
n = 196
Saxby 2016 Quantitative Community health Dietetics/Social N/S Individual or N/S N/S Burnout
Cross sectional service (Australia) Work/ group MBI
Qualitative Physiotherapy/
Qualitative Podiatry/ Job Retention
descriptive Occupational Intention to Leave
Therapy/ Scale
Psychology/Speech
Therapy
57% > 10 years Interview questions
n = 82 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?
(Continued )

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Table 1. (Continued)

Study Design Setting Participants Supervision Outcomes

(Quantitative) OR
Interview questions
(Qualitative)
(country) Supervisee Supervisor Type Frequency Duration
Profession Profession
Work Experience,
mean
n
Schroffel Quantitative Mental health service Social Work/ N/S Individual or Weekly 71% > 30 Job Satisfaction
1999 Cross sectional (USA) Counselling/ group minutes
Nursing/
Psychology
16 years JDI
n = 84 JIG
Severinsson Quantitative Psychiatric hospital Nursing Nursing Group Weekly 90 Work Environmenta
1996 Cross sectional (Sweden) 10 years minutes
n = 26
Severinsson Quantitative Acute hospital Nursing N/S N/S N/S N/S Work Environment
1999 Quasi- (Sweden) N/S Work Environment
experimental Measure
cross sectional n = 158
Teasdale Quantitative Acute hospital and Nursing N/S Individual, N/S N/S Burnout
2001 Quasi- community health 14 years group or MBI
experimental settings (UK) combination
cross sectional n = 211 Work Environment
Nursing in Context
Questionnaire
Wallbank Quantitative Acute hospital Nursing/Medical Psychology Individual N/S 60 Burnout
2010 Randomised obstetrics and N/S minutes ProQol
controlled trial gynaecology (UK)
n = 30 Well-being
IES
ProQol
Webster Quantitative Community mental Social Work/ N/S N/S N/S N/S Burnout
1999 Cross sectional health services (USA) Medical/
Psychology/
Counselling/
Nursing
N/S MBI
n = 151
White 1998 Qualitative Community, medical Nursing Nursing Individual or N/S N/S Interview
Qualitative ward, paediatric ward, N/S group Questions
descriptive management, School
of Nursing, A&E N = 12 N/S
department,
gynaecology ward, GP
unit, residential care
(UK)

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.

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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 sup-
port 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 base-
line 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 compo-
nent 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 influ-
ence 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 con-
trol 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 pro-
fessionals [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 partici-
pants), and workplace environment (five studies, n = 783 participants). Notably, a single ran-
domised 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.
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-imple-
mentation [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 burn-
out (four studies, n = 122 participants) (Fig 3A–3D), job satisfaction (four studies, n = 114 par-
ticipants), 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.
3. Association between effective clinical supervision and organisational outcomes.
Eight studies, including 1,376 participants, investigated the association between effective clini-
cal supervision and organisational outcomes [37, 38–43, 52]. Five studies included nursing

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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.
https://doi.org/10.1371/journal.pone.0260156.g002

professionals [37, 39–42], three studies included social work/psychology/counselling profes-

sionals [38, 43, 52] and one study included other allied health professions [52]. There was pre-
liminary 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.
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 mod-
erate 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 supervi-
sor 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 asso-
ciated with burnout, and positively associated with job satisfaction (Table 3).
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 per-
sonal 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.
Synthesised finding 1: Adequate clinical supervision mitigates the risk of burnout and
facilitates staff retention, while inadequate clinical supervision can lead to stress and burn-
out. Health professionals indicated that if clinical supervision was adequate or if they felt

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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.
https://doi.org/10.1371/journal.pone.0260156.g003

supported the risk of experiencing burnout or leaving the workplace was less likely. Con-
versely, health professionals, who felt that their supervision was inadequate, reported that clini-
cal 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 clin-
ical 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 cate-
gory was supported by four findings:
1. Some respondents felt that inadequate supervision had no impact; however, others identi-
fied personal consequences in terms of stress and burnout, feeling unsupported and there
being an impact on their work, the ward, and clients. (Unequivocal)
2. Supervision assisted them to manage the workplace stress and hence, reduce their risk of
burnout. (Unequivocal)
3. 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)
4. Opportunity to debrief challenging events provided supervisees with validation of their feel-
ings 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.

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 Effect size
within study (number of
studies)
- 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.

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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 Effect size
(number of studies)
- 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.

https://doi.org/10.1371/journal.pone.0260156.t003

Table 4. Summary of qualitative findings.

Synthesised Findings Categories Findings Illustrations
Synthesised Finding 1 Category 1.1 Some respondents felt that inadequate supervision ‘I feel my confidence is affected.’ (RN 2016)
had no impact; however, others identified personal (McCarron et al 2017, p. 153)
consequences in terms of stress and burnout, feeling
unsupported and there being an impact on their
work, the ward and clients. (UNEQUIVOCAL)
Adequate clinical supervision mitigates Adequate CS mitigates the risk Supervision assisted them to manage the workplace ‘When I first started with my supervisor I was in a
the risk of burn out and facilitates staff of burn-out, while inadequate stress and hence, reduce their risk of burnout. really bad place. . . . and I was sort of at the point of
retention, while inadequate clinical CS can lead to stress and (UNEQUIVOCAL) no return, so getting my clinical supervision
supervision can lead to stress and burnout organized and constantly every month, that gave me
burnout. back my confidence.’ (Saxby 2016, p. 175)
Supervision was helpful for the worker to gain a ‘We’re exploring. . . . the impact of that particular
greater understanding of the dynamics operating in case on myself as a worker. . . .. it seems to make it
the client interaction to ensure there were no negative clearer and give me insight into different ways of
impacts for the worker or the client. looking at that particular person.’ (Saxby 2016,
(UNEQUIVOCAL) p. 175)
Opportunity to debrief challenging events provided ‘I was absolutely gob-smacked with this new reform
supervisees with validation of their feelings and that could be coming in and potentially what could
consideration of different management strategies to happen to me in terms of where I’m going to be
reduce their distress. (UNEQUIVOCAL) 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 ‘Yeah, it’s supportive and I guess it’s an indication
evidence that the health service management ‘cared the organization does care about us enough to push
about’ her and her colleagues and valued and wished that. . . .. and they want to keep their staff.’ (Saxby
to retain their workers. (UNEQUIVOCAL) 2016, p. 173)
Implementation of effective CS Supervisees’ responses illustrated that supervision did ‘Now I feel like I can still cope with what’s going on
facilitates staff retention and enhance job satisfaction and reduce workers’ and that to me was worth it because otherwise I
reduces their intention to leave intention to leave. (UNEQUIVOCAL) 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)
The supervisor played an active role in encouraging ‘I guess, encouragement, being encouraged to do
staff to undertake career developing activities. something, maybe something that you didn’t think
(UNEQUIVOCAL) 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)
(Continued )

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Table 4. (Continued)

Synthesised Findings Categories Findings Illustrations

Synthesised Finding 2 Category 2.1 Midwives felt the structure of a safe space for regular ‘For me personally it has helped with dealing with
CS enhances team relationships reflection offered them continual opportunities for conflict stuff, and people, or my own personal issues
through improved self-development especially in terms of enhanced with other people without ever having to involve
communication communication and improved working relationships. them, because it was me that was able to adjust
(UNEQUIVOCAL) things.’ (Midwife 6) (Love et al 2017, p.278)
CS improves the work environment Midwives used words such as ‘courage’, ‘confidence’ ‘I would have just been left in limbo with that
through boosting staff morale, motivation and ‘strength’ to describe how their CS sessions had situation and that person I think. So it enabled me
to work, staff well-being and team fostered in them an improved ability to engage in to actually look at the situation and address it with
relationships difficult conversations at work. (UNEQUIVOCAL) that person.’ (Midwife 2) (Love et al 2017, p.278)
Category 2.2 Midwives described feeling more positive about the ‘It really boosted morale and got people motivated.’
work environment with an increased desire to ‘give (Midwife 3) (Love et al 2017, p.278)
back’ to the unit. (CREDIBLE)
CS promotes staff morale, Prominent valuable outcomes of clinical supervision ‘I think if you affect staff morale, that in turn has
motivation to work and well- at the level of organization were the strengthened got to affect patient morale, because the staff has
being relationships with work colleagues, which on such a strong influence over the patients. . . If the
occasion was reported as a challenge for senior staff, staff member feels supported, feels as if they’ve got
and increased staff morale. (CREDIBLE) 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)
Enthusiasm, growth and organisational commitment ‘... we did an evaluation just when we had our face
were identified by supervisors and supervisees. to face meeting, she said that she’s more enthusiastic
(UNEQUIVOCAL) 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 ‘It’s made such a difference to me as a practitioner.
engaged in their roles of delivering health care It helps you stay really focused on why am I here
services. These features of supervision increased allied and it helps you stay focused on the positives that
health workers’ sense of connection to the employing you are getting all the time because they are easy to
organisation and decreased their intention to leave. forget about.’ (Saxby 2016, p. 171)
(UNEQUIVOCAL)
Receiving positive feedback was particularly valuable ‘It’s quite a supportive relationship, so your skills
for workers (at the time of data collection) as they and your experience are recognised and that’s quite
were experiencing high uncertainty in many areas important in the current environment when
including changes to their roles and the focus of the everything else is being questioned and changed all
service. Feedback from supervisors provided the time.’ (Saxby 2016, p. 172)
reassurance, as well as a sense of stability amid the
evolving occupational landscape. (UNEQUIVOCAL)
Supervision increased staffs’ sense of connection to ‘What it does bring is a sense of being connected to
the employing organisation, enabling supervisees to the broader organisation. To feel connected, it’s just
feel that they individually had a place within the to feel connected to, that somebody has a clue what I
organisation and therefore a sense of belonging to do, that somebody thinks it’s ok, that it’s not just me
something greater than their immediate and often floating around here hoping like crazy, I’m doing
atomized local environment. (UNEQUIVOCAL) 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, ‘... and, we really do need to ensure that our
patient safety and clinical governance were identified clinicians are doing the best practice, that they are
by managers, supervisors and clinicians. supported to develop the skills they need for the role
(UNEQUIVOCAL) they do, and to have someone to support them to do
that, not just measure them against it. . .’ (Ducat
et al 2016, p.32)

https://doi.org/10.1371/journal.pone.0260156.t004

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:

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

1. 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)
2. Supervisees’ responses illustrated that supervision did enhance job satisfaction and reduce
workers’ intention to leave. (Unequivocal)
3. 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 motiva-
tion 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 catego-
ries 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 work-
ing relationships. This category was supported by two findings:
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)
2. 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 environ-
ment. This category was supported by six findings:
1. Midwives described feeling more positive about the work environment with an increased
desire to ‘give back’ to the unit. (Credible)
2. 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 chal-
lenge for senior staff, and increased staff morale. (Credible)
3. Enthusiasm, growth and organisational commitment were identified by supervisors and
supervisees. (Unequivocal)
4. 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)

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

5. Receiving positive feedback was particularly valuable for workers (at the time of data collec-
tion) 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)
6. Supervision increased health professionals’ sense of connection to the employing organisa-
tion, 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 sup-
portive 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 asso-
ciation between effective clinical supervision and job satisfaction was unclear, evidence from
four studies showed a positive association of an effective supervisor with job satisfaction. Qual-
itative 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 associ-
ation 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 work-
place environment. However, qualitative evidence highlighted that effective feedback from
supervisors were considered valuable and improved supervisee perceptions of the work envi-
ronment 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

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

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 ade-
quate 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 proce-
dures, 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 clini-
cal 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 train-
ing 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 evalu-
ations. 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 supervi-
sion within organisations.
Healthcare organisations also need to support clinical supervisors to build and foster posi-
tive 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 supervi-
sors and supervisees to enhance the effectiveness of clinical supervision, such as the develop-
ment 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

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

attributed to the careful design and delivery of training across different modes, which maxi-
mised 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 parame-
ters) seems to continue to plague supervision research, as again found in the survey of supervi-
sion 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, randomisa-
tion, and data-driven case studies are used in conjunction with ex post facto, and cross-sec-
tional 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 health-
care settings and health professionals represented in this review, the majority of included stud-
ies 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 super-
vision and helps to unpack the black box of clinical supervision practices that have the most
effect on organisational outcomes, is required.

Supporting information
S1 Checklist. PRISMA checklist.
(DOC)
S1 Table. JBI critical appraisal checklist for randomised controlled trials.
(DOCX)

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

S2 Table. JBI critical appraisal checklist for quasi-experimental studies.

(DOCX)
S3 Table. JBI critical appraisal checklist for analytical cross sectional studies.
(DOCX)
S4 Table. JBI critical appraisal checklist for qualitative studies (including qualitative com-
ponent of mixed methods studies).
(DOCX)
S5 Table. Results of studies investigating the effect of clinical supervision on organisa-
tional outcomes compared to control (no supervision).
(DOCX)
S6 Table. Results of studies investigating the effect of clinical supervision on organisa-
tional outcomes pre/post implementation.
(DOCX)
S7 Table. Results of studies investigating the association between effectiveness of clinical
supervision and organisational outcomes.
(DOCX)
S8 Table. Results of studies investigating the association between an effective supervisor
and organisational outcomes.
(DOCX)
S1 Appendix. Search strategy.
(DOCX)
S2 Appendix. Excluded studies.
(DOCX)

Acknowledgments
The authors would like to thank Ms Esther Tian for assistance with the literature search.

Author Contributions
Conceptualization: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David Snowdon.
Data curation: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David Snowdon.
Formal analysis: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David Snowdon.
Investigation: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David Snowdon.
Methodology: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David Snowdon.
Project administration: Priya Martin.
Resources: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David Snowdon.
Validation: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David Snowdon.
Visualization: David Snowdon.
Writing – original draft: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David
Snowdon.

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PLOS ONE Impact of clinical supervision on healthcare organisational outcomes

Writing – review & editing: Priya Martin, Lucylynn Lizarondo, Saravana Kumar, David
Snowdon.

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