MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN A RURAL CONTEXT: AN EXPLORATORY STUDY OF EXPERIENCES IN NORTHERN BRITISH COLUMBIA by Anthony Muturi Kariuki B.S.W., University of Northern British Columbia, 2006 M.S.W., University of Northern British Columbia, 2011 DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN HEALTH SCIENCE UNIVERSITY OF NORTHERN BRITISH COLUMBIA March 15, 2021 © Anthony Kariuki, 2021 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC ii Abstract The purpose of this study was to better understand how multidisciplinary mental health supervision might work in rural remote settings. There is a need for supervisory approaches that address the unique contextual challenges in rural and remote multidisciplinary service delivery, such as management approaches, isolation, and lack of support. This study focused on three areas linked to multidisciplinary mental health supervision: challenges and opportunities, role perception, and differences in approaches. This study also attempted to reconcile the core supervisory requirements with the contextual challenges. The few studies on rural remote supervision have primarily focused on general internal and external factors facing rural remote professionals. Despite its importance, knowledge of how multidisciplinary rural remote supervisors perceive and/or appreciate their roles is limited. This study was informed by social construction and symbolic interaction theories, and guided by three research questions: 1) What challenges and opportunities do mental health supervisors experience in northern British Columbia? 2) How do frontline workers, supervisors, and senior managers perceive the roles and activities of mental health supervisors in northern British Columbia? 3) How are supervisory approaches in various mental health disciplines different or similar in northern British Columbia? The research methodology was qualitative and the study design adopted an interpretive, social interactionist approach. Source triangulation enhanced both the credibility and transferability of the findings. The sources included three participant groups: frontline mental health workers, mental health supervisors, and senior mental health managers. Another triangulation source was the context and setting review of BC’s complex mental health MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC iii jurisdictions. Triangulation was also achieved by interviewing participants who worked in different settings, organizations, and geographic locations. Thematic analysis was used for data analysis resulting in 11 manifest themes and the following five latent themes: Difficult, overwhelming responsibilities; stressful, complicated decision making; the endless campaign for professional leadership support; mentorship in remote practice; and a struggle in collaborative plurality. Most of the participants expressed the wish for more support in their professional work. The findings from this study provide employers with new insights into multidisciplinary supervisory work and also emphasize the need for practical and specific ideas for much needed support for rural remote supervisors. Keywords: remote, rural, multidisciplinary, mental health, supervision, BC MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC v Table of Contents Abstract ............................................................................................................................. ii Table of Contents ............................................................................................................... v Tables ................................................................................................................................ x Figures .............................................................................................................................. xi Glossary of Key Terms ................................................................................................... xiii Abbreviations ................................................................................................................ xvii Acknowledgements ......................................................................................................... xix Dedication ...................................................................................................................... xxi Chapter One: Introduction.................................................................................................. 1 Preamble ........................................................................................................................ 1 My Place Within the Study ............................................................................................. 3 Graduate Studies ............................................................................................................ 5 Statement of the Problem ............................................................................................... 6 Importance of the Study ................................................................................................. 7 Research Purpose ........................................................................................................... 7 Research Questions ........................................................................................................ 8 Conceptual and Theoretical Framework.......................................................................... 8 Leadership, Management, and Supervision Theories ...................................................... 9 Social Constructionism ................................................................................................. 10 Symbolic Interactionism ............................................................................................... 10 Qualitative, Exploratory Design ................................................................................... 10 Expected Outcomes ...................................................................................................... 11 Chapter Two: Literature Review ...................................................................................... 13 Literature Search Criteria ............................................................................................. 13 Supervision in the Helping Professions: A Brief Historical Overview from a Social Work Perspective ................................................................................................................... 14 Administrative Roots of Social Work Supervision (1878–1910)................................ 15 Changes of Context of Supervisory Training and Emergence of a Literature Base (1911– 1945) ........................................................................................................................ 15 Influence of Practice Theory and Methods (1930s–1950s) ........................................ 16 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC vi Debate Between Interminable Supervision and Autonomous Practice (1956–1970) .. 16 Back to Administrative Function in the Age of Accountability (1980s–1995) ........... 16 The Importance of Supervision ..................................................................................... 17 Elements, Functions, and Models of Mental Health Supervision ............................... 22 Models of Social Work Supervision .......................................................................... 23 Models of Nursing Supervision ................................................................................. 24 Models of Counselling and Psychotherapy Supervision ............................................ 25 Models of E-Supervision .......................................................................................... 26 Supervisor Competencies and Training......................................................................... 27 Multidisciplinary and Interdisciplinary Implications in Mental Health Supervision....... 29 The Importance of Multidisciplinary Approaches to Mental Health Supervision ....... 29 Complications and Tensions and/or Conflicts Between Mental Health Disciplines .... 30 Interprofessional Collaboration ................................................................................. 36 Competing Demands and Practice Paradigms in Mental Health Supervision ............. 39 Expectations from Above and Below ........................................................................ 40 Limits to Autonomy and Discretion .......................................................................... 41 Professional and Human Diversity Challenges.............................................................. 41 Professional Diversity ............................................................................................... 41 Human Diversity....................................................................................................... 42 Research on Mental Health, Relating to Supervision in Rural and Remote Areas.......... 43 Mental Health Supervision in Rural Canada .............................................................. 43 Mental Health Supervision in Rural vs. Urban Regions ............................................. 45 Cultural Competence, Indigenous People, and Professional Supervision ....................... 48 Summary ...................................................................................................................... 50 Chapter Three: The Study Context and Setting................................................................. 53 A Brief Summary of Health Care in Canada—Historical Highlights, Funding Mechanisms, and Challenges ............................................................................................................. 53 Health Care Systems ................................................................................................. 53 A Brief History of Health Care in Canada..................................................................... 56 How Mental Health Fits Within the Canadian Health Care System: History, Funding, Challenges, and Tensions ............................................................................................. 57 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC vii Challenges in Canadian Health Care ............................................................................. 65 Rising Costs .............................................................................................................. 65 Acute Care Dominance ............................................................................................. 67 Regionalization of Health Care in British Columbia .................................................. 68 Introduction of For-Profit Health Care Financing ...................................................... 70 Organization and Management of Mental Health Services in Northern British Columbia: What a Context for Mental Health Supervisors ............................................................. 71 Organization of Mental Health Services .................................................................... 72 BC’s Ministry of Health and the Northern Health Authority...................................... 72 Regional Health Authorities ...................................................................................... 74 BC’s Ministry of Health Budget—Northern Health Authority ...................................... 77 Northern Health Authority: Mental Health Funding .................................................. 77 Governance of NHA: Board and Management .......................................................... 79 Indigenous Organizations.......................................................................................... 87 Boards and Commissions .......................................................................................... 87 Mental Health Review Board .................................................................................... 88 Medical Services Commission .................................................................................. 88 Northern Health Authority and Non-Government Organizations (NGOs) .................. 89 Supervisory Training in Northern British Columbia...................................................... 91 Supervisor Training at Northern Health Authority (NHA) ......................................... 91 Supervisory Training for Child and Youth Mental Health (MCFD) ........................... 92 Differences and Similarities Between NHA and MCFD Supervisory Training .......... 92 Summary ...................................................................................................................... 93 Chapter Four: Methodology ............................................................................................. 95 Research Methodology ................................................................................................. 95 Theoretical Framework ................................................................................................ 95 Leadership, Management, and Supervision Theories ................................................. 95 Research Design ......................................................................................................... 100 Site Selection Criteria ................................................................................................. 100 Methods ..................................................................................................................... 101 Data Collection Strategy............................................................................................. 102 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC viii Participants................................................................................................................. 102 Sampling Criteria ....................................................................................................... 103 Participant Selection and Procedure............................................................................ 104 Handling the Data ................................................................................................... 104 Data Analysis ............................................................................................................. 105 Coding ....................................................................................................................... 106 Member Checking .................................................................................................. 107 Ethical Considerations ................................................................................................ 108 Evaluative Criteria...................................................................................................... 108 Adequate Engagement in Data Collection ............................................................... 109 Triangulation .......................................................................................................... 109 Thick, Rich Description .......................................................................................... 110 Reflexivity .............................................................................................................. 110 Limitations ................................................................................................................. 111 Summary .................................................................................................................... 111 Chapter Five: Findings ................................................................................................... 113 Coding: Manifest (Emergent) Themes, and Latent (Superordinate) Themes................ 118 Manifest Themes .................................................................................................... 119 Latent Themes ........................................................................................................ 145 Summary .................................................................................................................... 149 Chapter Six: Discussion ................................................................................................. 151 General Implications of Findings ................................................................................ 151 Latent Themes ............................................................................................................ 160 Summary .................................................................................................................... 171 Chapter Seven: Recommendations, Limitations, and Conclusion ................................... 173 Practice Recommendations for Multidisciplinary Rural Mental Health Professionals.. 173 Overwhelming Task Load ....................................................................................... 173 Easing of Decision Making ..................................................................................... 174 Another Kind of Isolation ....................................................................................... 174 Alternative Training Within the Assemblage of Governance Entities ...................... 174 Recommendations for Future Research....................................................................... 175 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC ix Limitations of the Study ............................................................................................. 176 Personal Reflection .................................................................................................... 176 Conclusion ................................................................................................................. 178 References ..................................................................................................................... 181 Appendix A: Approval for Study 2018—Ethical Approval Certificate ........................... 203 Appendix B: Approval for Study—Ministry of Children and Family Development ........ 205 Appendix C: Approval for Study—Northern Health Authority ....................................... 207 Appendix D: Informed Consent Form ............................................................................ 209 Appendix E: Transcriber Confidentiality Agreement ...................................................... 211 Appendix F: Interview Guide—Frontline Workers......................................................... 213 Appendix G: Interview Guide—Supervisors .................................................................. 215 Appendix H: Interview Guide—Senior Managers .......................................................... 217 Appendix I: Mental Health and Substance Use Related Organizations ........................... 219 Appendix J: Job Description—Team Leader Child Protection and Guardianship (MCFD)225 Appendix K: Job Description—Standard Form (Northern Health Authority).................. 229 Appendix L: Generic Supervisory Expectations ............................................................. 233 Appendix M: Types of Professional Supervision ............................................................ 235 Appendix N: Social Work Supervision Model................................................................ 237 Appendix O: Supervisory Training for Child and Youth Mental Health (MCFD) ........... 239 Appendix Oa: Objectives of MCFD Supervisor Training ............................................... 243 Appendix P: Supervisory Training at Northern Health Authority ................................... 245 Appendix Q: Supervision Agreement (MCFD) .............................................................. 251 Appendix R: Performance Appraisal (MHAS) ............................................................... 253 Appendix S: Provincial Health Services Authority (PHSA)............................................ 257 Appendix T: Regulatory Colleges (BC).......................................................................... 259 Appendix U: NHA Mental Health and Addiction Services ............................................. 261 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC x Tables Table 1: Demographics of Participants ...........................................................................114 Table 2: Demographics of Frontline Workers .................................................................115 Table 3: Demographics of Supervisors ...........................................................................116 Table 4: Demographics of Senior Managers ...................................................................117 Table 5: Manifest Themes (Emergent)............................................................................118 Table 6: Latent Themes (Superordinate) .........................................................................145 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC xi Figures Figure 1: Organization of the Health System of Canada ................................................... 62 Figure 2: Actual and Projected Total CHT Entitlements, 2005/06 to 2023/24 ................... 63 Figure 3: Relationship between BC Ministry of Health and Health Authorities ................ 75 Figure 4: Northern Health Authority Operating Budget .................................................... 79 Figure 5: Management Hierarchy, Northern Health Authority .......................................... 81 Figure 6: Northern Health Authority Regional Map ......................................................... 82 Figure 7: Management Structure, Northern Interior Region .............................................. 83 Figure 8: Supervisory Structure of Mental Health Services, Northern Region................... 84 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC xiii Glossary of Key Terms Following are some of the key terminologies that feature in this study. The definitions of these terminologies are common in helping professions but may vary across other disciplines. Leadership: There are many definitions of leadership; most are related to political entities. According to Bass et al. (1990), leadership has been conceived as follows: as the focus of group processes, as a matter of personality, as a matter of inducing compliance, as the exercise of influence, as particular behaviours, as a form of persuasion, as a power relation, as an instrument to achieve goals, as an effect of interaction, as a differentiated role, as initiation of structure, and as combinations of these definitions. Management: Wren et al. (2009) define management as an activity that performs certain functions to obtain the effective acquisition, allocation, and utilization of human effort and physical resources to accomplish some goal. Supervision: According to Kadushin and Harkness (2002), from a social work perspective, supervision is divided into three categories: administrative, education, and support. Administrative functions include activities such as staff recruitment, inducting and placing workers, work planning, work assignment, monitoring work, evaluating workers, interpreting policy directives, and coordinating work. Education functions involve teaching workers, sharing experiences and knowledge, clarifying, guiding, advising, and enhancing professional growth. Support functions refer to actions by the supervisor that enable workers to deal with work-related stress. On the other hand, from a clinical perspective, Bernard and Goodyear (2009) define supervision as an intervention provided by a senior member of a profession to a junior MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC xiv member or members of that same profession; a relationship that is evaluative and hierarchical which extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior person(s). It also includes monitoring the quality of professional services offered to the clients that they see, and serves as a gatekeeper for those who are entering the particular profession. Professional supervision: Since supervision involves professionals of various disciplines, the term professional supervision is sometimes applied instead of supervision. Ferguson (2005) defines professional supervision as a process between a supervisor and a supervisee aimed at enhancing the helping effectiveness of the supervisee. The process may include acquisition of practical skills, the mastery of theoretical or technical knowledge, as well as personal development at the client/therapist interface and professional development. Multidisciplinary supervision in health care: Overseeing of the professionals who are involved in the mechanism that ensures truly holistic care for patients and seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary, and tertiary care (Jefferies & Chan, 2004). Interdisciplinary supervision in healthcare: Carrier and Kendall (1995) define interdisciplinary supervision in healthcare as: the overseeing of professionals who are willing to share and give exclusive claims to their specialist knowledge and authority, if the needs of clients can be met more effectively by other professional groups. Health care: World Health Organization defines health care as the services provided to individuals or communities by health service providers for the purpose of promoting, maintaining, monitoring, or restoring health (WHO Centre for Health Development, 2004). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC xv Mental health: Mental health is described in the APA Dictionary of Clinical Psychology (2013) as: “A state of mind characterized by emotional well-being, good behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish constructive relationships and cope with the ordinary demands and stress of life” (p. 352). The Social Work Dictionary (2003) describes mental health as “the relative state of emotional well-being, freedom from incapacitating conflicts, and the consistent ability to make and carry out rational decisions and cope with environmental stresses and internal pressures” (p. 269). Rural: Rural can be defined using seven different criteria as outlined by Schmidt (2009): population density, population by political boundary, political boundary, commuting patterns, economy, open country, and being outside Standard Metropolitan Statistics Areas. Hanlon and Kearns (2016) observed that commonalities that characterize rural include smaller populations, lower population densities, tendencies towards natural resource and primary production dependence, and boom/bust economic cycles. The authors, however, remarked that not all rural places experience the same risks and disadvantages, citing differences such as welfare and infrastructure as well as amenities and geographical distances to larger centres. Cultural competency (social work definition): National Association of Social Workers [NASW] (2001) defines cultural competency as follows: a process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, race, ethnic backgrounds, religious, and other diversity factors in a MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC manner that recognizes, affirms, and values the worth of individuals, families and communities and protects and preserves the dignity of each. xvi MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Abbreviations ABA Applied Behavioural Analysis APA American Psychological Association AWAC Association Advocating for Women and Children BCMHSUS BC Mental Health and Substance Use Services CAP Canada Assistance Plan CBT Cognitive Behavioural Therapy CEO Chief Executive Officer CHST Canada Health and Social Transfer CHT Canadian Health Transfer CM Case Manager CMHABC Canadian Mental Health Association of BC COO Chief Operating Officer CSFS Carrier Sekani Family Services CYMH Child and Youth Mental Health (BC) CYSN Children and Youth with Special Needs (BC) DOBC Doctors of BC HIDS Hospital Insurance and Diagnostic Services Act HPRAC Health Professions Regulatory Advisory Council IFSD Institute of Fiscal Studies and Democracy IRPbc Interprofessional Rural Program of BC MCFD Ministry of Children and Family Development (BC) MHAS Mental Health Addiction Services MHCC Mental Health Commission of Canada MSA Medical Savings Account NFC Native Friendship Centre NGO Non-Governmental Organization NHA Northern Health Authority PHSA Provincial Health Services Authority UHNBC University Hospital of Northern BC UNBC University of Northern BC WHO World Health Organization xvii MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC xix Acknowledgements First, I extend my sincere and deepest gratitude to my dissertation committee: Dr. Neil Hanlon, Dr. Glen Schmidt, Prof. Dawn Hemingway, and Dr. Henry Harder for their patience, understanding, unwavering support, and insightful feedback. I also thank my External Examiner Dr. Peter Gabor and my Defense Chair Dr. Bill Owen for their gracious advice. I am also grateful to my three beautiful daughters Ivy, Ida, and Sonie for their patience and love, which encouraged and sustained my resolve and perseverance to the very end. Next, I acknowledge the support of my mother Veronica Wanjiru, my late father Charles Kariuki, and my siblings Muthoni, Wangeci, Nyambia, Nyawira, and Wamuya for their understanding and unwavering support throughout my learning journey. I would also like to thank the following friends and colleagues who encouraged, supported, and cheered me along the way: Eyob and Fiki, Catherine, Jane, and Susan Kamau, Duzie Ezedebego, Dan Kerry, Lona McRae, Dr. Mohau Kolisang, Dr. Nathan Andrews, Dr. Nancy Black, Thathi Jonah, Kangwana Kariuki, and Mutahi Mwai. Finally, I would like to acknowledge the support of my university teaching and work colleagues. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Dedication for Ivy, Ida, Elayna my Mother and late Father xxi Chapter One: Introduction Preamble Despite a growing professional interest in health and human services employee supervision, research studies on multidisciplinary mental health supervision in rural and remote regions are rare. A basic library search confirms that the role of supervision in mental health services in rural remote areas is little researched or discussed in professional journals and books that focus on health care. In the absence of a clear definition of mental health supervisors’ responsibilities and/or training expectations, more research in this area is needed. The initial presumption was that there are geographic, discipline, and health sector differences in the delivery of mental health services. Given their experiences in a unique practice environment, practitioners who live and work in rural and remote regions should play a pivotal role in the planning and improvement of their working environment. Hence, an exploratory study designed to hear from mental health practitioners in northern British Columbia, their ideas and thoughts about supervision. In preparation for this study, a review of significant existing ideas was carried out including literature related but not limited to: leadership, management, and supervision specifically targeting health care; the Canadian health care history, nature, and challenges; elements, functions, and models of mental health supervision; and mental health supervision in rural and urban regions. This unique study that has culminated in this original research may be applicable to other comparable jurisdictions. A meta-analysis by Mor Barak et al. (2009), who studied the impact of supervision on workforce outcomes, underscored the importance of supervision. The study’s most important finding was that organizations might benefit from generating policies and investing resources MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 2 in nurturing the supervisor-supervisee relationship. The authors further addressed the importance of supervisory training that showed three supervisory dimensions— administration, education, and support (Kadushin & Harkness, 2002)—as statistically significant in increasing beneficial workforce outcomes and mitigating detrimental ones. In another recent study in the United States on rural and remote mental health supervision, researchers examined the effect of specific training and support for rural supervisors. The study involved participation as follows: forty supervisors participated in a one-day training program, and six supervisors participated in a six-month follow-up peer group supervision program. According to Paulson and Casile (2014): “pre-and post-test results indicated a significant improvement in overall self-reported supervision competencies and a drop in feelings of burnout. The researchers observed that the structured program provided a convenient, effective, and affordable way to improve supervision in rural areas” (p. 204). With their primary purpose of enhancing professional development and ensuring client welfare, supervisors are the gatekeepers to the mental health field and, as such, they carry professional, ethical, and legal responsibilities (Paulson & Casile, 2014). Supervision is therefore recognized as an essential component of effective service delivery in the mental health field and continues to grow as an area of specialization that requires knowledge, skills, and training (Bernard & Goodyear, 2004). Accordingly, this study was therefore designed to explore the nature of multidisciplinary mental health supervision in northern British Columbia. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 3 My Place Within the Study My reason for choosing this particular topic is three-fold: 1) my family’s challenges growing up with a mentally ill sibling in rural Kenya; 2) experience during my research for my Master of Social Work degree; and 3) experience as a recipient of supervision in mental health-related occupations for more than 13 years. Growing up in Kenya during the last quarter of the twentieth century, community and government involvement in the care and well-being of the mentally ill was generally poor. Many who suffered mental illnesses deteriorated over time, depending on the nature of their mental illnesses and/or the support provided by their immediate families. Many unfortunate mental health patients ended up homeless and living miserable lives on their own, mostly spending their nights on verandas outside shopping centres and other public places. A limited number of health care workers and doctors with high caseloads treated mental health patients in addition to others with various illnesses. Local faith healers and traditional healers supplemented hospital treatment. Mental health patients who had supportive families lived slightly better lives because they had shelter and did not have to scavenge for food. On a more personal level, one of my siblings suffers from a mental illness and our family has encountered various challenges while supporting her treatment, accommodation, and general well-being. Many a time I have wondered how services for the mentally ill could be improved. Although the lack of mental health practitioners was and remains a barrier in Kenya, as in many lower and middle income countries, there has been some improvement in recent years. However, formal supervision of mental health workers continues to fall under general medical services. Mental health patients in many lower and middle income countries can MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 4 benefit from sustained efforts to increase the skilled mental health work force. It is my hope that this study will not only be helpful in a rural Canadian context but also to other countries whose rural mental health services require improvement. As an example, Ndetei (2008) observed that Kenya and other low income countries could benefit from shifting the balance of funds allocation and related policies to give a proportionately significant part of resources for mental health training to medical students, middle level medical personnel, and highly skilled paramedics (Ndetei, 2008). The author further explains that health care personnel in Kenya who are not psychiatrists, including nurses, psychologists, social workers, occupational therapists, and clinical officers (i.e., college level medical personnel with clinical training in various aspects of clinical medicine) should be deployed in remote areas where services are most needed. Of particular interest to this study, the author also suggests that the medical personnel would take a leading role in mentoring (supervising) potential rural clinical mental health workers. In a comprehensive study on the state of mental health in low and middle income countries, Saraceno et al. (2007) reiterated that the inadequate number of well trained workers remains a major hindrance to the improvement of mental health services. In the same study, the author also cited other challenges such as: insufficient funding for mental health services; centralization of mental health resources in and near big cities and in large institutions; complexities in effective integration of mental health care in primary-care services; limited numbers and types of health workers trained and supervised in mental health care; and often deficient mental health leadership in public-health skills and experience. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 5 An interesting parallel outlined in an article by Dr. Marlene Hunter (2006) indicates that some of the above challenges prevail in northern British Columbia. Dr. Hunter highlighted the problematic nature of access to mental health care in northern, rural, and isolated areas of British Columbia. The challenges included lack of expertise, travel, residential school syndrome, alcoholism, family violence, cultural issues, and poor collaboration between mental health professionals and family physicians (Hunter, 2006). I have to acknowledge that my interest in this study has grown because I have always been intrigued by the common challenges facing rural mental health provision in Kenya and northern BC. Graduate Studies After completing my Bachelor of Social Work in Canada in 2006, I was employed by the Ministry of Children and Family Development (MCFD). In 2007, I enrolled in the Master of Social Work program, which I completed while working for MCFD. My research was on cultural competency in child protection intake work within northern British Columbia. During my Master’s degree research, there were many times when my research interviewees pointed out the inadequacy of support from their supervisors. Interviewees expressed that, although they had interest in pursuing culturally appropriate practice, agency supervisors in many cases were either disinterested or ignorant, creating a barrier to the advancement of culturally appropriate practice (Kariuki, 2012). Although other barriers emerged from the resultant content analysis, lack of support from supervisors resonated with me, since the same lack of adequate supervisory support was one of the frustrating reasons that precipitated my departure from Child Protection Work to pursue further studies. I assumed that, if the supervisors were formally trained, they would be MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 6 bound to some minimum expectations that would mitigate frontline workers’ concerns, some of whom work with vulnerable mentally ill children. After resigning from my child welfare position, I decided to take on a part-time position as a mental health clinician at the University Hospital of Northern BC (UHNBC). Little did I know that my work at the hospital would augment my interest in supervision and more so in mental health supervision. Working as a clinical mental health counsellor at the UHNBC since 2012, I have been involved in the admission of mental health patients, some of whom are from rural northern British Columbia. The patients have limited access to mental health services within their home communities and have to travel long distances to get to UHNBC. My recent experiences have augmented my interest in the research on mental health supervision, mainly because (other than grey literature) there is limited scholarly literature on how mental health workers are supervised in northwestern Canada; hence my endeavours to conduct a geographically-targeted study on supervisory services. Statement of the Problem The lack of mental health supervision research in rural regions hampers the development of policies that could help improve mental health services, including rural worker retention. Research is therefore needed to find creative strategies to support mental health services for populations in rural and remote regions of the world. The differing expectations in mental health supervisory work call for more appropriate management approaches that can reconcile the core contextual challenges in multidisciplinary mental health supervision. This is more critical in remote regions with their enduring locational challenges characterized by a difficult environment and marginalization. Supervision theories by Kadushin and Harkness (2002), as well as Bernard and Goodyear (2009), provide MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 7 descriptions of supervisory requirements for various helping professions. However, there is a need for supervisory approaches that address the unique contextual challenges in rural and remote multidisciplinary service delivery, such as poor management approaches, isolation, and lack of support. To provide a theoretical framework for this study, I have reviewed leadership theories, constructionism, and symbolic interactionism. Importance of the Study This study focused on three areas linked to multidisciplinary mental health supervision: challenges and opportunities, role perception, and differences in approaches. I hope that the study will contribute to the limited relevant literature and empirical research that exists with respect to rural and remote northern regions. This study has also attempted to reconcile the core supervisory requirements with the contextual challenges since different expectations within mental health disciplines may sometimes conflict. With the lack of consensus in supervisory approaches, this study identified the need to balance the existing supervisory function while considering the multidisciplinary and geographical contexts. Also, this study’s implications and findings may prove useful to organizations that seek to improve middle level administration and management within multidisciplinary mental health jurisdictions. Research Purpose The purpose of this study was to better understand how mental health supervision might work in rural settings by identifying the knowledge, skills, and needs of multidisciplinary mental health supervisors. The study also sought to determine the supervisory differences and/or commonalities among mental health supervisors in various MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 8 disciplines, viewed from the perspective of mental health care delivery and supporting caregivers. Research Questions What challenges and opportunities do mental health supervisors experience in northern British Columbia? How do frontline workers, supervisors, and senior managers perceive the roles and activities of mental health supervisors in northern British Columbia? How are supervisory approaches in various mental health disciplines different or similar in northern British Columbia? Conceptual and Theoretical Framework The conceptual framework for this study utilized an interpretive approach in trying to understand how some of the commonly featured terms, such as leadership, management, and supervision relate to this study. In addition to how the research would be conducted, the goal of a conceptual framework is to indicate the importance of what is being studied, as reflected by the research questions and the presumed significance of the study (Yin, 2016). The conceptual lens for this study, which is both interpretive and exploratory, was informed by the theories of social constructionism and symbolic interactionism. The strategy for this study begins with the research questions that address the core requirements and contextual challenges of multidisciplinary mental health supervision. The questions address the conflicting expectations among mental health disciplines and the enduring lack of consensus on how to address the conflict. The conceptual framework will therefore help analyze the data gathered from the research participants to help answer the research questions. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 9 On the other hand, there are pertinent theories related to this study which include leadership, management, and supervision theories, social constructionism, and symbolic interactionism. These theories represent just a few of the many theoretical influences pertaining to supervisory work. A theoretical framework describes how the topic of study fits within research and any competing theories or controversies in order to strengthen the findings (Creswell et al., 2004). Below is a brief overview of the above theories and their connection to this study. Leadership, Management, and Supervision Theories In studies of the above theories across all disciplines, a good overview of the history and evolution of the terms can be helpful despite the massive amount of information that is currently available. In chapters two and six respectively, a historical overview and the application of the three terms is included. In leadership, management, and supervision definitions, there are shared properties, but no property is necessary and jointly sufficient for category membership. As an example, Bass et al. (1990) observed that there are almost as many definitions of leadership as there are persons who have attempted to define it. The authors further observed that there is sufficient similarity among the definitions to permit a rough scheme of classification (see definition of leadership in the glossary). A search on the word leadership in Academic search premier at the Geoffrey Weller Library, University of Northern British Columbia, yielded more than one million journals, articles, and books on leadership. The retail giant Amazon’s catalogue includes over 50,000 paperback and over 40,000 hard cover copies on leadership topics (Amazon, 2019). Google Scholar has more than four million journals, articles, and books on leadership (Google, 2019). As one of the oldest occupations, leadership has served as both a hot topic and an MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 10 important driver of innovation for thousands of years (Bass et al., 1990). Although there have been many definitions of leadership, most of them contain similar aspects. Leadership theories are addressed further in the literature review. Social Constructionism I sought to gain insight on how mental health supervisors construct meaning in their work, as informed by their individual experiences. This was achieved by employing a flexible and inductive approach to understanding participants’ constructions and then, in turn, I made my interpretation and their interpretation explicit. Social constructionism calls for the researcher’s awareness of the individual’s perceptions of the world, as well as the individual’s awareness of culture within their workplace. Symbolic Interactionism A supplementary theory, closely related to constructionism, is symbolic interactionism, a theory that is also applicable to the analysis of the supervisor–supervisee relationship. According to Greene and Ephross (1991), “symbolic interaction theory focuses on how the self emerges through interaction and examines those regularities in human behavior made possible through communication and language” (p. 203). Hence the interaction of supervisors and supervisees through language and other forms of communication determines their individual behaviour and collaboration within their work setting. The above theoretical frameworks are discussed further in chapter three. Qualitative, Exploratory Design A single qualitative, exploratory design was employed to explore the nature of professional mental health supervision in rural settings. To address the research questions, methods included face-to-face interviews and a documentary analysis. Data collection took MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 11 place at mental health facilities across the northern region of BC—within the boundaries covered by the Northern Health Authority. Data collection strategy included semi-structured interviews of frontline workers, supervisors, and senior managers, as well as a review of internal management and organization documents. Related grey literature was also reviewed. Data was analyzed using the thematic analysis method described by Braun and Clarke (2006). Expected Outcomes There are three expected outcomes of this research. First and most importantly, the results of the multidisciplinary supervision study will provide a foundation for improving the supervision of mental health in rural remote communities. Addressing specific, prevailing, and persistent rural remote challenges will hopefully lead to changes in related government policies. Secondly, the results of the multidisciplinary supervision will help mental health workers make informed decisions on their choices of practice locations. For example, improved practice options and incentives may encourage and/or entice more mental health workers to consider the rural regions as possible practice locations. Lastly, the results of this study will provide an analysis of some of the research related to rural remote mental health services, as well as recommendations for future research. Chapter one provides a general introduction to my study. Chapter two includes summaries of significant literature on mental health supervision. Chapter three describes the study’s context and setting, and chapter four addresses the research methodology. Chapter five covers my findings, and the discussion of those findings is in chapter six. The study’s implications and recommendations for practice and future research, limitations, and the conclusion are in chapter seven. Chapter Two: Literature Review The purpose of this exploratory study was to better understand how mental health supervision works in northern British Columbia. This chapter presents a review of current and historical literature relevant to this study. In order to understand the nature of multidisciplinary mental health supervision in rural and remote regions of northern British Columbia, I conducted a library search on historical and relevant literature. Literature Search Criteria To conduct this literature review, I used multiple sources of information, including professional journals, periodicals, books, internet sources, dissertations, and grey literature. These sources were accessed through the following databases: Academic Search Complete, ERIC, PsychINFO, Business Source Complete, CINAHL, and MEDLINE. Also, accessed were PubMed, Science Direct, Proquest, Google Search, Google Scholar, and some discussion with professional colleagues. The Boolean literature search terms included but were not limited to the following search sets: • Leadership or management or career development or training or personnel management or executive training or occupational training or management methods or transformational leadership or leadership qualities or leadership style. • Work place or hospital* or health care facility or outpatient clinic or clinicians or social work* or nursing or nurse or nurses or psychiatrist or psychologist or counselling or counselling or counsellor. • First Nations or Indigenous or Aboriginal or American Indian or Indian of North America or Inuit or Metis. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC • 14 Cultural sensitivity or cultural awareness or cultural values or cultural competence. Other targeted searches included leadership and management and health care and theory; management and leadership and health care and mental health; leadership and mental health and multidisciplinary and rural; leadership and mental health and urban. To gather pertinent grey literature, Google searches were conducted on various health organizations’ websites, government websites, and in reputable local and international newspapers. Due to the nature of some historical components in this review, the date of publication was not used as a basis for inclusion or exclusion of sources. Supervision in the Helping Professions: A Brief Historical Overview from a Social Work Perspective The following timeline provides a helping profession example of how supervision has evolved over the last two centuries. Supervision in social work had its origin in charity organization movements in the nineteenth century. A concern for possible consequences of indiscriminate almsgiving led to the organization of charity on a rational basis, starting in Buffalo, New York, in 1878 (Kadushin & Harkness, 2002). Appendix L provides an example of generic supervisory expectations. According to Tsui (1997), the following five stages have helped in tracing the history of social work supervision: administrative roots; changes of context of supervisory training and the emergence of a literature base; influence of practice theory and method; debate between interminable supervision and autonomous practice; and back to administrative function in the age of accountability. Tsui observed that two key factors—the development of social welfare and the professionalization process of social work—have influenced the MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 15 development of supervision over the last 120 years. The author added that, only by tracing the roots of social work supervision can we identify its important features, understand its philosophy, and explain why social work supervision still exists. The author also wrote that, going back to 1878, the above five historical stages, each with its own dominant theme, are critical in explaining the history of supervision. Administrative Roots of Social Work Supervision (1878–1910) In North America in particular, the roots of social work supervision can be traced back to charity organization societies (Tsui, 1997). Although there are three widely recognized functions of supervision—administrative, educational, and supportive—it is still debatable which was dominant during the early years of the Charity Organization Society (COS) (Kadushin, 1992). There are those who believe education was important to train the volunteers, while others argue that administration and support were critical to manage the growing number of volunteers. Regardless of the above debate, administrative supervision was the dominant mode of supervision in the social work field throughout the 1800s (Tsui, 1997). Changes of Context of Supervisory Training and Emergence of a Literature Base (1911– 1945) Between 1898 and 1904, the initial formal training of modern social work started as summer training. In 1904, a one-year program became the first School of Social Work at New York’s Columbia University (Kadushin, 1992); the first course in supervision was offered in 1911 by the Russell Sage Foundation. According to Kadushin, before 1920, social work literature contained no reference materials on social work supervision. However, when MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 16 the need for student supervision became an integral part of social work education, theoretical underpinnings were required to support supervisors. Influence of Practice Theory and Methods (1930s–1950s) Tsui (1997) observed that major changes in social work during the 1930s to 1950s were not limited to the field of education. The psychoanalytic theory emerged as a major theory in the helping professions, having an effect also on supervisory processes such as training. According to Luyten (2015), the central tenets of the theory include (a) the theoretical language of psychoanalysis, (b) psychoanalytic technique and training, (c) psychoanalytic developmental theories, (d) object relational and attachment approaches within psychoanalysis, and (e) the nature of general explanatory models in psychoanalysis. Debate Between Interminable Supervision and Autonomous Practice (1956–1970) As earlier noted, supervision was initially a practice of overseeing the work of volunteers. Later on, formal social work training was set up at universities, which included field work supervision. After the integration of psychoanalytic treatment theories into social work practice, supervision became a therapeutic process. By the 1950s, the therapeutic emphasis had waned, and supervision came to be regarded more as professional development for social workers. A debate about independent practice and learning ensued during these years as some social workers perceived long term supervision as an insult to their professional status: hence the ensuing trend from interminable supervision to autonomous supervision. Back to Administrative Function in the Age of Accountability (1980s–1995) Beginning in the 1980s, human service organizations have experienced increasing pressure and demands from governments and communities to make sure that funds are spent MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 17 in a cost-effective manner. There is more insistence on efficiency and effectiveness of service delivery: hence the re-emergence of a need for this administrative function. Supervisors in human service organizations once again have to promote efficient service to clients (Tsui, 1997). In their 2002 edition of Supervision in Social Work, Kadushin and Harkness highlighted the persistence of the administrative trend in social work supervision. The authors observed that, due to the proliferation of labor-intensive social agencies, organizational survival may hinge on the ability of administrative supervision to fine-tune agency performance. The authors added that recognition of social work supervision is now formalized in most of North America. It is noteworthy that, in the area of mental health supervision, there is a longstanding intersection between social work psychology and psychotherapy: hence the shared term clinical supervision. The Importance of Supervision According to Ducat et al. (2016), professional supervision is a method that has demonstrated widespread benefits to health professionals in metropolitan settings. However, the authors add that there remains limited published literature relevant to rural and remote regions. In their meta-analysis The Impact of Supervision on Worker Outcomes, Mor Barak et al. (2009) observed that evidence from recent research has demonstrated that supervision of social work practice can improve service delivery, develop social work skills, enhance an understanding of social work ethics and values, increase job satisfaction, and provide a valued defense against emotional exhaustion and staff burnout. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 18 To appreciate the importance of supervision in mental health work, a clear understanding of supervisors’ responsibilities is crucial. Kadushin and Harkness (2002) state that: a social work supervisor is an agency administrative-staff member to whom authority is delegated to direct, coordinate, enhance, and evaluate the on-the-job performance of the supervisees for whose work he or she is held accountable. In implementing this responsibility, the supervisor performs administrative, educational, and supportive functions in interaction with the supervisee in the context of a positive relationship. The supervisor’s ultimate objective is to deliver to agency clients the best possible service, both quantitatively and qualitatively, in accordance with agency policies and procedures. Supervisors do not directly offer service to the client, but they do indirectly affect the level of services offered through their impact on the direct service supervisees. (Kadushin & Harkness, 2002, p. 23) Primarily, mental health supervision aims at producing change in clinician behaviour in order to produce benefits to client outcomes, as supervisors pursue their goals of (a) organization/administrative functions, (b) clinical practice, and (c) provision of personal support to employees (Spence et al., 2001). The authors observe that the importance of ongoing in-service professional development is critical because of the increasing awareness that practitioners frequently fail to use the best practice techniques acquired during training. An example is the work of Kavanagh et al. (2003). They found that, within six months to three years after completion of intensive training in an evidence-based, cognitive-behavioural family intervention for schizophrenia, very few mental health practitioners continued to use the techniques they had been taught. In that research, difficulty in obtaining supervision or MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 19 consultation was one of the most common reasons given for failure to implement programs. Notably, the importance of good supervision in contributing to the maintenance and enhancement of high-quality clinical practice is being increasingly acknowledged. More so by employers, registration boards, and professional bodies (Spence et al., 2001). Also, appropriate supervision may curb one of the most prominent occupational stresses: burnout. According to the APA Dictionary of Clinical Psychology, burnout is the physical emotional or mental exhaustion, in one’s job or career, which is accompanied by decreased motivation, lowered performance, and negative attitudes toward oneself and others. Burnout results from performing at high level, until stress and tension especially from extreme and prolonged physical or mental exertion or overburdening workload take their toll (APA Dictionary of Clinical Psychology, 2013). Burnout is noticeably high in social and health service professions and is seen as a factor in the poor quality of health and mental health services extended to clients (Acker, 1999). The emphasis on individual workers’ performance improvement is seen as a narrow approach to burnout intervention. According to Paris and Hoge (2010), burnout interventions have tended to focus on individual-centred approaches, even though, in other fields, research has demonstrated that organizational and situational factors are more significant contributors to burnout than individual factors. Consequently, the authors observe that, in the implementation of best practices, changes in organizations and systems must complement interventions that are focused on the individual. Additionally, in addressing burnout, the mental health field must turn increasing attention to the organization and system levels. Organizations are emphasizing clinical practice that is based on research: hence the rise of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 20 best practice documentation and guidelines, both of which help in bridging the gap between research and practice (Centre for Addiction and Mental Health, 2008). According to Miller et al. (2006), the most common strategies in enhancing or incorporating evidence-based practice has been through clinically-focused continuing education workshops. Research has, however, shown that training has minimal influence on clinical practice. The authors observed that reports of competence bear little or no relationship to actual behavioural proficiency in the delivery of treatment. Therefore there is some evidence that clinical training, combined with ongoing feedback and coaching (such as supervision), can yield significant improvement. In a more recent study, Maslach (2017) discussed the model known as areas-of-worklife (AW), which involves bringing together both person and job context factors in an integrated way. According to the author: instead of framing the burnout question as, is it the person or the job? the question should instead be, how does burnout result from the interaction of the person and the job?.... The AW model proposes that the greater the perceived incongruity, or mismatch, between a person and the job, the greater the likelihood of burnout; conversely, the greater the perceived congruity, the greater the likelihood of engagement with work. (Maslach, 2017, p. 149) Harder et al. (2014) addressed the importance of healthy workplaces and the role that managers or supervisors can play. The authors recommended a course by Galbreath (2011, cited in Harder et al., 2014), which is designed specifically to educate managers on how to create healthy workplaces. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 21 Another study by Gibson et al. (2009) revealed that the availability of high quality supervision has a positive relationship with satisfaction and staff retention because it provides a forum for the resolution of clinic and workplace challenges, and is also a potential source of empathy and praise. Also, the study deduced that positivity of the supervision relationship is of substantial importance for job satisfaction. In the same study on applied behavioural analysis (ABA) on children, Gibson et al. (2009) observed that the most consistent results reflected the central role of perceived supervisor support in understanding burnout, and perceived therapeutic self-efficacy in the work with children. It was also noted that high levels of perceived supervisor support were associated with reduction in emotional exhaustion, increased personal accomplishment, and an increase in perceived supervisory self-efficacy. In cases of perceived high levels of work demands, supervisor support acted to protect therapists from reduced personal feelings of accomplishment. Acker (2003) observed that appropriate mental health supervision has been credited with addressing role conflict and role ambiguity. According to Drolen and Harrison (1990), role conflict occurs when incompatible demands or expectations are placed upon workers, such as when they work with two or more groups that operate quite differently, and when they have to work on unnecessary tasks and cannot address client problems autonomously. Role ambiguity results from uncertainty as to what to do, and/or from questioning the impact of practice interventions in the lives of clients with mental illness. Examples of role ambiguity include situations where workers do not have clear, planned goals and objectives for their job, and when they do not know their responsibilities (Drolen & Harrison, 1990). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 22 With limited or no supervision, mental health workers are often required to perform multiple managerial and clerical tasks that give them less time for counselling and therapeutic work. When workers cannot contribute to the decisions that affect their professional lives, they may feel that they do not have control. It is not uncommon today for mental health professionals to view their professional activities as inappropriate and incongruent with their training, professional expertise, and desires (Acker, 1999). Mental health service providers, such as social workers, are particularly at risk of negatively experiencing the role changes introduced with the transition to managed care practices (Acker, 1999). One solution to the problem can be more midlevel supervisory support for mental health workers. Elements, Functions, and Models of Mental Health Supervision According to Spence et al. (2001), the three main elements of supervision include: clinical/client-centred, organizational/administrative, and personal support aspects of supervision. Clinical/client-centred components of supervision involve the transmission of knowledge, skills, and attitudes for enhancing the quality of clinical service to the client, while the organizational/administrative or agency-centred aspect of supervision focuses on the transmission of knowledge relating to the goals, expectations, systems, policies, operations, philosophies, dynamics, and culture of the organization. The authors added that the personal support aspect of supervision aims at optimizing motivation, morale, and commitment, as well as minimizing work-related stress, burnout, and employee mental health problems. Three of the earliest models of supervision, whose functions are closely related, include: the earlier mentioned from Kadushin (1976), which includes educative, supportive, MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 23 and administrative functions; the Proctor model (1988) in counselling, which includes the terms formative, restorative, and normative functions; and the Hawkins and Smith model (2006), about coaching supervision, which includes developmental, resourcing, and qualitative functions (Hawkins et al., 2012). There are numerous models of mental health supervision across various disciplines which, according to critics, have contributed little to the implementation and practice of supervision. In practice, evidence suggests that, irrespective of professional and theoretical background, supervisors engage in very similar supervisory practices (Ladany et al., 1999). The authors added that, despite the different roles and clinical practices across the professions of social work, psychology, occupational therapy, evidence shows there are far more similarities than differences in the aims, processes, and methods of supervision among these different professional groups. Munson (1993) observed that a good model explains a lot of information in a concise and understandable manner, adding that good models should include four components: 1) utility; 2) verifiability; 3) comprehensiveness; and 4) simplicity. These components envisage the fundamentals and credibility of supervisory work whose philosophies, values and knowledge are meant to benefit supervisees. Models of Social Work Supervision According to Bogo and McKnight (2005), the models of social work supervision of Kadushin and Harkness (2002) and Tsui (2005) can be differentiated by the levels of agency control. According to the authors, at one extreme is the casework model, which involves scheduled one-on-one individual social work supervision, based on high levels of administrative accountability. At the other extreme is the autonomous practice model (private practice) which is based on professional autonomy of the supervisee. In between the two are MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 24 three other models: group, team, and peer supervision. According to Kadushin et al. (2009) the social work supervision models includes: individual supervision, which is the most widely used model of supervision; group supervision, the second most widely adopted model of supervision; peer supervision led by a peer group; and in team supervision (a complete social work supervision model is outlined in Appendix N). Models of Nursing Supervision Important differences in theories and approaches to supervision are evident in the nursing literature. Sloan (1999) observes that there is no one model of supervision that can deal with the diverse clinical needs in the nursing profession. Cultural differences between countries are reflected in differences in definition, models, and the practice of clinical supervision. Jones (2005) identified three models of clinical supervision that are common in nursing literature, including: the growth model and support model by Faugier (1992); the integrative approach by Hawkins and Shohet (1989); and the three-function interactive model by Proctor (1986). Faugier (1992) described a growth and support model of the supervisory relationship as one that focuses on three areas: the relationship between the individuals; the role of the supervisor in facilitating both educational and personal growth for the supervisee; and provision of support for the developing clinical autonomy of the supervisee. Hawkins and Shohet’s model (1989) emphasized support and reassurance, as well as affective responses from a supervisor. According to Mental Health Coordinating Council (2012), the latter addresses six foci: Focus 1—reflection on the content of the therapy session (worker narrative). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 25 Focus 2—exploration of the strategies and interventions used by the worker (worker activity). Focus 3—exploration of the process and relationship (worker/consumer process). Focus 4—focus on countertransference (supervisee’s state). Focus 5—focus on the ‘here-and-now process as a mirror or parallel of the ‘thereand-then’ (supervision process). What has been discussed by others as parallel processes. Focus 6—focus on the supervisor’s countertransference (supervisor experience). (Mental Health Coordinating Council, 2012) The Proctor model (1986) is the most common model for nurses, especially in the United Kingdom. It is based on the following three functions: One, formative function, which is the educative process utilized in developing the knowledge and skills of those supervised. This is achieved through sharing knowledge and enhancing self-awareness. The second is the normative function, which is the management process required to maintain safe practice and standards of care. This is achieved through discussion of cases and identification of examples of poor practice. The third one is the restorative function which addresses the supportive process whereby nurses discuss and share experiences and anxieties with peers (adapted from Walsh et al., 2003; and Winstanley & White, 2003). Models of Counselling and Psychotherapy Supervision Other approaches from the counseling literature include Haynes et al. (2003) which provided common group models in clinical supervision including developmental models, psychotherapy-based models, and integrative models. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 26 Developmental models view supervision as an evolutionary process, and each stage of development has defined characteristics and skills. Examples of developmental models include the interactive developmental model (IDM), and process developmental models (Bernard & Goodyear, 2009). Psychotherapy models use psychotherapy concepts, applying them to supervision, i.e., “that which is used in bringing change with clients is likely to be useful in bringing about change with supervisees” (Haynes et al., 2003, p. 117). Examples include the psychodynamic model, person-centred model, cognitive-behavioural model, family therapy model, and feminist model. Haynes et al. (2003) explain that integrative models rely on more than one theory and technique. Examples included: a discrimination model developed by Bernard (1979); the systems approach to supervision developed by Holloway (1995); the reflective learning model by Davys and Beddoe (2009); the solutionoriented models by Thomas (2013); and the seven-eyed supervisor model by Hawkins and Shohet (2012). A relationship exists between some of the above models and various forms of therapy. According to Bernard and Goodyear (2009), some supervision models developed from the premise that the process of supervision should be based on the same change methods and theoretical principles as a particular form of therapy. The authors also observed that, since clinical supervisors were counsellors or therapists who practiced or applied particular therapeutic styles or focus, it is inevitable that the lens they learned to use in understanding their work would have substantial influence in their new supervisory role. Models of E-Supervision Due to technological advancements, supervision in many disciplines is no longer assumed to be face-to-face and some supervision training is delivered online. According to MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 27 Hawkins et al. (2012), the term e-supervision is used to include media such as telephone, video, and email. The authors further observe that, while it is possible to carry out effective supervision by telephone, video link, or email, these mediums have been more effective where initial face-to-face relationships are established. E-supervision can be helpful and convenient when geography is a factor. It can sometimes be challenging to provide supervision in remote and/or rural locations for various reasons, including access. Yet organizations have come up with alternative ways of ensuring service delivery. An important aspect of e-supervision raised by Hawkins et al. (2012) was the issue of choice of technological mode, whether telephone, video, or email. The authors noted that individual supervisors or supervisees may prefer one medium to another, depending on their dominant sensory mode. For example, the authors explained that a telephone may be convenient to some who would prefer the flexibility of moving around during the conversation (which is not possible on video). The authors have also noted that supervisors who are involved in e-enabled processes of supervisory training can easily develop e-supervision skills. Supervisor Competencies and Training To complement the above models, a number of supervisor competencies were identified in a study carried out in Ontario Canada. In the study, Hair (2012) addressed the issue of supervisory training. The mixed method web survey on supervision was completed by 636 social workers from a broad spectrum of social work practice settings and geographical locations in Ontario. Results from the study indicated that suggestions from social workers on what they appreciate about supervisors were needed to encourage ongoing debate to improve supervisory training. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 28 While other studies in clinical supervision emphasize the need for improvement in supervisee support, mentorship, and training, historically the apparent prominence of supervision in professional practice has not been accompanied by a concerted effort to train or support current and new supervisors (Russell & Petrie, 1994). The authors noted that the onus has been placed on supervisors to draw on their skills as therapists and their past experiences as supervisees. Bass et al. (1990) stressed the need for an academic component of supervisor training. The authors discussed a model of supervisor training known as “supervisor in training” (SIT). The model is characterized by two elements: One, it should have both didactic and experiential components, each sufficient without the other; and secondly, it should occur as a series of graded sequential experiences that provide learners with the opportunity to get consistent feedback on their practice. It is noteworthy that developmental theorists have, over the last 40 years, proposed supervisor development models, including models by Alonso (1983), Hess (1987), Rodenhauser (1994), Stoltenberg et al. (1998), and the Watkins models (1990, 1993), all of which bear their names (Bernard & Goodyear, 2009). In terms of competencies, various disciplines follow laid down principles, for example, clinical counselling in family therapy emphasizes the following basic principles: Supervision must be respectful; Supervision, like therapy, must be a safe place; A working alliance must be developed; A supervisor does not offer therapy to the clinical family; A supervisor does not offer therapy to the therapist in training; Supervision operates within a clearly defined clinical training system that includes intergenerational subsystems and dynamics; The dynamics of supervision include hierarchy and power; Supervision develops through predictable stages; Supervision MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 29 interventions are driven by theory; Supervision should be competency based; The supervisor has simultaneous responsibilities to the therapist, the clinical family, the clinical setting/institution, and the self; The supervisor, like the therapist, follows clear ethical principles of conduct and practice; Supervision is unique within each training system. (Lee & Everett, 2004, p. 4) Multidisciplinary and Interdisciplinary Implications in Mental Health Supervision As described in the definition of key terminologies (chapter one), multidisciplinary teamwork aims at ensuring truly holistic care and seamless services for patients throughout their disease trajectory (Jefferies & Chan, 2004). Multidisciplinary teamwork can be traced back to the 1950s movement of mental health care from hospitals to community care (Burns, 2001). According to Burns, the movement resulted from improvements in pharmacological treatments, along with key social, political, and economic trends. These included an increasing emphasis on human rights, deinstitutionalization and understanding the detrimental effects of institutionalization, as well as the influence of the therapeutic community movement. The latter emphasized the social determinants of mental illness and stressed the important role played by relationship in treatment (Burns, 2001). The Importance of Multidisciplinary Approaches to Mental Health Supervision Although the terms multidisciplinary and interdisciplinary are sometimes used interchangeably, the term interdisciplinary refers to the working together of professional groups in support of clients if needed (Carrier & Kendall, 1995). On the other hand, the term multidisciplinary refers to the mechanism that ensures truly holistic care for patients and seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary, and tertiary care (Jefferies & Chan, 2004). Since mental health services MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 30 in northern BC are essentially multidisciplinary and interdisciplinary, a number of professions are involved. Therefore, in BC, professional mental health services and supervision involve a number of disciplines, including but not limited to those who can prescribe and monitor medication, and provide therapy, assessment, and counselling—see a full list in Appendix I. The following account will address some of the complications and tensions that exist between the disciplines and how these can be linked to legislation and regulatory mechanisms. Complications and Tensions and/or Conflicts Between Mental Health Disciplines According to Patton (2014a), to the public eye, there are only a few tensions between mental health professions, mainly because some professions have no clear distinctions. The author observed that many lay people equate the professions of psychiatrist, psychologist, and psychotherapist, as very similar. Some mental health professionals have a clear association with specific settings; for example, psychiatrists are more associated with health care systems such as hospitals, while counsellors in Canada are employed in a variety of settings, including but not limited to hospitals, education institutions, and private practice (Patton, 2014a). Before addressing the complications and tensions among mental health professionals, it is worth noting that there is a pecking order and a gender aspect involved in these professions. According to Gazzola et al. (2009), psychiatrists and GPs, as well as other mental health professionals such as psychologists, psychiatric nurses, or social workers, who are part of the health system, are visible and sought after by consumers. The pecking order or MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 31 the hierarchy of status can also be attributed to levels of education, with psychiatrists, medical doctors, and psychologists topping the list. The hierarchy can also be traced back to historical labour relations. According to Cohen (2003), as recently as 1960, the roles of psychiatrists, psychologists, and clinical social workers tended to be distinct in Canada and United States. Psychiatrists had overall responsibility for patient care including psychotherapy, prescribing medication, and supervised hospital care. Psychologists conducted specialized tests and therapy, while clinical social workers performed psychosocial assessments (Cohen, 2003). Also, although the psychiatrist’s role in psychotherapy has been encroached upon by other mental health professionals, psychiatrists (with the exception of other medical doctors and nurse practitioners) are the only professionals who can prescribe psychotropic medicine in Canada, and they earn the highest salaries. A number of mental health professionals are at the lower end of the salary scale. These include clinical social workers, nurses, and counsellors (Cohen, 2003). In terms of gender composition, it is worth noting that, although women make up the largest percentage in the health care workforce in Canada, until recently they have been in the minority as practicing doctors, including psychiatrists (Gender & Work Database, 2015). The database adds that this can, in part, be attributed to discriminatory admission policies of medical schools towards women that began to be removed in the 1960s. However, according to the Canadian Institute for Health Information, there have been notable changes in Canadian first year medical school enrolment for men and women. More men than women enrolled each year until the early 1990s. Similar numbers of men and women enrolled in the 1990s. However, in 1993/94, women’s enrolment in medical school surpassed that of men MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 32 (Canadian Institute for Health Information, 2001). More recent studies indicate that 56% of Canadian medical students are women (Glauser, 2018). Closely related to the terms complications and tensions is the word conflict, which has been used widely to describe negative or contentious relationships between mental health professionals. Kreitner and Kinicki (2010) describe conflict as “a process in which one party perceives that its interests are being opposed or negatively affected by another party” (p. 373). The authors propose that the following antecedent circumstances tend to create conflict in health care: “blurred job boundaries; Battle for limited resources; Democratic decision-making; Collective decision-making; Poor communication; Competition amongst departments; Unreasonable work expectations (policies, rules, deadlines, time restriction); Unmet and/or unrealistic expectations (regarding salary, advancement, or workload), more complex organizations, and unsettled or repressed conflicts” (Kreitner & Kinicki, 2010, p. 373). The above circumstances are general and apply to various health care settings. However, a number may apply to mental health professionals and supervisors. In my own experience as a mental health counsellor, common complications and tension in hospitals among mental health clinicians, nurses, and mental health supervisors are sometimes related to communication, personality differences, and blurred job boundaries. According to Patton (2014a), the style of communication within health care fields, such as mental health, may lead to conflict: This includes lack of communication or verbal or non-verbal communication. Wright et al. (2014) give an example of a nurse’s description of non-verbal catalysts of conflicts. “A nurse working in an adjoining department consistently refrains from speaking to me. This seems deliberate as she speaks freely to others all around MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 33 me” (p. 31). Tensions and complications related to communication and personality differences may reflect deficiencies in standards of practice. In personality differences, according to Jha and Jha (2010), individuals have unique personalities and vary in “attitudes, opinion, beliefs, culture emotional stability, maturity, education, gender, language, etc.” (p. 77). The authors add that workers’ reactions to specific stimuli differ, which may cause some individuals to perceive some matters as undermining their position or refuting their values or world view. Jha and Jha (2010) add that oftentimes individual differences can adopt moral and/or emotional undertones, turning disagreement over who is right or wrong into a bitter squabble over who is morally correct. According to Patton (2014a), multiple scholars view blurred job boundaries as a source of conflict among interdependent health care workers, which may occur due to discrepancies as to which profession is responsible for which roles. This challenge may also lead to conflict between workers from differing disciplines working under a supervisor whose background is not broad enough to cover all the subordinates’ disciplines. In the absence of recent literature on complications and tensions among mental health workers in BC, I chose to interview a BC psychiatrist (not identified for confidentiality reasons). According to the psychiatrist (personal communication, January 14, 2016), communication issues (which have been addressed above) lead to most of the challenges among various mental health professionals. The psychiatrist argued that most of the communication conflict among mental health professionals results from poor interpersonal communication and differing styles of communication. He explained that gossip, harsh language, rumour-spreading, bickering, and degrading comments are just a few examples. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 34 According to the psychiatrist (personal communication, January 14, 2016), another circumstance for conflict is unclear job boundaries that can be equated to standards of practice and regulation. The correspondent further explained that there has been enduring conflict between psychiatrists and psychologists related to the prescribing of medication. In BC, only psychiatrists (and other medical doctors), and nurse practitioners can prescribe medications. The psychiatrist also notes that, while some psychologists choose prescribing mental health medication, others are opposed, and in favour of psychotherapeutic options. Unlike BC, some states in the US have allowed psychologists to prescribe medication, but only those who have completed relevant training (personal communication, January 14, 2016). This conflict between psychiatrists and psychologists, as well as mental health professionals who do not prescribe medication, can be attributed to a social/environmental approach versus a medical/illness approach. The social/environmental approach, as represented by psychologists, social workers, nurses, etc., leans more towards psychotherapy, while the medical/illness approach represented by psychiatrists leans more towards treatment with medication (drug prescription). Rogers and Pilgrim (2006) assert that: “psychiatrists are trained to see their role as identifying sick individuals (diagnosis), predicting future course of their illness (prognosis), speculating about their course (aetiology), and prescribing a response to the condition, to cure it or ameliorate its symptoms (treatment)” (p. 2). The authors add that biological psychiatry tries to reduce psychological phenomena to biology. On the other hand, psychotherapy tends to lean more towards social/environmental or psychosocial factors with the view that “mental disorders originate in stressful or difficult life experiences” (Davis, 2014, p. 8). Therefore, the above two approaches—medical/illness MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 35 (biological) and social/environmental (psychotherapy)—are sometimes in opposition because of perceived differences in goals, or interference in goal attainment. This conflict points to the philosophy and value base of their respective professions (Rogers & Pilgrim, 2006). Conflict involving psychiatrists and therapists may emanate from different orientations (personal communication with psychiatrist, January 14, 2016). Depending on standards of practice, a therapist’s school of thought may be different from that of a psychiatrist. For example, the application of cognitive behavioural therapy (CBT) and psychodynamic orientations could lead to misunderstanding and complications (personal communication, January 14, 2016). The psychiatrist further notes that, whereas CBT focuses on a client’s current state of mind, psychodynamic therapy considers the past and its effect on the present. Since the regulation of various mental health colleges and unions determines the salaries of their respective professionals, the psychiatrist (personal communication, January 14, 2016) observes that some therapists have, for many years, argued that the variation in remuneration among mental health professionals may not be consistent with work expectations. As an example, workers such as psychiatric nurses and clinical social workers argue that psychiatrists should attend to more therapeutic duties since they earn much more than other workers in the mental health field (personal communication, January 14, 2016). The psychiatrist (personal communication, January 14, 2016) also cited complications in the prescription and dispensing of psychotropic medication that may arise when a pharmacist differs with a psychiatrist’s prescription. Pharmacists may cite adverse side effects as the reason for changing the psychiatrist’s prescription. He notes that such MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 36 complications may lead to delays in patients’ prescriptions, and mistrust among professionals. Another overarching cause of conflict is what Davis (2014) refers to as “professional imperialism.” According to the author, viewing the actions of mental health practitioners in terms of a number of obligations to clients and other stakeholders is one way, but a different, more skeptical view is seeing the group behaviour as reflecting simple selfinterest. There are skeptics who see professional activities in terms of turf-guarding or turfexpansion, an example from psychiatry being the resistance to extending prescription powers to non-physicians (Davis, 2014). Interprofessional Collaboration According to Health Canada (2019), interprofessional collaboration in health care delivery refers to teamwork with one or more members of the health care profession who each make a unique contribution to the aim of achieving a common goal, enhancing the benefit for patients. Each individual contributes from within the limits of their scope of practice. “The process involves communication and decision making that enables the separate and shared knowledge and skills of different care providers to synergistically influence the care provided through changed attitudes and behaviours, all the while emphasizing patient-centred goals and values” (Health Canada, 2019). Antecedents of conflict, such as personality differences, can be used to determine situations that may generate conflict, since conflict is more likely to occur under certain circumstances (Patton, 2014a). Leaders who are aware of these antecedents can prepare to intervene when appropriate (Kreitner & Kinicki, 2010). However, Patton (2014a) purports that not all effects of conflict are negative, because reasonable degrees of conflict can lead to MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 37 the generation of ideas, and can foster team cohesion. Almost (2006) observes that once the conflict is resolved, the involved workers feel more united and capable. Within Canada and indeed in other countries, policymakers are addressing interprofessional collaboration by reviewing legislative and regulatory mechanisms. A number of Canadian provinces are actively involved and in BC, the Health Professions Act has been undergoing significant transformation (Health Professions Regulatory Advisory Council—HPRAC, 2008). According to the Advisory Council, BC is in the process of implementing the shared scope of a practice/reserved action regulatory model similar to one in place in Ontario (HPRAC, 2008). According to Health Professions Regulatory Advisory Council (2008, p. 11): “This approach abandons the concept of professional exclusivity in which legislation prohibits any person other than a member of the profession from performing certain services or procedures, except where another profession is also specifically authorized in legislation to do so….” This enhances inter-professional and multidisciplinary practice and increases consumer choice, while maintaining patient safety and public protection. Hanlon and Kearns (2016) observed that “there are unique opportunities for interprofessional collaboration in rural and smaller town settings for different elements of the local society, including indigenous communities… and broader elements of local society” (p. 68). An initiative in BC addressing interprofessional learning that has been influential in addressing complications among various professionals is the Interprofessional Rural Program of BC (IRPbc). The program was initiated by University of British Columbia Social Work professor Grant Charles in response to the recruitment and retention needs of health care professions in rural/remote BC (Charles et al., 2008). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 38 According to Charles et al. (2008), the program was aimed at exposing students in the health professions to rural communities while also training future practitioners to work effectively together. One of the benefits of IRBbc includes an increase in students’ knowledge of the benefits of collaborative and team-based practice. Also, the participating students “reported that they had increased their knowledge and appreciation of the role of their own professions and the role of those with whom they worked” (p. 47). Charles et al. (2008) observed that “perhaps the most important lesson in the creation of IRPbc was that the model can be used as an effective strategy for developing interprofessional team skills and collaborative practice habits among participating students during the pre-licensure education” (p. 49). Finally, in what is referred to as the shared mental health care model, the Canadian government supports an integrated and collaborative practice with mental health professionals as part of interdisciplinary teams (Health Council of Canada, 2006). The term interdisciplinary defines different health care professionals working together in partnership as they apply methods of their respective disciplines to their practices. The teams include but are not limited to social workers, psychologists, nurses, and psychiatrists (Scott, 2008). In conclusion, although there are many factors that complicate relationships among mental health professionals, two initiatives in BC—interprofessional collaboration, and the Interprofessional Rural Program of BC—are instrumental in reducing professional complications, tensions, or conflict. There are negative consequences that arise from tension and conflict between health professionals and this can impact the lives of patients (Patton, 2014a). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 39 Competing Demands and Practice Paradigms in Mental Health Supervision A number of competing demands and practice paradigms are associated with mental health supervision. Using examples, the following account will provide an overview of some of the competing demands and practice paradigms. The first of three sections will address the competing demands facing the mental health supervisor, followed by a brief discussion on the essence of cultural safety and, finally, a review of three relevant practice paradigms. Mental health supervision encompasses several interrelated activities, which ensure that clients are protected and receive competent and ethical services from frontline professionals. Although there are varied terminologies for the main supervisory activities, there is a consensus among the helping professions on three specific activities. As previously noted, from the social work perspective, the activities of supervision are captured by three domains: administrative, education, and support (Kadushin & Harkness, 2002). The administrative functions include activities such as staff recruitment, inducting and placing workers, work planning, work assignment, monitoring of work, evaluating work and workers, interpreting policy directives, and coordinating work. Education functions involve teaching workers, sharing experiences and knowledge, clarifying, guiding, advising, and enhancing professional growth. In some disciplines, the education function is often referred to as clinical supervision. Support functions refer to actions by the supervisor that enable workers to deal with work-related stress (Kadushin & Harkness, 2002). Social support, emotional support, information, referral, and advocacy are all part of supportive supervision (Mor Barak et al., 2009). In mental health services, supervisors contend with various competing demands. In this section, I address three common demands that may apply in most of the mental health- MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 40 related agencies: 1) expectations from above and below; 2) limits to autonomy and discretion; and 3) challenges of human diversity. All are related to the administrative, education, and support functions of supervision (Kadushin & Harkness, 2002). Before addressing the above three demands, it should be noted that administrative, education, and support functions are broad, and some supervisors may be unclear about their roles, a phenomenon that Feldman (1999) describes as the “Middle Management Muddle” (p. 281). Hence, according to Kadushin and Harkness (2002), some of the antithetical requirements for mental health supervision include: “permitting the greatest degree of worker autonomy while adequately protecting the rights of the client; helping preserve agency stability while promoting agency change; being supportive to the worker while communicating challenging expectations; acting as an agent of the bureaucracy while being loyal to the profession; and balancing the individual needs of the worker and the needs of the organization” (p. 296). To balance the above antithetical expectations, the supervisor has to reconcile job demands with the human demands of managing, focus on productivity and quality, as well as supervisees’ satisfaction and morale (Kadushin & Harkness, 2002). Expectations from Above and Below The supervisor is simultaneously pulled between conflicting expectations—the “working unit and the organization unit” (Kadushin & Harkness, 2002, p. 296), placing the supervisor in a difficult situation. The supervisor’s membership in each unit is marginal; usually pressure occurs from both units when the supervisor attempts to act as a buffer and mediator. Kadushin and Harkness (2002) added that sometimes the directives from administration and the demands of workers are contradictory. In responding to one group, the MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 41 supervisor risks incurring the hostility of the other group and compromising the power to influence. Also, to effectively implement their responsibilities, the supervisor requires agency-provided resources, which include “enough workers assigned to the unit and enough workers with a particular level and variety of skills” (Kadushin & Harkness, 2002, p. 296). In many cases, supervisory problems result from a short supply of workers to cover caseloads, or from assignment of employees with deficiencies in knowledge and skills. This may limit the productivity of the unit, to the detriment of the supervisor’s reputation. Limits to Autonomy and Discretion According to Kadushin and Harkness (2002), supervisors face the frustration of limits of autonomy, constrained by “administrative policies, union regulations, client advocacy organizations, the reporting requirement of legislative sources of agency funding, accrediting standards, licensing standards, and affirmative action and civil rights regulations” (p. 296). The authors observe that, the supervisor has discretionary authority to make autonomous decisions such as work assignments. However, in some cases, there may be a need to inform administration after some decisions are made. Moreover, some decisions (such as hiring, dismissal, or purchase of assets) require prior approval. “Such internal and external constraints limit the supervisor’s freedom to act vis-à-vis the supervisee in accordance with the supervisor’s best judgment” (Kadushin & Harkness, 2002, p. 296). Professional and Human Diversity Challenges Professional Diversity Mental health supervision in many cases involves multi-disciplinary work. Depending on the supervisor’s training background, they may at certain times refer the supervisee to seek advice from a discipline’s expert. For example, a mental health supervisor from a social MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 42 work background may require a mental health nurse to seek advice from a senior nurse to clarify a medical issue. Human Diversity In mental health supervision and related helping professions, human diversity is an ongoing stress for supervisors because supervisors, supervisees, and agency clients vary in race, ethnicity, gender, and affectional orientation (Beckett & Dungee-Anderson, 1996; Bruss et al., 1994; Tsui & Ho, 1997). This, according to Kadushin and Harkness (2002), challenges interactive assumptions about the process of helping. This has led to increasing theoretical and empirical supervision literature. Where race and ethnicity is a factor, supervisors need to make an effort to learn some details of the supervisee and/or client cultures, lifestyles, communication patterns, discrimination experiences, attitudes towards authority, and approaches to problem solving. While working with supervisees who are either members of a victimized group and/or First Nation communities, a supervisor should be sensitive, given the general vigilance by supervisees who will cautiously check the speech and nonverbal reaction for any hint of prejudice or bias while assessing the level of sophistication of the supervisors knowledge of African American or First Nation culture. Also, interracial discussions will likely be uncomfortable and awkward, with the supervisee, who is in a less powerful position, being more hesitant to initiate relevant discussions. The authors conclude that the supervisor should be alert to the needs for such dialogue, take initiative to open discussions, assist and encourage supervisees during the interactions (Kadushin & Harkness 2002). In light of the above complications, tensions, and conflicts, Shore et al. (2012) propose that the most meaningful way to support teams is to provide them with basic MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 43 building blocks of successful team interaction that can lead to interprofessional collaboration. The following final section provides a review of some of the research on mental health, relating to supervision in rural and remote areas. Research on Mental Health, Relating to Supervision in Rural and Remote Areas Mental Health Supervision in Rural Canada According to World Bank (2018) population density estimates, the Canadian population has an average population density of four people/sq km, compared to the United States, with 36/sq km. A slight increase to Zapf’s estimates (1985) had Canadian population density at four people/sq km, compared to the United States at 30.7 people/sq km. As in Australia, displacement of Indigenous people by European settlers occurred in Canada. Canadian Indigenous people have experienced difficulties similar to Australian Indigenous people: stolen generations; poverty; displacement; poor health outcomes; and substandard living conditions. Approximately two thirds of Canadian Indigenous people are reported as living in rural and remote regions. The average life span for Indigenous people in Canada is six years less than the national average (77 years compared with 82.8). However, this is six years more than the average reported for Indigenous people of Australia (71 years). According to Schmidt (2009), although there is substantial literature pertaining to supervision, the aspect of geography has not been well considered. Literature on mental health supervision is even more limited. In a study that involved social work supervisors from British Columbia, Alberta, and Yukon, Schmidt established a number of unique supervisory challenges. The study cited child welfare supervisors whose work involved mentoring and supervising social workers around mental health aspects of child welfare. Turnover and retention issues were topmost of challenges facing supervisors in rural areas, MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 44 which meant that supervisees would be less experienced in their work in the north. On a positive note, supervisors described the northern rural social work environment as less rigid and more flexible, which allowed for more creativity, with the need to pursue a generalist practice. Schmidt (2009) concluded that supervision in the northern rural areas included a significant amount of education because of younger and less experienced staff members. Also, the need to support supervisees’ personal and social challenges is high because of feelings of isolation for those new to that environment. Due to geographical influences, demands placed upon social work supervisors in northern Canada are unique, and social work supervisors need a clear understanding of generalist social work practice. In one of the few reports from rural Canada, Hunter (2006) observed that some issues complicate access to mental health in northern British Columbia. Problematic issues include cultural issues, lack of expertise, travel, residential school syndrome, alcoholism, family violence, and poor collaboration between mental health professionals and family physicians. The author pointed to some interim solutions, such as collaboration in the form of teleconferencing and workshops. To describe how poor mental health services are in northern BC, Hunter stated: “all the parties identified mental health care as the most underserviced aspect of professional health care in non-urban areas…. a huge area—about the size of France. The nearest psychiatric unit is in Terrace… 6 hours from Dease Lake by road” (p. 74). Hunter (2006) underscored that, in Canada, there is a need for more studies in rural social work supervision; more so in mental health supervision. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 45 Mental Health Supervision in Rural vs. Urban Regions A “one size fits all” approach (Ducat et al., 2016, p. 29–30) does not hold true in rural remote supervision and more research is needed to investigate factors that contribute to effective supervision. In their Australian study titled Oceans Apart, Yet Connected, these authors addressed the health status of metropolitan versus rural and remote settings. They observed that recruitment and retention of staff as well as professional isolation are persistent challenges in rural settings. The authors concluded that, despite its useful and positive influences, there are numerous barriers to supervision in rural remote settings that heath care and stakeholders should consider when implementing supervision practice. In Canada “Overall, rural Canadians are less likely than urban Canadians to experience mental illness and more likely to experience social support, belonging in community, and low stress. However, young rural Canadians, especially males, are at greater risk of completed suicide and there is considerable variability across rural communities” (Brannen et al., 2012, p. 238). Hence the unique need for mental health services and supervision. As an example of such uniqueness, according to Kuhn (2009, as cited in Paulson and Casile, 2014), supervisors who work in rural areas report feeling unprepared and developmentally unequipped for roles as clinical supervisors and that, unlike urban areas, lack of supervision training and support is a main reason for unsound practices in rural areas. In rural areas, supervisors face tremendous responsibilities and demands, which can impede their supervisees’ growth and development (Bernard & Goodyear, 2004). Rural supervisors also face many challenges which require specific supervisory training and support. However, according to Casile et al. (2007), agencies do not provide support to prepare counsellors for supervisory roles. The challenges outlined above are MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 46 unique to the rural context and can have a profound effect on the quality of supervision as well as the services provided. Scott et al. (2006) observed that it is unfortunate that supervisors who do not receive initial training often continue to provide supervision without additional training. In the US, Gellis et al. (2004) undertook a comprehensive survey titled Urban and Rural Differences in Job Activities, Job Stress, and Job Satisfaction. The authors observed that, since 1988, the adult case management initiative has been operating in New York, a state comprising 38 urban and 24 rural counties that have local administrative authority over mental health services: Case managers (CMs) primarily serve individuals with serious and persistent mental illness, individuals who have frequently used acute inpatient services, and individuals who have extended stays in state inpatient psychiatric facilities. In New York state, the objectives of case management services are: “(1) to employ a client-centered focus to improve individual outcomes and recovery, (2) engage leadership in the processes of decision-making within the mental health service delivery system, and (3) to identify systemic barriers to effective interventions” (Gellis et al., 2004, p. 43). Gellis et al.’s study (2004) examined differences among CMs working in urban and rural settings in their perceptions of job-related stressors. The study also investigated the intensity and frequency of the occurrence of job stress among the sample. According to the author, urban-based CMs reported higher overall job stress, and greater frequency of lack of organizational support than did their rural counterparts. The higher the levels of job stress, particularly the recurring perception of a lack of organizational support, the lower the level of job satisfaction scores was for both groups. The observed differences in the scores of the two MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 47 case management groups can be interpreted by examining the individual job stressors that were perceived by the urban and rural workers (Gellis et al., 2004). According to the above study (Gellis et al., 2004), urban CMs attributed greater job stress intensity and frequency than did rural workers to stressors related to coordinating service activities. Examples included: conflicts with other departments’ services; lack of participation in policymaking decisions; internal agency factors such as fellow workers not doing their jobs; experiencing negative attitudes toward organization; and individual intrinsic motivating factors—for example, lack of opportunity for advancement. The authors concluded that the perceived lack of organizational support was more apparent than were job pressure stressors. The lack of organizational support as a key job stressor is consistent with previous research, in which human service providers who believed they had fewer job supports reported high stress (Gellis et al., 2004). Some researchers argue that a positive perception of organizational support increases employee commitment through the recognition and rewarding of individual efforts. In the above study, differences between urban and rural CMs in the US could be attributed to distinct regional experiences and practices in mental health agencies, as is the case in many other countries. Gellis et al. (2004) surmised that urban CMs often have to deal with higher living costs and perhaps a more stressful environment, whereas rural CMs may deal with long distances and the scarcity of resources. The above findings demonstrate the complexity of the challenges facing mental health workers in urban and rural jurisdictions. Other differences between rural and urban mental health supervision are related to racial and cultural diversity. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 48 Cultural Competence, Indigenous People, and Professional Supervision According to Te Pou (2009), professional supervision is one of a number of ways of developing cultural competence. Cultural competence involves assisting the supervisee to understand the perspectives of people of a different cultural group, as well as the impact of the interaction of these cultures. “Culture as a term encompasses ethnic, gender, religious, sexual identity, ability and age diversity. Competence in this area is critical to providing culturally safe and effective mental health and addiction nursing and therefore improving outcomes for service users” (New Zealand Ministry of Health, 2006, as cited in Te Pou, 2009). As helping professionals practicing in either rural or urban locations often encounter clients from diverse cultural backgrounds, the need for cultural competence in mental health practice has been described as a professional as well as a moral and ethical imperative (Scerra, 2012). As an example, although nurses were traditionally educated not to recognize people’s differences in the provision of nursing care (Papps & Ramsden, 1996), in recent decades the Canadian health care system has provided care for an increasingly diverse population. According to McKinney (2006), cultural supervision has been described as the means for achieving cultural competency, whereas cultural competency is considered as the ability to work with those from other cultures through acquired skills that enable the worker to gain a greater understanding of the other culture. The author adds that cultural supervision is also associated with cultural safety, which centres on the acknowledgement of the impacts of colonization on clients. In urban centres and in some rural areas of Canada the emphasis on cultural safety involves various minority groups, Indigenous and non-Indigenous Canadians. According to Scerra (2012), cultural MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 49 understanding needs for supervisors are not limited to Indigenous populations. Gardner (2002) studied cross-cultural supervision relationships with a sample of mainly AfricanAmerican counsellors. Regarding supervisor competence, the author noted that: “supervisees felt supervisors were competent if they were knowledgeable, demonstrated good facilitative skills, and possessed attributes of compassion, concern, fairness, and honesty. This perceived competence led supervisees to express confidence in their supervisors and in themselves” (Gardner, 2002, p. 102). However, according to the Supervision Directory Steering Group (2005) in New Zealand, the use of the term cultural supervision is not generally accepted; it has been suggested that it should be considered redundant as it highlights a supervision that is different from the mainstream western forms of supervision. There is, however, agreement and acceptance among Maori nurses of New Zealand that clinical and cultural issues in practice should be addressed together. According to Scerra (2012), the strongest literature on cultural supervision comes from Aotearoa, New Zealand, around models of supervision of Maori staff. The author explained that, although there is some international literature on cultural supervision, countries should develop their own models of supervision because there are significant differences in the cultural needs of staff. The author, however, provided the following five questions, which can be considered when developing a model of supervision specifically for Indigenous staff: (1) Are there specific Aboriginal practices/stories that can be used as a framework for an appropriate and culturally relevant model of supervision? (2) Are there Aboriginal terms that have greater cultural meaning that could replace the term ‘supervision’? (3) Are cultural practices more aligned to individual supervision or peer/group MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 50 models? (4) Would the use of stories provide a culturally safe way for Aboriginal staff to explore practice issues? And (5) Who should the supervisor be? (Scerra, 2012). A handbook from the Centre for Addiction and Mental Health (2008), Clinical Supervision Handbook, provides some guidelines on clinical supervision. According to the handbook, there are two distinct but interrelated levels within the supervision process: 1) developing a clinician’s capacity in cultural competence; and 2) addressing the dynamics of culture and difference within the supervisee-supervisor relationship. Summary In conclusion, the importance of mental health workers in various communities is clearly underscored by the definition of their job, provided earlier under key terminologies. Also important is the supervision of mental health workers to ensure not only quality of service to the community, but also support and training for mental health workers. There is acknowledgement by researchers, professionals, and policymakers that mental health workers deal with a host of stressful experiences in their day-to-day work: hence the importance of appropriate supervision in mental health. In this literature review, various aspects of mental health supervision identified to be crucial to successful supervision have been explored, including (a) organization/administrative functions, (b) clinical practice (education), and (c) provision of personal support to employees. Since research studies on mental health supervision in rural remote settings are limited, and given the challenges faced by the front line workers within these settings, this research study sought to explore the nature and potential challenges faced by mental health supervisors. Literature reviews on mental health indicate that supervisors are usually responsible for administrative work, which may include an organization’s daily operational MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 51 requirements, such as allocation of duties. Supervisors are also responsible for ensuring that best practices in clinical work are upheld, as well as supporting supervisees in their professional development. This review also looked at the history, nature, and challenges in Canadian health care with emphasis on mental health policies, all of which should be clear to those seeking mental health supervisory responsibilities in rural remote regions. Mental health supervisors require proficiency to manage the above listed tasks, and success in their work hinges on how professionally prepared they are, hence a need for education and ongoing refresher courses. Unlike their supervisees, mental health supervisors in many parts of the world do not have formal training and are usually promoted into their supervisory jobs. As evident in this literature review and other research, with the exception of New Zealand, training of mental health supervisors in many parts of the world is mostly informal, limited, or non-existent. The comparative differences in mental health work and supervision between lower and higher income countries is also evident in this review. Due to economic challenges, lower income countries are not in a position to support some medical or mental health services. More research is needed to establish affordable strategies in mental health services and supervision for low income countries. As more research is carried out in rural regions in different parts of the world, the relationship between appropriate supervision in rural regions and worker retention is also attracting attention. Challenges faced by rural populations are unique to their geographical locations and require a uniquely trained workforce. Therefore, mental health supervision in rural areas presents some unique training challenges, where workers will require more education and experience. The disparities between mental health supervision in urban and MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 52 rural areas provide a unique lens through which the challenges of rural mental health supervision may be looked at and addressed. Consedine (2000) surmises that appropriate supervision enables people to develop by encouraging them to process appropriately the experience(s) they are struggling with in their professional practice, rather than forcing them to struggle with what we (others) think is important for them. Hence the need for ongoing research on supervisory challenges. The lack of any local research on this topic necessitated my research study on mental health supervision in northern British Columbia. The next chapter addresses the study context and setting. Chapter Three: The Study Context and Setting A Brief Summary of Health Care in Canada—Historical Highlights, Funding Mechanisms, and Challenges Health Care Systems A good background in broad pertinent health care knowledge can be helpful before embarking on supervision in Canadian mental health services. There are four different health care models used in industrialized nations: the Beveridge model; the Bismarck model; the national insurance or Tommy Douglas model; and the out-of-pocket model (Smith et al., 2012). The Beveridge model, named after social reformer William Beveridge, characterizes systems financed and provided by governments. This system best characterizes health care in the United Kingdom, Spain, Scandinavia, and New Zealand. The Bismarck model, named after Prussian Chancellor Bismarck, is insurance-based and funded by employers and employees through payroll deductions. Countries such as Germany, France, Belgium, the Netherlands, Japan, and Switzerland use this model. The National Health insurance model has both Beveridge and Bismarck elements and uses private sector providers. The National Health Insurance Model is used in Canada, Taiwan, and other countries. The fourth model is the cash payment or out-of-pocket model, which is found in low income countries that cannot afford to maintain a health care system (includes countries in Africa, South America, India, China, and others) (Smith et al., 2012). China is a unique case as over the last 10 years the world’s most populous country has gradually adopted the National Health Insurance Model, a basic health care safety net. According to a report on International Health Care System Profiles from the Commonwealth Fund, since 2016, 95% of China’s population has medical MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 54 coverage under two main programs: 1) voluntary, residency-based, basic medical insurance; and 2) mandatory, employment-based program for urban residents with formal-sector jobs. By the year 2020, China plans to establish an equitable and effective health care system by strengthening health care delivery and security (Meng et al., 2019). As a massive long term social endeavour, China’s health care system’s 10-year reform plan, which started in 2009, may provide many lessons on future health care reform and research. Measures to ensure effective delivery and quality of care among the above countries differ. As an example, Canada’s health care system is shaped by a federalist division of responsibilities with a national public health insurance administrated by provinces/territories, each running their own health plan (Commonwealth Fund, 2020). Countries such as France have mandatory accreditation systems for hospitals as well as external assessments of doctors, every five years. Whereas there is no system of continuous revalidation of physicians in Canada, hospitals are accredited, and there is an expectation of lifelong learning by provincial jurisdictions. Quality of care improvement is mainly monitored at the provincial and territorial level (Commonwealth Fund, 2020). Conversely, there are some significant common endeavours among the above countries, mainly related to addressing health disparities of vulnerable groups, such as the Indigenous people of Canada, Australia, and New Zealand, and those in poverty. These countries have designated bodies that address respective disparities within their health care systems, an example being the Public Health Agency of Canada (2020). In terms of cost, due to the historical rise in costs, the complexity of sustainability in health care systems has been addressed in various ways, for example, higher fees to users in market-based systems (Lega et al., 2013). However, the idea of putting in more money has MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 55 not solved the problem of ever-increasing costs. According to Lega et al. (2013), since the 1960s, western countries have seen the development of new health techniques, challenges, and technologies, such as pharmaceuticals, the aging population, high prices of health care management (input), to name a few, necessitating new efforts in cost containment. By 1990, the option of matching the high cost with increases in funding led many health care systems and organizations to overlook inefficiencies in the production process, which has in turn worsened sustainability issues (Lega et al., 2013; Starkey, 1992). These authors further explain that, throughout the 1980s, sustainability issues and the inefficiency of health care were addressed by more funding and increases to insurance fees. And when the delivery system needed more resources, health care professionals pressed politicians for more funding. This led to a continuous vicious cycle, with little effort made to address effectiveness or inefficiencies of health care systems. For example, the authors point to “clinicians focus on the individual patient, the effectiveness of the care, and evidence-based practices with little attention to cost control” (Lega et al., 2013, p. 46). Instead, Lega et al. and Starkey propose that addressing managerial and sustainability issues requires a vision oriented toward the entire population, with greater attention to allocative efficiency and cost control. There is increasing interest in evaluating the impact of management on clinical and other aspects of performance. Managers in health care face inconsistent and conflicting external stakeholder expectations, various institutional forces brought about by political influence, and strong market forces (Lega et al., 2013; Starkey, 1992). For example, since the 1980s, Canadian provincial governments have been exploring ways of addressing inefficiency and the growing cost of Medicare with several major reports completed in 2000– MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 56 2004. While the Canadian health care reform focuses on the financial sustainability of the public health care system, much of the debate has centred on whether to allow private involvement to reduce the pressure on the public system (Bryant, 2016). As a follow-up to the general overview, and some challenges in modern international health care management systems, the next section recaps the history of Canada’s health care with some examples of the challenges facing the health care system. The following history of Canada’s health care provides a background of the context in which mental health supervisors’ work. A Brief History of Health Care in Canada Canada’s health care history can be traced back to the Canadian Constitutional Act of 1867, which defined the powers of the federal, provincial, and territorial governments (Health Canada, 2019). Under the Constitutional Act (1867), the responsibility for managing and maintaining hospitals, asylums, and charitable organizations was handed to provinces. Although the Federal Department of Health was created in 1919, health care was mainly privately delivered, with limited coordination between the federal government and the provinces, until the late 1940s (Health Canada, 2019). After the Second World War, provinces, led by the government of Saskatchewan, introduced province-wide, universal hospital care. The federal government, in its 1957 Hospital and Diagnostic Services Act, offered to reimburse the provinces for half the cost of hospital care. Ever since, a number of changes to the Canadian health care system have been instituted, including the gradual implementation of provincial medical insurance plans, and Canada Assistance Plan (CAP) and the Medical Care Act (1966), which established 50/50 cost sharing between the federal and provincial/territorial governments: Three First Ministers’ Accords, signed by provincial and territorial governments in 2000, 2003, and 2004, to review health care; and two MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 57 commission reports by Hon. Roy Romanow and Hon. Michael Kirby provided additional directions for improvements to Canada’s health care system. Health Canada (2019) reported the Canadian health care system has faced challenges in recent years due to a number of factors, all of which are expected to continue in the future. The challenges include changes in the way services are delivered, fiscal constraints, the aging baby boom generation, and the high cost of new technology. Trends in the Canada Health Care System are characterized by the following: primary care system that requires ongoing improvement; advancement of eHealth with modern recordkeeping innovation; wait time reduction; and patient safety (Health Canada, 2019). Governments are no longer just throwing money at health care problems, for example, there appears to be greater interest in patient-focused models and primary health care development. How Mental Health Fits Within the Canadian Health Care System: History, Funding, Challenges, and Tensions Until the creation of the Mental Health Commission of Canada in 2007, Canada’s federal government was not involved in the funding of specific provincial and territorial mental health services (Marchildon et al., 2013). However, in the form of transfer payments to provinces, Canada’s federal government has contributed to Canadian health care services for nearly a century (Maioni, 2015). According to Maioni, national health insurance in Britain and United states started in 1911 and 1912 respectively, but it was not until after the end of WWI in 1919 that Canada’s federal Department of Health was created. Between 1919 and 1947, the federal government’s support for health care services was privately delivered and funded (Fierlbeck, 2011). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 58 Between 1947 and 1962, major changes in health care organizations took place. All Canadian provinces and territories introduced province-wide, universal hospital care, and in 1957 the federal government passed the Hospital Insurance and Diagnostic Services Act (HIDS) (Health Canada, 2011). With this act, the federal government offered to reimburse, or cost share, one-half of provincial and territorial costs for specified hospital and diagnostic services. All the provinces and the territories joined HIDS, with Quebec being the last to join the program in 1961, marking the beginning of the federal and provincial and territories’ wavering health care relationship (Health Canada, 2011). In the early 1960s, as a result of pressure from some provinces, most prominently Saskatchewan which advocated for universal health care, the federal government appointed a Royal Commission on health services (Maioni, 2015). The commission’s support for universal health care culminated in an influential 1964 report, passed by the federal parliament as the Medical Care Act, in 1966. The new act offered to reimburse one-half of provincial and territorial costs for medical services provided by doctors for outpatient cases (Health Canada, 2011). The same year (1966), the federal government passed the Canada Assistance Plan (CAP), a cost-sharing arrangement for social assistance (Gauthier, 2012). Notably, between 1957 and 1977, the federal government committed to finance half the cost of health care for all provincial and federal expenditures on insured hospital and physician services. In 1977, the 50–50 cost sharing between the federal government and the provinces and territories was replaced by block funding, referred to as the Federal–Provincial Fiscal Arrangements and Established Programs Financing Act (EPF) (Marchildon et al., 2013). Marchildon et al. explain that block funding in this particular case meant a combination of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 59 cash payments for services such as Health Care and Diagnostic Services (HIDS), health care, and post-secondary education. The authors further note that this new funding arrangement would allow provincial and territorial governments flexibility to invest health care funding according to their needs and priorities. However, EFP turned out to be a fiscal restraint measure as funding was tied to the rate of national economic growth (Maioni, 2015). According to Provincial and Territorial Ministers of Health (2000), introduction of EFP gradually reduced the federal government’s contribution from 26.9% at the beginning of block funding in 1977–78 to 16.3% in 1995–96. To consolidate the federal/provincial/territories’ HIDS arrangement, the landmark 1984 Canada Health Act legislation was passed, replacing federal hospital and medical insurance acts (Marchildon et al., 2013). The authors add that one of the aims of the new act was to ensure universal health access and preclusion of user fees to all Canadians throughout the provinces and territories. Within the Canada Health Care Act, the federal government introduced the following five conditions as funding criteria by which provinces and territories would receive funding for health care services: Public Administration: The provincial and territorial plans must be administered and operated on a non-profit basis by a public authority accountable to the provincial or territorial government. Comprehensiveness: The provincial and territorial plans must insure all medically necessary services provided by hospitals, medical practitioners, and dentists working within a hospital setting. Universality: The provincial and territorial plans must entitle all insured persons to health insurance coverage on uniform terms and conditions. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 60 Accessibility: The provincial and territorial plans must provide all insured persons reasonable access to medically necessary hospital and physician services without financial or other barriers. Portability: The provincial and territorial plans must cover all insured persons when they move to another province or territory within Canada and when they travel abroad. The provinces and territories have some limits on coverage for services provided outside Canada and may require prior approval for non-emergency services delivered outside their jurisdiction. (Health Canada, 2011) More health care funding cuts by the federal government followed in 1995 with amalgamation of the following programs: health care support, post-secondary education, and social services support/social assistance, to form the Canada Health and Social Transfer (CHST) (Provincial and Territorial Ministers of Health, 2000). According to the Provincial and Territorial Ministers of Health report, the unilateral measures by the federal CHST went into effect during the 1996–97 financial years. By the following fiscal year, 1997–98, “the value of federal government transfers to provinces and territories had fallen to $12.5 billion. CHST was $6.5 Billion—or 33% less than EPF and CAP had been in 1994–95” (Provincial and Territorial Ministers of Health, 2000, p. 8). Between 1999 and 2000, the federal government partially supported the CHST with a one-time supplement of $3.5 billion and increased the CHST base amount from $12.5 billion to $15 billion (Provincial and Territorial Ministers of Health, 2000). The CHST arrangement lasted until the year 2003, when a provincial and territorial health ministers’ meeting agreed on the Accord on Health Care Renewal, which was aimed at providing structural change to Canada’s health care system to support access, quality, and MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 61 long term sustainability (Health Canada, 2011). As a result, in 2004, the federal government split CHST into two sections: Canada Health Transfer for Health, and Canada Social Transfer, which covered post-secondary education, social services, and social assistance (Health Canada, 2011). The First Ministers also announced further reforms in a 10-year plan to strengthen health care which included: wait time management; health human resources; Indigenous health; home care; and primary health care, among several commitments. In support of the changes, the federal government increased cash transfers to the provinces and territories in 2006–2007 to 2013–2014 (Health Canada, 2011). Also, the provincial and territorial ministers agreed that, effective April 2004, the change would include an increase to federal health care support for Canada Health Infoway, to stimulate new telehealth initiatives (Canada Health Infoway, 2006). The following health system diagram (Figure 1) explains the relationship between Canada’s federal government and the provinces and territories. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 62 Figure 1: Organization of the Health System of Canada Source: http://www.euro.who.int/__data/assets/pdf_file/0011/181955/e96759.pdfIn In 2011, in a new fiscal proposal, the late Jim Flaherty, Federal Finance Minister, provided provincial and territorial finance ministers with a plan for renewal of major transfers, beginning 2014–2015 (Council of the Federation Secretariat, 2012). The secretariat observed that this change, which was confirmed in the 2012 federal budget, would collectively (in comparison to the 2007 federal commitment) reduce health care transfers to provinces and territories by $36 billion between 2014–15 and 2023–24. Similar cuts in funding would also impact other transfers such as CST, Equalization payments, Territorial Formula Financing (Council of the Federation Secretariat, 2012). Although future federal funding for health care appears grim, it is noteworthy that a change in Canadian federal MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 63 political leadership may continue to alter the course of Canada’s future fiscal policies on health care funding. The following graph (Figure 2) shows trajectories of Canada Health Transfer between 2005 to 2024. Figure 2: Actual and Projected Total CHT Entitlements, 2005/06 to 2023/24 Source: http://www.canadaspremiers.ca/phocadownload/publications/cof_working_group_on_fiscal_arrange ments_report_and_appendices_july.pdf As observed earlier in this review, until 2007 the Canadian federal government was not involved in the funding of specific provincial and territorial mental health services, leaving that responsibility to the provincial and territorial governments (Kirby, 2008). The author noted that Canada was the only G8 country that did not have a mental health strategy until 2012. However, in 2007, Out of the Shadows at Last—the first federal senate committee report on mental health (Dr. Kirby, Chair)—was completed. The report, known as the Kirby Report, recommended the formation of the Mental Health Commission of Canada (MHCC). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 64 This was endorsed and supported by the provincial and territorial governments. The commission’s strategic initiatives were to develop a national mental health strategy, combat stigma and discrimination, and promote knowledge exchange. The long-awaited first Canadian mental health strategy was unveiled in 2012 with the following recommendations: The promotion of mental health across the lifespan in homes, schools, and workplaces, and prevent mental illness and suicide wherever possible; fostering of recovery and well-being for people of all ages living with mental health problems and illnesses, and upholding of their rights; provision of access to the right combination of services, treatments, and supports, when and where people need them; reduction of disparities in risk factors and access to mental health services, and strengthening the response to the needs of diverse communities and Northerners; working with First Nations, Inuit, and Métis to address their mental health needs, acknowledging their distinct circumstances, rights and cultures; and finally, mobilization of leadership, improvement of knowledge, and fostering of collaboration at all levels. (Mental Health Commission of Canada, 2012) According to Lurie (2014), the above strategy was hailed as an important milestone. But some critics have observed that, due to poor funding, the commission may have limited impact mainly because health care is under provincial and territorial jurisdiction, which complicates the latter’s financial matters. The author further purports that, although MHCC has an operating budget of $15 million, the federal government has so far not provided the commission with the support funds amounting to $536 million, meant for improvement of mental health services. According to Lurie, since 2012, the federal government has only provided a one-time amount of $110 million meant for housing research projects spread over MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 65 five years, which amounts to $7 million per annum support for the national mental health strategy. The author also noted that “over the past twenty years all provinces developed mental health plans, but while they set out policy direction, they lacked targets and funding commitments. As a result while there has been increased funding for health care over the past 10 years, very little of the increase was allocated to mental health” (p. 685). The 2012 Canadian mental health strategy is a step in the right direction, to help address the challenges facing the continuing deinstitutionalization in mental health, but only if investment in community services is forthcoming. According to Lurie (2014), corporate Canada is taking an increased interest in mental health, which may influence and contribute to the creation of a political will that might hopefully make mental health a priority. However, with the rise in health care costs and diminishing support from the federal government, the provinces’ and territories’ chance for increased mental health funding is limited (Lurie, 2014). Public spending on mental health in Canada is 7% of public health spending on health overall (Jacobs et al., 2010). Pressure is mounting on Canada to increase the funding of mental health to 9% of the national health expenditure on by the year 2022, considering that it is currently lower in comparison to most OECD countries (Canadian Institute for Health Information, 2019). After reviewing Canadian national mental health history and policies, the next sections will look at the challenges in Canadian health care, focusing more specifically on northern British Columbia. Challenges in Canadian Health Care Rising Costs There are concerns about rising health care costs and acute care dominance within the Canadian health care system. These concerns have been persistent for at least four decades. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 66 Significant pertinent reports on health care reform strategies were issued between 2000 and 2004, which included the 2001 Mazankowski Report, prepared for the Alberta Government; the 2002 Romanow Royal Commission on Health Care; the 2002 Kirby Report from the Canadian Senate; the 2001 Fyke Commission on Medicare in Saskatchewan; and the 2001 Clair Commission on the Study of Health and Social Services in Quebec (Bryant, 2016). Although some more than others, various recommendations from these reports remain influential in the quest for Canadian Medicare sustainability. The Mazankowski, Kirby, and Romanow reports proposed changes to the current coverage of health services which included; public cost sharing strategies such as user fees, premiums, deductibles, and taxation. A key recommendation by both the Mazankowski and Kirby reports was the medical savings account (MSA), a high-deductible health insurance that can be set up by individuals, employers, or governments. Other cost-related recommendations included health care guarantees that would reduce wait times and public-private partnership (Bryant, 2016). Another complicating factor has been the drop in federal health care funding, which has complicated the provincial and territorial health care budgets. According to the Institute of Fiscal Studies and Democracy (IFSD, 2019), Canadian health care spending is the largest item in all provincial–territorial budgets and historically health care has grown faster than the rate of growth in domestic product. This report further states that Canada’s aging population and the advancement in technology have led to an increasing demand for health care (IFSD, 2019). These trends are expected to continue as indicated by a noted gradual spending increase. An earlier report by Jason Fekete, cited in the National Post of September 16, 2013, noted that the reduction in Canada Health transfers by the then-ruling Conservative government would lead to severe financial strains for the provinces and territories. The report MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 67 added that the federal funding cuts would lead to an increase in the struggle for affordability of health care services within provinces (Fekete, 2013). In a more recent report by IFSD (2019), the future of federal funding to provinces and territories, also known as the Canadian Health Transfer (CHT), is bleak, with the forecast by IFSD indicating that the cost of health care will continue to rise over the next 25 years. In addition, the report states that the rising cost will be unsustainable, hence the need for alternative funding policies (IFSD, 2019). Acute Care Dominance Ongoing Canadian reviews on hospital-based and outpatient-based services have indicated a need for expanded post-acute care resources. Despite concerted efforts to improve primary and community care services, acute care remains a challenging and costly undertaking. Long term health care cost savings may be achieved, in part, by efficient acute care services that reduce the demand for hospitalization. For example, persistent challenges in Canada’s acute care services are evident in the long wait times. According to a Commonwealth Fund report, How Canada Compares (2016), 29% of Canadians had to wait four or more hours when they visited the hospital emergency department. The same report observed that once admitted to hospital, patients remained in the emergency department for an average of 32.6 hours which was 11% longer compared to 2015. Another acute carerelated challenge has been long wait times for alternative long term care patients (ALS) due to the lack of or limited community care alternatives. According to the Ontario Hospital Association (2019), in October 2018, there were 600 more ALC cases than in 2015, an increase of almost 15 percent. The above two examples call for an expansion of community care services for post-acute care patients. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 68 One of the strategies used by a majority of Canadian provinces to address the rising cost and acute care dominance has been the regionalization of health care services. According to Bryant (2016), regionalization refers to the devolution of decision making in health care to local authorities whereby the responsibility for delivery of health services is referred to municipal or regional governments. “The rationale for regionalization is that local or municipal government are perceived as best positioned to identify and are most responsive to local needs” (p. 227). The following is a brief review of regionalization in BC. Regionalization of Health Care in British Columbia To address the rising cost of health care and acute care dominance, BC and other Canadian provinces had adopted regionalization by the early 1990s. According to Hanlon (2017), regionalization in the context of Canadian health care involves the transfer of responsibility for the delivery of health services to a geographically delineated board or organization. One of the aims of regionalization was to reduce geographical disparities in program function and service availability. In BC, the Liberal government under Campbell overhauled the provincial regionalization strategies by reducing the NDP’s 52 medical boards to five regional health authorities and one provincial health services authority. The Provincial health Service Authority was to oversee highly specialized care (Hanlon, 2017). Bearing recommendations from a 1991 Royal Commission on Health Care and Costs, there was much support from politicians across the political spectrum for proposed health care regionalization (Morrow et al. 2010). Those who supported regionalization saw it as: a tool to increase involvement in the care process by residents; as way of fostering local accountability; as an opportunity to improve mental health care due to the proposed relocation of mental health from large institutions to community settings; MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 69 and as a way of encouraging local responsiveness of access to health services provided closer to home. (Morrow et al., 2010, p. 15) These hopes led to increased energy towards working out the details of regionalization of mental health care, which culminated in the 1998 BC Mental Health Plan. According to Morrow et al. (2006), while interested parties such as bureaucrats, health managers, patients, and communities were preparing for the shift, other changes were happening. As the implementation of regionalization was taking place, a dramatic shift in the provincial political climate was also taking place, which included sharp policy shifts, and cutbacks to the social welfare system. In addition, some studies have suggested that all the prevailing changes led to adverse impact on community-based supports for people with mental illnesses. “Thus, any assessment of regionalization in BC must take this wider policy context into account” (Morrow et al., 2010, p.15). Subsequently, in her remarkable address to the 2015 National Health Leadership Conference, Louise Bradley, President of the Mental Health Commission of Canada, addressed the above challenges from wider policy context, emphasizing the need for increases in mental health spending. Ms. Bradley went on to remind the participants about some relevant national statistics including: that 70% of adults who suffer from mental illness experienced the first signs before the age of 18, with an estimated 4,000 Canadians dying by suicide each year. By age 40, one in two Canadians will have had, or have, a mental illness; in any given year. Also, one Canadian in five experiences a mental health problem or illness. Also, every week, 500,000 Canadians miss work due to mental health problems or illnesses, and that 30% of all work-related disability claims in Canada are attributed to mental illness. Finally, Bradley (2015) observed that short and long term disability claims for mental health MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 70 problems cost organizations twice the amount they pay out for non-mental health related claims. Introduction of For-Profit Health Care Financing Proponents of health care reform advocate for the inclusion of private sector clinics to address some of the challenges in Canadian health care. Colleen Fuller (2015), of the Canadian Centre of Policy Alternatives, gives an example of the attempt by Cambie, a private sector clinic which advocates challenging the right to universal public health care. The author explains that the ongoing case in British Columbia’s Supreme Court “poses the most serious threat to the principles of equality and universality that Canada’s public health care system is built upon” (p. 5). The matter, famously known as the Cambie case, remains unresolved with the plaintiff emphasizing that “You cannot have it both ways. You cannot promise health care, then not deliver it in a timely way, then outlaw the patients’ ability to access it independently” (Bains, CBC News, 2019). The Cambie private sector clinic lost the years-long case at BC Supreme Court on September 10, 2020 (Dutt, Toronto Star, 2020). Another involvement of the private sector has been the employers’ funding of employees’ health care benefits. Statistics from Canadian Centre for Policy Alternatives indicate a declining number of employer-sponsored health and dental benefits since the late 1990s. According to the report, in 2005, the last year for which statistics are available, only 40% of Canadian workplaces offered health-related benefits, covering 51.3% of employees for health care, and 56.1% for dental care (Fuller, 2015). According to the report, in 2014 the percentage of BC workers with employer-sponsored health benefits (excluding dependents) stood at 36%, one of the lowest rates in Canada. The author further observed that Canadians are open-minded about health care reforms and are willing to learn from experiences in other MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 71 provinces and countries. However, “polls indicate that Canadians are not inclined to support the right to pay over other considerations” (p. 34). As an example, although mental health services in Canada and United States vary significantly in contemporary times, the two countries share significant historical mental health management trends. In summary, various politics and market oriented voices continue to advocate for changes to Canadian health care. Political voices reflect the unified desire to provide access to health care to all members of society on the basis of need while the market oriented voices advocate for health care privatization and commodification to address inequities in access (Bryant, 2016). A sizeable share of health spending in Canada is in the private sector; this type of spending is one way of gauging the shortcomings of universally accessible health services. As an example, according to CMHA, Canadians spend close to a billion dollars ($950 million) on counselling services each year and 30 per cent of it is out of pocket (Canadian Mental Health Association, 2018). The following section addresses the complex organization and management of mental health services in northern BC. Organization and Management of Mental Health Services in Northern British Columbia: What a Context for Mental Health Supervisors The review provided in this section helps in understanding the context of mental health care delivery in northern BC. It will include an overview of relevant government reports regarding the context within which mental health supervision and training are carried out within the region. The focus will be the involvement of various ministries, Indigenous organizations, and NGOs in mental health service delivery. The overall goal of this review is: 1) to gain an understanding of the challenging bureaucracy and the opportunities experienced by mental health supervisor, and 2) to review the disciplinary/jurisdictional differences MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 72 and/or similarities in mental health supervisory approaches. For this analysis, supervision refers to the leadership role by middle level managers who oversee frontline mental health work and whose supervisory functions include administration, education, and support (Kadushin & Harkness, 2002). Organization of Mental Health Services The Northern Health Authority (NHA) is one of six British Columbia regional health authorities: It covers most of the province’s vast northern region. The federal and provincial governments jointly fund Canada’s health care, and the historical relationship between the two levels of government was discussed earlier in literature review. First, I will address the relationship between BC’s Ministry of Health and the Northern Health Authority (NHA). Second, I will address the governance and management of the NHA, with emphasis on mental health services. Third, I will address the involvement of various ministries, Indigenous organizations, and NGOs in mental health service delivery. Within each step of this review of mental health care delivery in northern BC, relevant legislative acts that govern health care and, more specifically, mental health, will be addressed. This analysis is derived from federal and provincial government documents, diagrams, maps, and charts. BC’s Ministry of Health and the Northern Health Authority The Ministry of Health in BC is responsible for ensuring the provision of quality, appropriate, cost-effective, and timely health services to all British Columbians, and operates under the following Acts: 1) Medicare Protection Act and regulations which governs the provision of British Columbia’s public health care system; 2) Health Professions Act which regulates health profession; 3) Public Health Care Act which supports key public objectives to MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 73 promote health and prevent disease and injury; 4) Health Care Costs Recovery Act which allows the province of British Columbia to recover health care costs related to personal injury claims whether or not a lawsuit has been filed; and 5) Mental Health Act which deals with implications for individuals requiring involuntary treatment or receiving voluntary treatment under the act, their families and service providers. (BC Ministry of Health, 2020) The Ministry also oversees several provincial programs, including the Medical Services Plan, which covers most physician services; PharmaCare Plan, which provides prescription drug insurance; and BC Vital Statistics, which registers and reports on vital events such as birth, death, or marriage (BC Ministry of Health, 2020a). BC’s Ministry of Health oversees several organizations that provide mental health services including the health authorities; Indigenous organizations; non-government organizations; professional colleges and associations; and self-help and support organizations (for full list, see Appendix I) (BC Ministry of Health, 2020a). An important mental health initiative by BC’s Ministry of Health is the Healthy Minds Healthy People, a collaboration, unveiled in 2010, with the Ministry of Children Family Development (MCFD) and academic and community partners. The purpose of the 10-year plan was to: Improve the mental health and well-being of the population; improve the quality of services for those with mental health and substance use problems; provide timely and effective service to children youth and adults; reduce the economic to public and private sector resulting from mental health and substance use problems; and focus on evidence based practice using a collaborative approach of both public and private sector. (BC Ministry of Health, 2020a) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 74 Although the 2010 Healthy Minds Healthy People initiative matures in 2020, my review is only concerned with the 2010 plan as this was the guiding policy during my data collection. BC’s Ministry of Health also oversees five geographical regions (Health Authorities) across the province which are responsible for the provision of various health services to meet the needs of the population within each geographic region. A sixth health authority, the Provincial Health Services Authority, manages the quality, coordination, and accessibility of services for some province-wide health programs. BC’s Ministry of Health also partners with the First Nations Health Authority to improve the health status of the First Nations of British Columbia (BC Ministry of Health, 2020a). Northern Health Authority (NHA) is one of the five regional health authorities. Regional Health Authorities The five regional health authorities are: Fraser Health; Interior Health; Northern Health; Vancouver Coastal Health; and Vancouver Island Health Authority. The authorities govern, plan, and deliver health care services within their geographical area and are responsible for the following: “identifying population health needs; planning appropriate programs and services; ensuring programs and services are properly funded and managed; and meeting performance objectives” (BC Ministry of Health, 2020a). Provincial Health Services Authority (PHSA). A sixth health authority, PHSA, is not a geographical region but one that plays the crucial role of partnering with the other five regional health authorities as well as health care professionals, to ensure appropriate provision of health services within the province. PHSA also collaborates with the other authorities to improve access to evidence-informed practice closer to BC residents, effective promotion of health, prevention of illnesses, managing of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 75 chronic conditions, and generally lessening the burden of disease (Provincial Health Services Authority, 2018). Following is a diagram (Figure 3) showing the relationship between BC’s Ministry of Health and the Health Authorities. Figure 3: Relationship between BC Ministry of Health and Health Authorities Source: http://www.ipac.ca/documents/ALL-COMBINED.pdf Based in Vancouver, BC, the PHSA is responsible for the delivery of highly specialized care services in BC, such as heart surgery and cancer treatment. It therefore oversees the ten service agencies (for full list, see Appendix S) in addition to a research mandate as a health science organization for conducting: 1) Basic and clinical research to inform health care and health service decision-making; 2) Multidisciplinary, integrated research programs supporting translational science; and 3) Education and training in the specialized health and human services provided by our agencies (BC Ministry of Health, 2020a). PHSA Involvement in the Provision of Mental Health Services. BC Mental Health and Substance Use Services (BCMHSUS), a branch of PHSA, provides a number of specialized mental health and substance use services for children, MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 76 adolescents, and adults across the province. BCMHSUS is mainly responsible for the following three services: 1) Forensic Psychiatric Services (for management of adults with mental illness who are in conflict with the law); 2) Children and Youth with Mental Health (for specialized psychiatric assessments and treatment of children, youth, and their families from all over BC) and 3) Provincial Specialized Eating Disorders. Both BC Children’s Hospital and St. Paul’s Hospital provide inpatient and outpatient assessments and treatments for BC residents living with eating disorders (Provincial Health Services Authority, 2020). First Nations Health Authority. Another non-geographical authority is the unique First Nations Health Authority, which is aimed at improving health outcomes for First Nations people of British Columbia, and is responsible for: 1) Planning, managing, delivering and funding First Nations health programs and services previously provided by Health Canada’s First Nations and Inuit Health Branch; 2) Working with BC’s Ministry of Health and health authorities to address service gaps and improve health outcomes for BC First Nations; and 3) Improving the quality, accessibility, delivery, effectiveness and cultural appropriateness of health care programs and services for First Nations (BC Ministry of Health, 2020a). To achieve the above goals, First Nations Health Authority (non-geographical authority) has signed accords with each of BC’s five regional health authorities aimed at supporting the improvement of First Nations Health in BC (BC Ministry of Health, 2020b). The Northern Partnership Accord is Northern Health Authority’s branch of First Nations Health Authority, whose implementation is overseen by the Northern First Nations Health Partnership Committee (Northern Health Authority, 2018). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 77 BC’s Ministry of Health Budget—Northern Health Authority BC’s health budget for 2019–20 was $21 billion. Approximately 75% of funds are allocated to health authorities. According to Northern Health Authority’s website, it is responsible for delivering health care across the Northern British Columbia region, with services that include acute care, mental health, public health, addictions, and home and community care (Northern Health Authority, 2019). Approximately 7,000 staff members work for NHA, serving a population of 350,000 citizens spread out over almost two-thirds of British Columbia, where 13% of the population is Indigenous, the highest proportion in BC (Northern Health Authority, 2018). Within Northern Health Authority, there are 25 acute care facilities, 14 long term care facilities, and many public health units and offices providing specialized services (Northern Health Authority). Northern Health Authority is divided into three operational Health Service Delivery Areas: Northeast, Northern Interior, and Northwest. This structure provides a greater degree of local operation and decision making for health facilities across Northern British Columbia. Northern Health Authority: Mental Health Funding As noted earlier, since funds provided for mental health services by the federal government through MHCC are barely sufficient, provincial and territorial governments are responsible for most of the mental health services budget within their respective jurisdictions. According to the Canadian Institute for Health Information (2015), Canada spends 10.9% of its gross domestic product (GDP) on health care, amounting to $291.1 billion, with a total health care spending per capita estimated at $6,105 for 2015 (Canadian Institute for Health Information, 2015). In the financial year 2015–2016, Canadian provinces and territories will MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 78 receive $68 billion in transfer payments from the federal government. Of that amount, British Columbia will receive $6.1 billion (Department of Finance Canada, 2015). BC provincial health spending as a percentage of the province’s overall budget in 2014 was 43 percent. As an example, the BC government’s health funding data indicates that, in the 2018– 2019 financial year, the province spent $20.8 billion on health care, with $15.4 billion of that going to the Health Authorities (BC Budget, BC Ministry of Finance, 2018). The 2018-19 budget allocation for mental health services by Northern Health Authority is just over 7% of its annual budget. Available data indicates that the allocation has remained the same over the last five financial years. However, Bell (personal communication December 6, 2015) explains that the 7% allocation for mental health service is not accurate because some mental health inpatient services are funded using the funds allocated for acute care. As an example, Bell observes that some community mental health residential and elderly services are also funded by the acute care budget. The following chart for Northern Health Authority’s 2017–18 budget (Figure 4) does not indicate the allotment for mental health services. However, as Bell (personal communication, December 6, 2015) explains, funding for mental health is available from both acute care and community services funds. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 79 Figure 4: Northern Health Authority Operating Budget Source: https://www.northernhealth.ca/sites/northern_health/files/about-us/reports/annualreports/documents/annual-report-highlights-2017-2018.pdf Governance of NHA: Board and Management The governance of Northern Health Authority is comprised of a ten-member board of directors, including a chair, all of whom are appointed by the Government of British Columbia. The board meets every two months and some of its functions include: Governance and oversight responsibilities; Setting overall strategic direction for the organization; Approval of budget submissions and business plans submitted by staff; Receiving progress reports on organizational activities and business plans; Reviewing and approving capital plans; Granting privileges for physicians to practice in Northern Health facilities, on the advice and recommendation of the Northern Health MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 80 Medical Advisory Committee; and Reviewing and approving overarching strategies to address aspects of the performance agreement Northern Health holds with the Province of British Columbia. (Northern Health Authority, 2018) The NH board’s strategic position is crucial to the overall governance of the health authority, however, mental health strategies and initiatives are prioritized and overseen by the Chief Executive Officer (CEO) as explained below. Management of Northern Health Authority. Northern Health Authority’s operations are overseen by a team of executives headed by a chief executive officer (CEO). According to NHA’s website, some of the functions of the executive team include: Developing operational plans for objectives set out by Northern Health Authority’s Board and making sure that those plans are acted upon; Preparation of budget, capital, and human resources plans; Approving consistent regional standards for programs and services; and Approval of regional policies for the organization (Northern Health Authority, 2019). Northern Health Authority has three geographical regions—Northeast, Northern Interior, and Northwest, also known as the health service delivery areas (HSDAs). All are managed by chief operating officers (COO). The three COOs are given some discretion over programming within their jurisdictions but mainly report to Northern Health’s CEO (Northern Health Authority, 2018). The following figure (Figure 5) is a management hierarchy illustration of Northern Health Authority which portrays a complicated, fragmented governance complex. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Figure 5: Management Hierarchy, Northern Health Authority (President and CEO Reports to the Board of Directors) Source: F. Bell (March 11, 2019) The Northern Health Authority’s regional map follows (Figure 6). 81 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 82 Figure 6: Northern Health Authority Regional Map Source: https://northernhealth.ca/Portals/0/About/Quick_Facts/documents/7631NH_RegionMap.pdf MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 83 Mental Health Departments. The next level in the complicated northern health management hierarchy is the mental health department. The following diagram (Figure 7) shows the management structure of the Northern Interior region, outlining the middle management hierarchy. This diagram illustrates the Northern Interior region’s management structure. The other two regions which are part of the NHA are Northeast and Northwest regions, and they have a similar structure. Figure 7: Management Structure, Northern Interior Region Source: F. Bell (personal communication, March 11, 2019) According to Northern Health Authority (2018), Mental Health and Addiction Services is one of 18 departments that make up the NHA. Within the mental health and addiction department, outpatient and inpatient clients are served by the programs in Appendix U (Northern Health Authority, 2018). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 84 The following diagram (Figure 8) shows the supervisory structure of the mental health services department at Northern Interior Region, headed by the Director of Mental Health Services. Figure 8: Supervisory Structure of Mental Health Services, Northern Region Source: F. Bell (personal communication, March 11, 2019) While it is fair to suggest that mental health services receive more than the 7% of NHA’s budget, considering the additional funding from the acute care budget, funding support for mental health services remains inadequate since more funds are needed to support mental health deinstitutionalization-related services within the health region (F. Bell, personal communication, November 6, 2015). Other Ministries, Indigenous Organizations, and Non-Governmental Organizations. In addition to the federal and provincial governments (BC Ministry of Health), NHA also collaborates with other ministries, Indigenous organizations, and NGOs. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 85 Ministerial Partnerships. The following ministerial partnership information overlaps where the age and nature of mental health conditions correspond. As an example, both the Ministry of Children and Family Development and the Ministry of Education provide Children and Youth with Special Needs (CYSN) services in Northern BC. Ministry of Children and Family Development is responsible for Child and Youth Mental Health services. The Ministry of Children and Family Development (MCFD) provides community-based, and some residential, child and youth mental-health services. The Ministry of Health on the other hand provides acute and specialized mental-health care through the five regional health authorities and the Provincial Health Services Authority. Together, the two ministries provide a full complement of services for children and youth with mental health challenges (BC Ministry of Children and Family Development, 2018). Although BC’s children’s mental health needs are met by the two ministries, the bureaucratic maze that characterizes the services delivery can complicate the structure of mental health supervisory work. Supervisors from the two ministries have to collaborate and coordinate multidisciplinary mental health services—a tedious task at times. CYSN services in the Northern Health Authority region are situated in several towns across northern BC. In the city of Prince George, there are five centres that provide mental counselling for children and youth between 5–12 years: 1) Intersect Youth and Family Services Society; 2) Prince George Native Friendship Centre; 3) Walmsley and Associates Therapy and Consulting; 4) Gateway Behaviour Services; and 5) Sources Behavioural Support Services. BC Ministry of Education is responsible for Comprehensive School Health including mental health services. In addition to resources for medical and physical health of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 86 school age children, the Ministry of Education has a plan for mental wellness that entails the following: “Adopting a positive mental health approach strengthens student engagement and academic functioning. It also proactively addresses key relationship concerns such as the prevention of bullying and oppositional behaviors and attitudes” (BC Ministry of Education, 2018). Services provided to students by BC’s Ministry of Education include: 1) Positive Mental Health Toolkit; 2) Child and youth mental health services; 3) Kelty mental health resources (BC Ministry of Education, 2018). As indicated above, school children access mental health services provided by MCFD. NHA collaborates with MCFD and the Ministry of Education by providing inpatient mental health services. Ministry of Justice is responsible for Mental Health Services—Programs and Case Management Approaches. According to the Ministry of Justice (2020), more than half of offenders (56%) admitted into correction systems are believed to have a mental illness disorder and/or substance abuse. The Corrections Branch of the Ministry of Justice coordinates assessment and treatment of offenders, with mental health disorders being supervised in the community. Northern Health Authority collaborates with BC Corrections to enhance community safety and to reduce hospital and/or psychiatric admissions. Northern Health Authority also works in collaboration with the following ministries to address various social needs for mental health service recipients: Ministry of Social Development and Social Innovation is responsible for Persons with Disabilities; Ministry of Finance is responsible for Liquor Control and Licensing Branch; Ministry of Natural Gas Development is responsible for Provincial Housing Strategy and Programs; Ministry of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 87 Aboriginal Relations and Reconciliation is responsible for Social Initiatives (BC Ministry of Health, 2020a). Examples of such services provided by these ministries include but are not limited to: housing, financial support, special needs for individuals with disabilities, and cultural considerations for First Nations Communities (BC Ministry of Health, 2020a). Indigenous Organizations Northern Health Authority partners with Indigenous organizations to provide culturally appropriate health services to the Indigenous communities of northern BC. For example, the Association of BC First Nations Addictions Services provides a First Nations forum to promote culturally relevant best practices to enhance, excel, and advance the continuum of care in addressing addictions. Other First Nations organizations involved in services for Indigenous people include: First Nations Health Authority; Metis Nation BC; BC Association of Aboriginal Friendship Centres; Health Canada First Nations and Inuit Health; BC Aboriginal Network on Disability Society (BC Ministry of Health, 2020a). Boards and Commissions Northern Health Authority is also required to work with boards and commissions, public bodies established by statute or regulation. Members of these public bodies are mainly appointed by the Minister or Order in Council to perform various duties. According to the BC Ministry of Health (2018a), BC’s Health Boards are involved in independent appeal tribunals, administrative tribunals and include: Mental Health Review Board; Community Care and Assisted Living Appeal Board; Emergency Medical Assistants Licensing Board; MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 88 Health Professions Review Board; Hospital Appeal Board; and Patient Care Quality Review Boards. Mental Health Review Board The Mental Health Review Board, which was established in 2005, is an independent tribunal that conducts review panel hearings under the Mental Health Act. Among other duties, the board ensures that patients admitted by physicians and detained involuntarily in provincial mental health facilities have access to an objective review process (BC Ministry of Health, 2020c). Commissions, on the other hand, are involved in overseeing the management of some government services, and the Commission on Health in BC manages the Medical Service Plan (MSP) on behalf of the BC government, in accordance with the Medicare Protection Act and Regulations (BC Ministry of Health, 2020c). Medical Services Commission The MSC is a nine-member statutory body made up of three representatives from government, three representatives from the Doctors of BC (DOBC), and three members from the public, jointly nominated by the DOBC and Government to represent MSP beneficiaries. This unique partnership ensures government, doctors, and BC residents all have a voice in the administration of MSP (BC Ministry of Health, 2020c). Northern Health Authority also collaborates with non-profit professional organizations that provide information, leadership, advocacy, and support services to their members. These regulatory colleges are governed by the Health Professions Act (for full list, see Appendix T). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 89 Also included is BC College of Social Workers (Regulatory College under the Social Workers’ Act), which is under MCFD. Northern Health Authority also partners with various mental health and substance use organizations that are a combination of ministry- and privately-funded non-governmental organizations. The mental health and substance abuse organizations (see Appendix I) are governed by the Societies Act of BC to ensure that they are legally permitted to provide services, and are not-for-profit. Northern Health Authority and Non-Government Organizations (NGOs) The funding of NGOs in BC is a complicated and combined contribution of direct and indirect funding by BC government ministries, health authorities, corporate donors, and charitable organizations (Canadian Mental Health Association of BC—CMHABC). The BC branch of the Canadian Mental Health Association, as an example, is funded by BC Mental Health and Substance Use Services (a branch of PHSA), BC Ministry of Children and Family Development, BC Ministry of Health, BC Ministry of Justice, BC Ministry of Social Development, and other donors. It also operates internal fundraising programs such as Ride Don’t Hide (Canadian Mental Health Association of BC, 2018). According to CMHA BC, 2014–2015 budget funding was provided as follows: Ministry of Health—33%; MCFD grants—22%; PHSA grants—10%; plus other donors (CMHABC, 2015). Decisions regarding funding of NGOs are made by elected board members; for example, mental health NGOs funded by PHSA are managed by British Columbia Mental Health Society Branch (Provincial Health Services Authority, 2018). Northern Health Authority (NHA) partners with mental health associations and also contracts some mental health services to agencies. It is unclear how much of NHA’s budget MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 90 goes to mental health contractors because, in the Vendor section of the 2014–2015 financial statements, contractors are not indicated by medical departments (Northern Health Authority, 2015). However, a conversation with Jim Campbell (personal communication, December 15, 2015), a NHA Lead (senior manager), sheds some light on the NHA–NGO relationship. Campbell explained that NHA has a unique mental health and addiction model, different from more typical models used by other regional health authorities in BC. Campbell explained that alcohol and drug services and mental health have traditionally been addressed separately, with mental health following a medical model, and alcohol and drug services following a self-recovery model. But, according to Campbell, six years ago, NHA unilaterally made a cultural and structural shift that combined the two, forming mental health and addiction services. The change (per Campbell) essentially incorporated alcohol and drug services into in-house (inpatient) treatment—a medical model. NHA’s reasons for adopting the new model were mainly because drug abusers may also suffer from mental illnesses (dual diagnosis), and also a recognition that alcohol and drug withdraw may sometimes result in physical withdrawal, which may require medical intervention (J. Campbell, personal communication, December 15, 2015). NHA also incorporated outpatient mental health and addiction services and provides training for workers, especially counsellors. Alcohol and drug services counsellors and mental health counsellors have in the past only addressed their respective areas of expertise (J. Campbell, personal communication, December 15, 2015). The cultural and structural shift also affected the funding process of both mental health and addictions services as they were incorporated into NHA’s administrative structure. NHA funds a number of NGOs through MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 91 ongoing contracts. For example: NHA has ongoing contracts that fund outpatient addiction services through the eight Native Friendship Centres (NFCs). NHA funds multi-year contracts that support NGOs such as Schizophrenia Society of Prince George, and finally; NHA also has ongoing contracts with residential housing (shelters) that support mental health and alcohol and drug clients. Examples include the Association Advocating for Women and Children (AWAC), Ketsoyo, and St. Patrick’s House among others (J. Campbell, personal communication, December 15, 2015). Supervisory Training in Northern British Columbia Since there is no formal training for mental health supervisors in British Columbia, two organizations have developed their own. Mental health services in northern BC are mainly provided by two main mental health employers—Northern Health Authority and the Ministry of Children and Family Development. There are similarities and difference in supervisory training within NHA and MCFD. Following is an outline of the supervisory training offered to NHA and MCFD supervisors’ respectively. The supervisory training is meant for all supervisors within the two organizations and not specifically for mental health supervisors. Supervisor Training at Northern Health Authority (NHA) A generic form of leadership training known as Leadership LINX that is available to all six BC health authorities was developed by Provincial Health Services Authority (PHSA) for the BC Health Leadership Development Collaborative (BCHLDC). I have attached detailed excerpt overviews of the training modules (see Appendix N).The Leadership LINX training takes a constructivist approach since the instructional support provided is task-based MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 92 and reflective. Employees are engaged in active learning and in-service training that is meant to enhance their leadership skills. Supervisory Training for Child and Youth Mental Health (MCFD) The MCFD Provincial Model of Supervision, which also supports child-centred and strength-based practice, forms the foundation of all services in British Columbia (Ministry of Children and Family Development, 2011). Child and Youth Mental Health (CYMH) is a department within MCFD which manages mental health services for children and youth. Supervisors are therefore included in MCFD’s provincial model of supervision. The following is an overview of MCFD’s clinical supervision model, introduced in 2011. The model, which is also constructivist, includes client-centred, professional, and supportive elements of practice. Specific skills for effective supervision for this model include mindfulness; emotional intelligence; relationship and trust; self-reflection; learning styles; coach approach, and mentoring (BC Ministry of Children and Family Development, 2011). See Appendices O and Oa for MCFD’s provincial model of supervision, and MCFD’s Clinical Supervision Agreement. Differences and Similarities Between NHA and MCFD Supervisory Training Since this research has adopted the Kadushin and Harkness (2002) model of supervision (administration, education, and support), the extent to which the two organizations are similar and/or different are as follows: Similarities: While the approaches differ, both NHA and MCFD are invested in one area—the education (clinical) aspects of training. Both organizations have limited administrative and support aspects, a few of which are presented in the identification of goals MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 93 and responsibilities of supervisors in respective job descriptions (see Appendices J, K for job ads). Differences: The main difference between NHA and MCFD training models is the lack of supervisors’ support in the NHA model. While MCFD acknowledges the importance of an informed and emotionally-grounded team in its supervisory model, there is no mention of such support in the NHA training model. Another difference is the expectation of accountability between supervisors and supervisees. Unlike the MCFD training model, which provides written clinical supervision agreement (see Appendix O). NHA has no such agreement. However, NHA has a generic appraisal form that may provide some form of yearly agreement if consistently administered. A new hire’s job description for mental health supervisors for NHA differs from MCFD’s because of the varied disciplines within both organizations. While MCFD supervisors are mostly social workers and a few nurses, Northern Health Authority supervisors’ disciplines include nurses, social workers, eating disorder specialists, as well as alcohol and drug counsellors. Given the complicated nature of the mental health service structure in British Columbia, there is a need for a basic standardized form of training for mental health supervisors that can be used for accreditation. Summary Mental health supervisors in Northern BC work within the confines of all of the above jurisdictions. This account is an overview of the organization structure of mental health service within the Canadian and provincial jurisdictions, aimed at a better understanding of the governance, management, and funding of NHA’s mental health services. A brief review of supervisory training is also outlined. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 94 It is evident from the above account that NHA’s mental health services are part of an assemblage of governance entities which include various national, provincial, regional, and community agencies and societies which care for the mentally ill. Overall, despite the governance complex, there seems to be a leeway for adaptation and accommodation in the challenging service delivery environments of northern BC. This contextual overview is part of the source triangulation which will be discussed in the following research methodology chapter. Chapter Four: Methodology Research Methodology This qualitative exploratory study adopted an interpretive, social interactionist approach aimed at better understanding mental health supervision in northern British Columbia. Since qualitative research generally embraces a rich diversity of overall design, this study is informed by the tenets of case study methodology (Marshall & Rossman, 2016). Theoretical Framework This framework, which was introduced in chapter one, includes leadership, management and supervision theories, social constructionism, and symbolic interactionism. The following section explains how the above theories relate to this study. Leadership, Management, and Supervision Theories An overview of the history and evolution of leadership, management, and supervision theories was included in chapter two. Attempting to distinguish between the three terms can be frustrating due to their close relationship. However, Callaly and Minas (2005) suggested thinking of these terms in a way of getting things done that is more or less appropriate in different circumstances. The three terms are closely related, and perhaps a realistic descriptive view of the relationship can be Ludwig Wittgenstein’s family resemblance theory, which addresses closely related categories. Nyström (2007) refers to the family resemblance idea, which posits that complex concepts can be understood as a network of overlapping similarities. The practice of supervision involves an intersection of the three theories; however, it is unclear what it takes for supervisors to succeed in their work. Whether supervisory aptitude is innate or learned is debatable because many supervisors within the helping professions start their supervisory careers without formal supervisory MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 96 training. Furthermore, multidisciplinary supervision may require additional supervisory skills to support the needs of various professions. The researcher approached the study with the assumption that it is not enough to have natural supervisory skills; one also requires training to supplement innate abilities. In traits theory, Marquis and Huston (2009) observed that leaders were endowed with superior qualities that differentiated them from their followers. In other words, trait theories refer to what makes people good leaders, including characteristics such as integrity, empathy, assertiveness, and good decision making. Traits were determined by researchers studying prominent people throughout history, but there is dispute by contemporary opponents, such as Drucker (1974), a management scholar who argued that leadership skills can be taught, not just inherited (Marquis & Huston, 2009). The debate on what it takes to be a good leader is critical to this study because it provides a springboard from which policymakers in health care can determine management and supervisory needs. For example, the timing of, and training opportunities for the majority of mental health supervisors is critical, given the grandparenting entry to most supervisory positions. Social Constructionism. Social constructionism has been widely adopted in social sciences since the 1960s. It originated in sociology and has been associated with the postmodern era in qualitative research (Andrews, 2012). According to Philp et al. (2007), social constructionist ideas derive from the broader postmodern movement as a rejection of certain modernist assumptions, such as the existence of a knowable objective reality, and a singular and external truth (Flaskas, 2002). Social constructionism acknowledges that there is no objective reality and is concerned with how knowledge is constructed and understood; it therefore has MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 97 an epistemological, not an ontological perspective (Andrews, 2012). It regards the social practices people engage in as the focus of inquiry. Gergen (1985) observes that: Social constructionist inquiry is principally concerned with explicating the process by which people describe, explain or otherwise account for the world (including themselves) in which they live. It attempts to articulate common forms of understanding as they now exist, as they have existed in prior historical periods, and as they might exist should creative attention be as directed. (Gergen, 1985, p. 266) Early thinkers whose influence relates to social constructionism include Burr (1995), who acknowledges the major influence of Berger and Luckmann (1991) in its development. The latter in turn acknowledge the influence of Mead et al. (cited in Andrews, 2012) on their thinking. The writings of these thinkers constitute a synthesis of these influences. According to Burr (2015), “the insistence of social constructionism upon the importance of the social meaning of accounts and other texts often lead logically to the use of qualitative research methods as the research tools of choice” (p. 28). Little is known about mental health supervision in northern BC, which necessitates an exploratory study with a qualitative approach. According to Gergen (1985), social constructionism places great emphasis on everyday interactions between people and how they use language to construct their reality. In this study, the assumption was that interaction between supervisors and workers determined the nature and quality of service at the workplaces. The manner in which supervisors interacted, engaged, and communicated with workers determined the response from workers, and vice versa. Social constructionism acknowledges that there is no objective reality, and is concerned with how knowledge is constructed and understood. Finally, Burr (1995) lists MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 98 some of the key principles of social constructionism as: “a critical stance toward taken-forgranted knowledge; holistic and cultural specificity; knowledge sustained by social process; and knowledge and social action together” (pp. 3–5). The above list calls for the researcher’s awareness of the individual’s perceptions of the world, as well as the individual’s awareness of culture within their workplace. In this study, responses from participants were analyzed using the above principles to determine the nature of supervisory processes in multidisciplinary mental health practice. Symbolic Interactionism. A supplementary theory, closely related to constructionism, is symbolic interactionism, a theory that is also applicable to the analysis of supervision. A part of this study involved a review of interpersonal relationships between three participant groups (frontline workers, supervisors, and senior managers) during both data collection and analysis. Symbolic interactionism emerged from the work of pragmatists Charles Cooley and George Herbert Mead, who thought that other people could play a significant role on an individual’s social ideals or how they viewed themselves (Plummer, 1991). While Cooley thought that human groupings or many people could influence an individual’s life, Mead thought only some people could influence an individual and only during certain periods of life. Mead’s best-known book, Mind, Self, and Society (2015), was critical in the development of symbolic interactionism. The following are Herbert Blumer’s three premises that set the boundaries for the symbolic interactionist perspective: 1. Human beings act toward things on the basis of the meaning those things have for them. 2. The meaning of such things is derived from, or arises out of, the social interaction that one has with one’s fellows. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 99 3. These meanings are handled in, and modified through, an interpretive process used by the person in dealing with the things he or she encounters. (cited in Sandstrom et al., 2014, p. 9) Sandstrom et al. (2014) further observe that understanding symbolic interactionism not only deepens the understanding of social psychology, but also helps us understand ourselves and those around us. Whether it is by looking at the interaction between supervisors and the supervisee or their interaction with other relevant groups, adapting the theory according to the authors has two benefits: 1) gaining a better understanding of how and why we think, feel, and act as we do, and 2) gaining helpful insights into how others affect our behaviour and how our behaviour affects others, particularly as we engage in joint action. Also, according to Greene and Ephross (1991), “symbolic interaction theory focuses on how the self emerges through interaction and examines those regularities in human behavior made possible through communication and language” (p. 203). Hence the interaction of supervisors and supervisees, through language and other forms of communication, determines their behaviour and collaboration within their work setting. Whereas social constructionism is concerned with how knowledge is constructed and understood, symbolic interaction is concerned with “how and why people and organizations communicate the way they do” (Greene & Ephross, 1991, p. 204). The authors further observe that interaction is a “reciprocal perspective because it involves the transfer of meaning between and among people” (p. 208). Therefore, since communication is an integral part of supervisory work, symbolic interactionism assisted in identifying how supervisors, supervisees, and senior managers interacted and interpreted each other’s roles and actions. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 100 Research Design I have used the qualitative, exploratory design to broadly explore and obtain knowledge about northern BC’s mental health supervision. A qualitative exploratory design is appropriate for this research because this area of study has not been previously studied, hence the need for an in-depth search for “new knowledge, new insight, new understanding, and new meaning” (Blink & Wood, 1998, p. 312). Some elements of case study as a method were incorporated, consistent with Merriam’s (1995) explanation that case study as a method of inquiry examines in depth a program, event, activity, process, of one or more individuals, using a variety of data collection procedures. A sample of 29 participants was drawn from mental health agencies across northern British Columbia. The participants included frontline workers, supervisors, and senior managers. I also used documents as an additional data source. I acknowledge that the literature review and the data from the three groups of mental health employees (participants) regarding mental health supervision were not enough for my investigation, hence the inclusion of a chapter on the study’s context. I therefore included a contextual overview in chapter three which allowed gathering of appropriate data from a variety of sources (Baxter & Jack, 2008). The organization and management data in the contextual overview describes the complex reporting relationships that characterize mental health services delivery in northern British Columbia. Site Selection Criteria The geographic boundary was northern BC, which included the areas covered by the Northern Health Authority and the Ministry of Children and Family Development. Several sites across northern BC were identified where interviews of participants were conducted. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 101 The criteria for identifying sites were based on a participant’s employment in the following areas: 1. NHA inpatient and outpatient mental health and addiction services. 2. Psychiatry wards, withdrawal management units, and outpatient counselling. 3. Public, not-for-profit, and private sector mental health and addiction services. 4. Mental health associations, and private counselling agencies. 5. Child and youth and mental health services (MCFD). 6. Child and Youth Mental Health (CYMH) agencies across northern BC. 7. Adult correction mental health services (Ministry of Justice). 8. Mental health and addiction services, and adult forensic services. The in-depth interviews formed the basis of the analysis, which enabled the researcher to gain insight to supervision strategies or approaches in different situations and circumstances across northern BC. Methods This section includes details on how I conducted my research, including participants, data collection, data analysis, ethical considerations, and evaluative criteria. In addition to indepth interviews, I reviewed internal documents on supervisory policy and/or training manuals on mental health supervision from NHA and MCFD’s Child Youth Mental Health (CYMH) and other sources. These documents included regional as well as province-wide documents for comparative purposes. The use of the two data collection sources helped in triangulation during data analysis. According to Simons (2009): “Document analysis is often a helpful precursor to observing and interviewing, to suggest issues it may be useful to explore in the case and to provide a context for interpretation of interview and observation MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 102 data” (p. 64). Therefore, the evidence collected includes data from frontline worker interviews, supervisor interviews, and manager interviews, as well as documents from mental health organizations. Data Collection Strategy This strategy included a contextual overview of mental health supervision in northern British Columbia and a semi-structured interview guide with predetermined questions. The interview process involved the use of open-ended questions used flexibly with probing questions (See Appendices F, G, and H). I generated the interview questions based on my experience in the mental health field. I piloted my interview guide with a friend who is a former mental health supervisor. I chose this person because of his good insight into leadership and much experience in the mental health field. He provided me with suggestions for follow-up questions. Interviews were conducted either face-to-face or by telephone at locations and times agreed upon by the researcher and participants. According to Merriam and Merriam (2009), “interviewing is necessary when we cannot observe behavior, feelings, or how people interpret the world around them” (p. 88). I triangulated my data by using the documentary review, the interviews, and the literature review. Also, having three interview data sources added to triangulation. Although none of the participants used the services, I provided participants with a list of appropriate counselling agencies in case any of them were upset by the interview. Participants I employed purposive non-probability sampling, convenience sampling, and snowball sampling. The purposive sampling method involves a researcher’s investment in identifying MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 103 participants who have the most relevant characteristics for a study (Suzuki et al., 2007). According to Merriam and Tisdell (2015), convenience sampling is where the selection is based on aspects such as time, money, location, and the availability of sites or participants. As an example, snowball sampling involves locating a few participants who easily meet the criteria established for study, and as early participants are interviewed, each of them is asked to refer the researcher to other participants. Following is a brief description of the 29 participants I recruited. Participants included eight frontline mental health workers, 18 mental health supervisors, and three senior mental health managers in the public, not-for-profit, and private sectors. The 29 participants were a manageable number because the qualitative data from in-depth interviews was considerable. Also, northern BC is a sparsely populated region with a limited number of mental health supervisors. Sampling Criteria Participants held a minimum of a degree at the undergraduate level. All participating supervisors supervised at least one qualified mental health worker, and could be supervisors of workers from other fields of practice. Also, all participants who agreed to participate were requested to provide demographic information related to gender, age, race, ethnicity, and number of years of supervisory experience, discipline, and education. A questionnaire was part of the interview guide to assist in collecting the above demographic information. I used some descriptive statistics to indicate certain features of my participant sample. Participants engaged in the research on a voluntary basis. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 104 Participant Selection and Procedure Participant recruitment strategies included contacting professional associations such as the Association of Registered Psychiatric Nurses of BC; the BC Association of Social Workers, as well as health and social services networks—e.g., the Federation of Community Social Services of British Columbia, and Board Voice BC. The above organizations have websites, electronic or print media, and professional journals. They also accepted advertisements for research recruitment. Also, a brief description of the research was provided in the research advertisement which included my contact information. Participants were asked to indicate their consent to individual interviews. In reports or publications that have resulted from this research, participants have not been identified. Participants did not represent their organizations or agencies and they participated voluntarily. This helped generate both objective and subjective feedback, since participant involvement was independent of their employment. Where purposive and convenience strategies were inadequate, snowball sampling was used to maximize the recruitment. Handling the Data In order to protect participant, I used random identification codes. I stored the codes on the UNBC secure shared drive, and I plan to delete them after a successful defense of this study. My recordings during the study and all research notes have been stored in a locked filing cabinet, in a locked room in my office at UNBC. I have stored electronic files in a secure drive provided by UNBC. Following completion and defense of this study, all paper copies will be appropriately recycled at a secure facility, audio-recordings deleted, and the electronic files in the secure UNBC shell will be deleted. Also, the codes linking the data to participants will be deleted. A password-protected electronic copy of the data will be stored MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 105 by a member of my committee on his UNBC computer, secured by password protection. Five years after the completion of this study, this stored electronic copy will also be deleted. Also, to ensure confidentiality, I used pseudonyms when using direct quotations from participants. Data Analysis According to Morehouse (2012), all qualitative data analysis begins with a verbatim transcription of any audio- and/or video-recorded material; the recording should be transcribed exactly, as much as possible, in participants’ words. Given the number of participants, I used the services of a transcriber, providing the transcriber with a declaration of confidentiality form. During the transcribing process I read and familiarized myself with the transcript contents. Thematic analysis focusing on identifying themes was used for data analysis. I followed Braun and Clarke’s (2006, p. 87) analysis guide, which outlined their sixstep guidelines. (In the following citation, my steps are inserted, in brackets.) 1. Familiarize myself with the data, and the transcription of verbal data. (I immersed myself in the data by reading and rereading the interview transcripts to ensure that I was fully familiar with the content. I took notes while searching for meanings and patterns within the transcripts.) 2. Generating initial codes. (After reading and familiarizing myself with the data and generating initial ideas about the data, I proceeded to the next stage— generating initial codes from the data. Codes identify features of data that are interesting to the analyst, which involve organizing data into meaningful groups. According to Guest et al. (2012, p. 87), a code is “a textual description of the semantic boundaries of a theme or a component of a theme”). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 3. 106 Searching for themes. (This involved gathering and analyzing codes to determine how different codes could be combined to form overarching themes. This was done using tables or illustrative maps.) 4. Reviewing themes. (This involved checking whether themes worked in relation to the coded extract and whether they formed a coherent pattern.) 5. Defining and naming themes. (This entailed the generating of clear definitions and names for each theme.) 6. Producing the report. (This was the final analysis that culminated in my scholarly report of the findings.) Coding I chose manual coding using Microsoft Word to label interview data from three participant groups: 1) frontline workers, 2) supervisors, and 3) senior managers. I used an inductive approach to thematic analysis, a well-structured approach which allowed the data to determine my themes (Nowell et al., 2017). In the analysis, an inductive method for developing themes was used. However, following the generation of themes, I had to use a deductive aspect while tracking and counting the frequency of common answers from participants. My initial coding step was reading through the transcript while listening to the recorded interviews, to familiarize myself with the data while also ensuring accuracy. I settled for a structured coding method due to its suitability to large interview data (Saldaña, 2016). Structural coding is a question-based method where labelling and indexing “allows a researcher to quickly access data that is likely to be relevant to a particular analysis from a large data set” (Guest et al., 2007, p. 141). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 107 My second step involved reading the interview transcripts a second time, noting and writing significant responses to each of the questions, which I did using Microsoft Word comments. The comments were answers to questions and probes that were asked of each participant. I noted every pattern of answers that indicated an alignment of the excerpts with the interview questions. I found it easier to address subsequent coding using three separate documents for each research question. Therefore, using my research questions, I created a code book using three Microsoft Word documents to use in the recording of all relevant text segments related to the questions. I reread the transcripts again, and using three colours representing each of the three research questions, I highlighted relevant sections which aligned with participants’ interview questions. I pasted the coloured paragraph excerpts to their respective Word documents. I read through the transcripts again to identify more relevant quotes, and noted the frequency of similar answers. I printed the three Word documents (code book) and examined comparable segments, relationships, as well as common responses and/or differences (Saldaña, 2016). I underlined all relevant and repeated participant answers and generated initial categories. Next I completed a second and third reading which generated initial codes, followed by a search, naming and defining manifest (emergent) and latent (superordinate) themes consistent with Braun and Clarke (2006). The analysis produced 11 manifest themes and five latent themes. Member Checking Member checking occurs when transcripts and or summaries of the themes are sent to participants for their comments (Mays & Pope, 2000). I sent electronic copies of the transcripts to participants by email for accuracy assessment, requesting that they make any MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 108 changes where necessary. Nineteen participants responded to the electronic copies with clarification; most needed no changes. But I also made follow-up telephone calls to eight participants to confirm information. Ethical Considerations The process of planning and designing a qualitative study required a consideration of ethical issues that might surface during the study, as well as a plan for how these issues should be addressed (Creswell & Creswell, 2013). Ethical issues in qualitative research can be described as occurring “prior to conducting the study, at the beginning of the study, during data collection, in data analysis, in reporting the data, and in publishing a study” (p. 57). The following ethical considerations were observed in this study: Adherence to the provisions of the Tri-Council Policy Statement; letters of support and/or approval for participants’ interviews were granted by Northern Health Authority, Ministry of Children and Family Development, and other agencies that employ mental health workers in the northern interior of northern British Columbia; prior to conducting this study; ethics approval was sought from the Ethics Board of the University of Northern British Columbia, and from the Northern Health Research Review Committee. Other ethical considerations included informed consent, confidentiality, rigour, do no harm, beneficence, and use of self. Evaluative Criteria Finally, to enhance trustworthiness, a number of mechanisms were applied. They include: adequate engagement in data collection; triangulation; peer examination; thick, rich description; knowing the importance of reflexivity; and clarifying researcher bias (Merriam & Tisdell, 2015). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 109 Adequate Engagement in Data Collection Although there was no definitive duration for engagement in data collection, I allowed ample time averaging between 1to 2 hours for interaction with participants in order to derive credible data. I addressed rigour in the application of theory and methods by critically analyzing the literature, documents, and interview transcripts (frontline worker interviews, supervisor interviews, senior manager interviews). In line with what Lincoln and Guba (1985) refer to as compliance with the research community’s public standards and agreement about the appropriate ways to create knowledge, the use of multiple sources of data created triangulation. To establish rigour, I applied the four strategies of assessing trustworthiness by Guba (as cited in Krefting, 1991): 1) credibility, 2) transferability, 3) dependability, and 4) conformability. My strategy for ensuring credibility included peer examination, reflexivity, member checking, and triangulation, which is explained below. My strategy to ensure transferability included the comparison of the sample to demographic data. My strategy for dependability included triangulation and peer examination. Finally, my strategy for conformability included triangulation and reflexivity (Guba, as cited in Krefting, 1991). Triangulation I used source triangulation, which involved the use of multiple sources of data which in addition to my perspectives enhanced both the credibility and transferability of the findings (Farmer et al., 2006). The use of data sources triangulation, involved a documentary review of the study context, interviewing frontline mental health workers, senior mental health managers, and mental health supervisors who were employed in several different MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 110 mental health organizations across northern British Columbia. According to Yin (2014), case study findings and/or conclusions are likely to be more convincing and accurate when they are based on a number of different sources of information. This is an important aspect in most qualitative approaches. Thick, Rich Description According to Patton (2002), “thick, rich description provides the foundation for qualitative analysis and reporting (p. 437).” To ensure that the information provided was consistent with the data collected, I sought sufficient details, using my interview guide, to derive appropriate details for thick, rich description. I specifically used appropriate, probing questions that encouraged participants to freely discuss pertinent details in order to elicit relevant information. During the transcribing collation stages, I ensured that all pertinent details, including direct quotes, were identified for an accurate description and interpretation of participants’ experiences. Reflexivity “Reflexivity refers to active acknowledgment by the researcher that her/his own actions and decisions will inevitably impact upon the meaning and context of the experiences under investigation” (Horsburgh, 2003, p. 308). Since I have some experience in the mental health field and am still involved in various capacities, I engaged in reflexivity. To continually examine my personal reactions and assumptions during the research process, I used a self-reflective journal to identify and address personal biases throughout the research process. Nevertheless, it is worth noting that my knowledge of the field brought strength to my research. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 111 Limitations One, this study was based on a small number of participants recruited from a sparsely populated north. Hence, the findings are not generalizable to the larger population or to all rural supervisors and situations. Since there is limited prior research in this topic, I relied on literature from other unrelated geographical regions. Two, I have worked in the mental health field for several years and as is the case in qualitative research, my analysis was subjective and inherently prone to researcher bias. Creswell, (2012) observes that research bias is inherent in all qualitative research. With that mind, I used reflexivity and triangulation as a means of reducing my bias, while interpreting participants’ statements. Three, mental health supervision is largely multidisciplinary with a variety of agencies using different forms of leadership and/or management. This study therefore, addressed elements of supervision which were at times alien to some participants, who found some of the ideas and discussions incompatible with their organization’s operation. Alien elements were therefore skipped. Four, recruitment of a diverse sample was a challenge due to female gender overrepresentation in the helping professions. For example, nurses and social workers are quite a homogeneous group (female and well-educated). Five, in small practice areas where participants knew me and knew one another, I may have created performance anxiety where some supervisors may have been hesitant to disclose certain information regarding their limitations or negative experiences. Summary This chapter has highlighted leadership, constructionism, and symbolic interactionism as the theoretical framework for the research. The three theories helped in addressing the various ways in which meaning is created through individual experiences in various cultural MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 112 settings as well as individual perceptions of the real world. The chapter also addresses the research design and methods. Next, the research findings from the data analysis, including both manifest and latent themes, are presented in chapter five. . Chapter Five: Findings The purpose of this study was to better understand how mental health supervision works in northern British Columbia. The first four chapters of this dissertation included: the purpose of the study and an introduction to multidisciplinary mental health supervision in rural northern British Columbia; a description of the case study context and setting, as well as the literature on multidisciplinary mental health supervision; followed by a chapter on the methodology that was used for this study. This chapter will present the findings from the data collected and analyzed based on the study’s conceptual framework. The themes discussed in this chapter that resulted from 29 interviews are aimed at addressing the three research questions: Question 1: What challenges and opportunities do mental health supervisors experience in northern British Columbia? Question 2: How do frontline workers, supervisors, and senior managers perceive the roles and activities of mental health supervisors in northern British Columbia? Question 3: How are supervisory approaches in various mental health disciplines different or similar in northern British Columbia? Participants in this study included frontline workers (FL), supervisors (S), and senior managers (SM). Although the majority of participants were supervisors, the deliberate inclusion of other participating categories is a form of triangulation. Triangulation is an “analytic technique, used during fieldwork as well as later during formal analysis, to corroborate a finding with evidence from two or more different sources” (Yin, 2016, p. 340). The following four tables provide pertinent demographic information about the participants. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 114 Table 1: Demographics of Participants (29) All Participants Gender # 30-64 Child & Youth Mental Health (CYMH @ MCFD) 8 2 10 Mental Health & Addictions (NH & Other Agencies*) 14 5 19 Frontline Workers (FL) Gender # Age Range Female 6 Male 2 Total 8 30-64 Child & Youth Mental Health (CYMH @ MCFD) 3 2 5 Mental Health & Addictions (NH & Other Agencies) 3 0 3 30-64 Child & Youth Mental Health (CYMH @ MCFD) 3 1 4 Mental Health & Addictions (NH & Other Agencies) 12 2 18 Senior Managers (SM) Gender # Age Range Female 2 Male 1 Child & Youth Mental Health (CYMH @ MCFD) 1 0 Mental Health & Addictions (NH & Other Agencies) 1 1 1 2 Female** Male Total 22 7 29 Supervisors (S) Gender # Female Male Total Total 13 5 18 3 Age Range Age Range 50-64 *Other Agencies: Adult Forensic; Counselling UNBC; CMHA (Canadian Mental Health Assn of BC); CSFS (Carrier Sekani Family Services); NFC (Native Friendship Centre) **Two participants identified themselves as Non-Binary and have been included in the Female count for reasons of confidentiality. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Table 2: Demographics of Frontline Workers (8) Category Characteristics Numbers Age Range 18–29 years old 30–49 years old 50–64 years old 65 years and over 0 7 1 0 Male Female 2 6 High school certificate Some college, no degree Certificate Diploma Associate’s degree Bachelor’s degree Master’s degree PhD 0 0 0 0 0 5 3 0 White First Nation, Inuit, Metis Black or African Canadian Hispanic or Latino South Asian Chinese 2 2 1 Urban Suburban Rural 5 0 3 8 Public sector Private sector Not-for-profit 8 0 0 8 0 1 2–29 10–24 25–99 0 0 0 0 0 Less than 5 years More than 5 years More than 10 years More than 25 years 3 3 2 0 Gender Education Ethnicity Participant’s Location Employer Category Number of Supervisees Duration in Current Position Total 8 8 8 8 1 0 0 8 115 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Table 3: Demographics of Supervisors (18) Category Characteristics Numbers Age Range 18–29 years old 30–49 years old 50–64 years old 65 years and over 0 12 6 0 Male Female 5 13 High school certificate Some college, no degree Certificate Diploma Associate’s degree Bachelor’s degree Master’s degree PhD 0 0 0 2 0 11 5 0 White First Nation, Inuit, Metis Black or African Canadian Hispanic or Latino South Asian Chinese 16 1 0 0 0 0 Urban Suburban Rural 9 1 8 18 Public sector Private sector Not-for-profit 14 0 4 18 0 1 2–29 10–24 25–99 0 0 1 17 0 Less than 5 years More than 5 years More than 10 years More than 25 years 12 4 2 0 Gender Education Ethnicity Participant’s Location Employer Category Number of Supervisees Duration in Current Position Total 18 18 18 18 18 18 116 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Table 4: Demographics of Senior Managers (3) Category Characteristics Numbers Age Range 18–29 years old 30–49 years old 50–64 years old 65 years and over 0 0 3 0 Male Female 1 2 High school certificate Some college, no degree Certificate Diploma Associate’s degree Bachelor’s degree Master’s degree PhD 0 0 0 1 0 0 2 0 White First Nation, Inuit, Metis Black or African Canadian Hispanic or Latino South Asian Chinese 3 0 0 0 0 0 Urban Suburban Rural 1 0 2 3 Public sector Private sector Not-for-profit 3 0 0 3 0 1 2–29 10–24 25–99 0 0 1 0 2 Less than 5 years More than 5 years More than 10 years More than 25 years 1 0 2 0 Gender Education Ethnicity Participant’s Location Employer Category Number of Supervisees Duration in Current Position Total 3 3 3 3 3 3 117 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 118 Coding: Manifest (Emergent) Themes, and Latent (Superordinate) Themes The initial review of the interview transcripts from 29 participants involved reading and re-reading of all transcripts for familiarization, followed by a second and third reading for the coding process. The rigorous coding process generated initial codes, followed by a search, naming and defining manifest (emergent) and latent (superordinate) themes consistent with Braun and Clarke (2006). The analysis produced 11 manifest themes and five latent themes. The manifest themes will be presented first and they are summarized in Table 5. Table 5: Manifest Themes (Emergent) 1. Numerous perpetual challenging policy implementations/ Lack of administrative support 2. The sandwich situation/ Balancing multiple priorities/ Working with unions 3. Managing team dynamics/ Dual role—supervising and carrying caseloads 4. Loneliness and Isolation; Climate; Rural remote pastimes 5. Crisis management/ Shovel-down effect 6. Discomfort of sitting in ambiguity/ Internal cognitive dissonance 7. Disciplinary meetings and decisions/ Addressing workplace conflicts 8. Overwhelming amount of work/ Time limits/Avoiding perfection mindset 9. Limited leadership preparation (grandparenting)/ Maintaining competency— in-service training/ Training and mentorship in rural remote settings 10. Multidisciplinary responsibilities/ Interdisciplinary conflict/ Lack of appropriate management expertise for multidisciplinary teams 11. Collaboration challenges in interdisciplinary and multidisciplinary teams/ Managing team dynamics between disciplines/ Power struggles between professional disciplines/ Preference of discipline-specific supervision MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 119 Manifest Themes 1. Numerous Perpetually Challenging Policy Implementations/ Lack of Administrative Support The majority of the 29 participants (frontline workers, supervisors, and senior managers) described as challenging the various tasks involving linking policies and/or directives from senior managers to frontline workers. The participants not only raised concerns but also provided insightful suggestions. Participants from the three categories (FL, S, and SM) provided some common views despite differences in their job expectations. For example, one FL worker explained the importance of offloading (reducing) some of the mental health supervisors’ responsibilities. The worker proposed a horizontal management process where more authority is granted to frontline staff, as opposed to vertical, which has a pyramidal top-down structure. According to Williams and Wilson (2010), vertical supervision discourse is controlled by strong distributive rules that regulate power relations, while Beddoe (2012) explained that horizontal supervision represents limited power inequalities and minimal barriers to free expression. Participants discussed the most common tasks and responsibilities typical of mental health supervision. The tasks included numerous perpetual policy implementations, and overwhelming administrative work with limited support. Although no solutions were brought up regarding perpetual policy implementations, some FL and Supervisors suggested the hiring of administrative staff for their team. Below, a frontline worker described an alternative to current supervisory expectations. I guess in spite of the challenges that supervisors face, I see their value, also I would like to see what it would look like if we had a less hierarchical organizational structure… what it would look like if the role of a supervisor was spread throughout MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 120 the team. The way it is now is that supervisors have a unique set of rules which is a position of power above the frontline workers, and, I mean, I haven’t done any research into it, but vertical organizations aren’t the only way of organizing. I wonder what it would look like if those privileges—if those duties—if those challenges were spread out, and what could we accomplish if we worked together to make decisions? (FL2 – NH) Three participant supervisors described the different responsibilities and demands that their job entailed. Although these participants worked for different mental health organizations in northern BC, they did express some common challenges. Most of the concerns raised by supervisors were consistent with Kadushin and Harkness’ (2002) functions of administration, education, and support. Below, supervisors explain some of the common tasks. When you’re in frontline you can devote yourself to… being client-centred and doing the right thing, but in a supervisory role you have different responsibilities that are competing, for example, work-safe—you’re not just responsible for clinical service to a client—you’re responsible for the safety of that worker which puts some limits and constraints; you’re responsible for providing feedback to workers… and they may not necessarily want to hear about their practice or their performance in general as employees. You’re also caught in the middle quite often as a supervisor between frontline staff and those that you report to. This can also be challenging because you want to be professional and it is sometimes your job to implement initiatives and policies that you don’t necessarily agree with (S8 – NH) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 121 There’s always something happening at a higher level, and it gets pushed down through managers at different levels and eventually… onto team leaders—different policies that have to be incorporated into how we do our work. For example, someone is attacked by a client, and… an ADM (Assistant Deputy Minister) has a new policy… that requires… extra precautionary measures and assessments and so forth, and every time something negative happens in this ministry, it seems like new policies are introduced to prevent things like that from happening again—and so all the paperwork we have to read, all the policies we have to implement—it becomes quite tedious at times—that’s the part of the job I don’t like, and sometimes I feel all those policies and directives and so on stand in the way of me doing what I would most like to do, which is clinical supervision and program development. (S11 – MCFD) The majority of participants also talked about their frustration in having to deal with union matters on a regular basis, especially when disciplinary measures were necessary. For me, sometimes it’s the process of working with a union—if someone is not working to their potential or not working as expected, it’s a long-drawn-out process in trying to get any actions taken… that’s frustrating because other staff see the work that person does or does not… it creates resentment and animosity within a team. (S5 – NH) 2. The Sandwich Situation/ Balancing Multiple Priorities/ Working with Unions The Sandwich Situation. The majority of participating supervisors discussed their role as intermediaries between FL workers and senior managers in what one supervisor termed a “sandwich MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 122 situation.” As intermediaries, supervisors attend to numerous meetings with both/either upper management and the supervisees. Supervisors sometimes have to make difficult decisions, affecting required changes while also delegating some of the duties. Participants expressed that they often had no solutions to some of the challenges at work. Below are examples from three supervisors. Especially given how you are in a sandwiched situation, the frontline workers may be expecting that you have solutions, and there’s no solution coming from the other end, from the upper management. Feeling that you’re responsible for knowing the answer, and getting blamed if you don’t. (S2 – MCFD) In this position particularly, I am more of a middle manager, so I am the person the staff complain to when they are unhappy, if the clients are unhappy they come to me, and if management is unhappy, they come to me. I feel like I am sandwiched, I seem to be the one everyone comes to—to complain. (S1 – NH) The third supervisor described some of the challenges when implementing policies that were against her personal views, adding that getting caught in the middle… as a supervisor… between frontline staff and upper management was very challenging “because you want to be professional and it is your job to implement initiatives and policies that you don’t necessarily agree with… it becomes a challenge to translate the policies in a way that would make sense to frontline staff. (S13 – NH) Balancing Multiple Priorities. Regardless of organization, all mental health supervisors raised the issue of work stress, and provided examples of challenging and stressful situations and responsibilities. The majority of them expressed concerns that the nature of the job rendered it stressful because of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 123 ambiguous tasks, crisis management, conflict resolution, endless responsibilities, time limits, and change management. A participant supervisor described her busy schedule in youth forensic work: Absolutely my job is stressful. Main sources I’d say is balancing multiple pressing priorities every day. I look at my stack of all my emails and my stack of paper and I think… not sure what I’m going to do today. The day goes zipping by, and I think, “Ha, shoot, I’m not sure what I did today.” My job is stressful because I feel like I have a burden—of really seeing if someone is treated or not as far as public protection goes and rehabilitation and reintegration goes. Competing priorities—you know, court deadlines, somebody needs something right now—thankfully we’re not a crisis organization… we don’t take walk-ins, but if somebody, a young person that we serve, comes off the street in crisis, obviously we have to intervene. (S7 – MCFD) Working with Unions. Just over half of the participant supervisors expressed challenges related to labour union-related issues. One supervisor observed that, since the majority of mental health workers are members of various labour unions, they often seek support from the unions whenever they face disciplinary actions. Also, some supervisors expressed that working through union grievances was not only challenging but also time-consuming. One supervisor stated that: “Most of my time is taken up by union management meetings, dealing with staff, disciplinary issues that take a lot of time.” (S11 – NH) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 124 Another supervisor provided an example of a nurse on her team who was on parental leave and was not expected back for one year. Her position was posted and a relief nurse was hired who required training. After four months, the nurse on parental leave called to report that she would resume work in two months. The supervisor wondered because the position was posted until December which was five months away. The relief nurse had given up a job elsewhere to come into this job, and a lot of training was involved. The supervisor expressed her frustration: “so my immediate reaction is you cannot come back, well, they can—they have a right according to their collective agreement.” (S14 – NH) 3. Managing Team Dynamics/ Dual Role—Supervising and Carrying Caseloads Issues related to team management dynamics were prominent with more than half of the participant supervisors. The two concerns most amplified were the issues of: 1) supervising and carrying caseloads, due to attrition, and 2) lack of resources for clients. Regarding supervising and carrying caseloads, participating supervisors expressed that attrition challenges led to shortages of workers which increased the team workload. Consequently, the supervisor takes up some of the extra cases, in addition to the supervisory duties. One supervisor explained that team composition fluctuates often because of the transient nature of a rural remote work force. As an example, less experienced workers take up positions in remote areas for the purpose of gaining work experience, after which they return to urban areas. When I first came here I had a caseload, right now, I have five clinicians, back then, we were down to two, and I had to take on some of the frontline work. Now I have a full team and it’s very nice. But they are going to start moving soon, a couple of them have their two years this year already. (S17 – MCFD) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 125 A widely documented recurrent theme regarding rural remote work was high attrition and the shortage of resources for affected communities. Lack of human and material resources continue to be a persistent challenge in the rural north. As an example, mental health supervisors often have to make transportation arrangements for patients with acute mental illness for treatment at bigger metropolitan hospitals. Attrition, on the other hand, remains a major staffing challenge in northern rural remote regions. Below, a supervisor explains the persistent worker attrition: the struggles working in the north especially in mental health is, our clinicians are supposed to have a Master’s degree. So, the challenges have always been hiring qualified staff, yet… we have constant turnover. More recently it has actually been easier to get some people with Master’s degrees but they are traditionally from southern BC, and they just want to get their foot in the door of CYMH and after working for two years… apply to positions in the south. I’d say I spend a lot of time recruiting and training. (S17 – MCFD) 4. Loneliness and Isolation; Climate; Rural Remote Pastimes Loneliness and Isolation. Another consistent theme that emerged was the loneliness and isolation experienced by mental health supervisors. The majority of participant supervisors expressed that taking up supervisory responsibilities meant that relationships with their former frontline colleagues had to change to ensure appropriate working relationships and boundaries. Some participants also expressed that becoming a supervisor meant limited direct interaction with clients, hence more limitations to human interaction. Below, a participant supervisor describes how her life MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 126 changed after assuming supervisory duties. She was unable to continue partaking in the rural remote pastimes—hunting and camping with former frontline colleagues. I know when I was not in clinical leadership—I was friend to all the staff; we went out hunting together… camping together, and that all changed because I’d also seen other managers who were friends with the staff and couldn’t do their job well… they couldn’t separate that. I felt I had to do that—separate work from this in order to be effective. It hasn’t been hard for me because the longer I was in management it became just part of the job. You know, you’re the leader, you’re the manager, and if they’re in trouble you’re the one who’s going to deal with it; so, you can’t be a friend. I’m still sociable, but I don’t hang around with them or anything like that because… we used to have Christmas parties and I don’t participate in any of that. It’s hard to discipline people that you socialize with, and that’s part of my job. So, it’s a matter of getting a different network of people which is not always easy. (S9 – NH) Another supervisor cited lack of commitment by multidisciplinary supervisory colleagues. Perhaps due to busy schedules, many would commit to socializing but failed to honour promises, hence continued isolation. The issue of dual relationships within smaller communities was also raised as a reason for a lack of socializing opportunities, and a course of loneliness. Two supervisors observed: We did some training on managers’ isolation… months ago now—it was on creating a culture of commitment, and there were… about 20 of us managers and directors, and then we had a plan of getting together and… keeping that going, and one of my MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 127 colleagues was going to make that happen and it only happened once. I would like to see that happen—that’s just a grassroot—we’re going to take care of ourselves as supervisors, and, you know, this week it’s my turn to share one of the concepts or one of the principles and we’ll talk about it and practice it and try to create that safe space. Maybe next time it’ll be your turn to share something that you’re working on. I would love to see us get committed to this as managers. (S17 – NGO) I am more in a leadership role and less in direct client care, working more with staff. A lot of the work that I do… is very much staff-focused, and I feel some isolation from the team that I work with…. I do feel we work collaboratively, but there is still sort of a bit of a divide… not an intentional divide; but there is an isolation piece that is different in terms of sharing as a supervisor compared to when you’re not in a supervisory role. There’s a loneliness aspect to it… that relationships and roles and responsibilities change, and that is something that can be difficult to prepare for. (S12 – NH) Regarding the rural remote practice and lifestyle, all participating supervisors commented about their experiences in rural remote practice and/or lifestyle. Although most participants consistently emphasized challenges of worker attrition, and lack of resources in the north, they also commented on the rural remote lifestyle. Climate. Most of the participants described the double-edge sword nature of the northern climate, on one hand, severe cold weather that made it difficult to travel, and on the other hand, good opportunities to enjoy winter sports and other winter pastimes. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 128 Rural Remote Pastimes. Many participants expressed their appreciation for the rich northern Indigenous culture with unique practices, while others discussed their appreciation of northern wilderness adventures, such as fishing, hunting, and camping. 5. Crisis Management/ Shovel-down Effect The majority of supervisors expressed the feeling of perpetual crisis management. The crises included handling of complicated client issues in conjunction with frontline workers, as well as dealing with directives from upper management. A frontline worker addressed supervisors’ bureaucratic challenges, describing a shovel-down effect. The worker, who also had supervisory experience as an acting team leader, provided some views from both perspectives. One of the concerns was the management of two multidisciplinary teams by one supervisor. I think it’s a shovel-down effect. I think, above our supervisor there’s another supervisor, and I think whatever comes in through the door just gets pushed down, until it finally gets to our supervisor. And that’s what I’m talking about, that, you clear one thing off your desk and there are two other things sitting there. I don’t think the workload is balanced appropriately. After being in that supervisor’s job… for six months, the workload never stops coming. Like I said, you would get one thing off your desk, and you look over, and there are two more piles of stuff. As an acting team leader, I can tell that this is still going on. Even when I am not in my acting capacity, I’ve been privy to conversations that indicate that things have not changed, in fact, I think the workload has even increased, especially now with our supervisor has two positions. So instead of having one person doing one unit and one MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 129 person doing the other, now the supervisor covers both positions. So, I can’t imagine what the workload would be like now. I think the workload could be distributed more evenly, whether it’s upper management—above our supervisor taking on some, or having an extra person taking on some of that work. Just so that our supervisor can be more accessible to us at work. (FL5 – NH) 6. Discomfort of Sitting in Ambiguity/ Internal Cognitive Dissonance Discomfort of Sitting in Ambiguity. The majority of participant supervisors expressed that they experienced stress due to pressures to resolve complex matters that arose within their workplace. Participants pointed out that some of the matters they had to deal with were complicated with no easy resolutions, leaving them in ambiguous circumstances. Participants also expressed that they often had internal cognitive dissonance—where they had certain answers to problems which could not be applied due to protocols or operational requirements. One supervisor had this to say about stress at work: “The main source for me is questioning my competence, inexperience and lack of full breadth of knowledge around our agency… makes it difficult to perform supervisory duties.” Another issue that was commonly raised by the majority of the participant supervisors was transmission of tasks and responsibilities, emanating from upper management, to frontline staff. Many supervisors expressed that the tasks they received were sometimes ambiguous or distressing to frontline workers—ambiguous, because some directives were either difficult or tedious to implement without enough workers and/or resources, and MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 130 distressing, since supervisors are sometimes the bearers of good and bad news, and have to deal with responses from frontline workers. Yes, and it’s the problem solving—the problems you’re not quite sure how to solve. You know, I’ve thought about this, and this is a little bit like the finding that I came across in my own thesis in the terms of that comfort with ambiguity—like social workers having to feel comfortable with going into a situation and not knowing what the answer is and having to sit in that ambiguity and the discomfort of that until you make your way to a conclusion or a decision as things unfold to that end. But you do not know what the answer is at the beginning of your engagement of the problem, and supervision is like that, too, because someone will come to you with serious conflicts, and people will make accusations, and you have to sit down and talk about it, and you have to be open-minded, you can’t come to conclusions, you have to stay neutral and balanced and objective. So when you have to conduct an investigation, you have to talk to, you know, at least two people if not more before you can come to a conclusion, and even then sometimes you don’t know the full truth of what’s going on, and that is very stressful. What did I not know before I took on supervision was that there are no rules for everything, right, or if there are rules they’re just not comprehensive enough to address the nuances of a particular context. Problems will arise where you have to figure out the answers, and there’s no immediate solution, right, and so that makes it stressful—feeling responsible when people get hurt, you know, in work-safe incidents and feeling like you… wish you had been able to do more. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 131 So, not having enough resources, not knowing the immediate answers, being put in the situation where people expect you to have the answers and you don’t have the immediate answers. (S13 – NH) Internal Cognitive Dissonance. One participating supervisor described the challenges of dealing with difficult matters such as discipline and/or downsizing workforce. Having to make some difficult decisions may result in cognitive dissonance, considering the repercussions of the decision. For example, one of the participant supervisors noted that workers are retrenched because of organizational downsizing; supervisors have to make some of the difficult decisions and are usually the bearers of the bad news. Supervisors understand that the organization needs to downsize, yet they prefer that none of the frontline workers are retrenched. Well, I guess it was an internal cognitive dissonance, right, and I guess I reconciled that in my mind by recognizing that, on one hand, I still believed it was the right thing to do from an organizational perspective, and I had a responsibility to the organization as a supervisor and manager, right? I had a responsibility to the organization to do the right thing over the long term for the organization. My concerns around negatively impacting disempowered disenfranchised staff was to be particularly patient and to follow a fair process, seeking consultation from those staff who were impacted, listening to what they had to say, revising the plan as much as I was able within the constraints, you know, and finally implementing the changes in as fair a process as I could. I spent a lot of time letting people be really angry at me. (S8 – NH) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 132 7. Disciplinary Meetings and Decisions/ Addressing Workplace Conflicts Participating supervisors also expressed the discomfort they experienced whenever they were involved in disciplinary matters. The supervisors noted that they felt the need to address issues of incompetence among FL to avoid grave mistakes. Since some of the disciplinary meetings would lead to loss of employment, supervisors had to make sure the worker had a fair hearing. Participating supervisors also pointed out that workplace conflict was common in multidisciplinary and interdisciplinary settings. In some cases, supervisors will find themselves in dilemmas, as explained by a supervisor’s example below. Another example that I can think of is when I became aware that a staff person had perhaps breached confidentiality, and I struggled, Well, it was difficult, and it was awkward—I think my struggle was whether or not I believed the person—maybe that was it because, I respected this person, it was a serious issue and I reported to the manager who had to take it upon, in a more formal disciplinary way. It was determination that the person had breached confidentiality despite the explanations that were provided, but I struggled with that one. I think it was around wanting to believe this person, wanting to believe that this person wouldn’t lie to me, but then I recognizing that actually the explanations did not make sense… The person did not provide sufficient explanation about what had happened. (S13 – NH) 8. Overwhelming Amount of Work/ Time Limits/ Avoiding Perfection Mindset The majority of participating supervisors expressed that dealing with policies and procedures, was time consuming, and sometimes overwhelming. One participant noted that “to get something simply done—there’s such a complex maze to go through to get to the end MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 133 point can be frustrating” (S5 – NH). The comment below illustrates further the difficulties from what has been described as shovel-down effect. There is always something happening at a higher level, and it gets pushed down through managers at different levels and eventually gets thrust onto team leaders— different policies that have to be incorporated into how we do our work… so someone is attacked by a client, you know, in Courtenay on the island, and all of a sudden an ADM has a new policy… that requires a whole bunch of extra precautionary measures and assessments and so forth, and every time something negative happens in this ministry, it seems like new policies are churned out to prevent things like that from happening again—and so all the paperwork we have to read, all the policies we have to implement—it becomes quite tedious at times—that’s the part of the job I don’t like, and sometimes I feel all those policies and directives … stand in the way of me doing what I would most like to do which is clinical supervision and program development. (S10 – MCFD) Another supervisor from MCFD (forensics) described the overwhelming nature of her work: Oh my goodness. Main sources of stress I’m going to say is balancing multiple pressing priorities every day at work. I look at… all my emails and my stack of paper and I think, huh, not sure what I’m going to do today. The day goes zipping by, and I think, ‘Ha, shoot, I’m not sure what I did today. My job is stressful because I feel like I have ongoing—should I to call it a burden?— of ensuring that someone is treated or not… that is as far as public protection, rehabilitation and reintegration goes. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 134 Competing, you know, priorities—you know, court deadlines, somebody needs something right now—thankfully we’re not a crisis organization—like we don’t take walk-ins, but if somebody, a young person that we serve, comes off the street in crisis, obviously we have to intervene. So, main sources of stress—I’m going to say the nature of the work is stressful. (S6 – NH) 9. Limited Leadership Preparation (grandparenting)/ Maintaining Competency—InService Training/ Training and Mentorship in Rural Remote Settings Turning to another contentious issue in rural remote practice, the majority of participants talked about education and training opportunities, and the challenges in maintaining competency. It is common practice in mental health work that many supervisors are promoted from frontline workers to supervisors after gaining experience, which is sometimes described as grandparenting. The majority of participant supervisors had less than five years’ experience. The supervisors—many of whom were newly promoted, had limited or no leadership training and were expected to acquire skills on the job. Below, one participant expressed that there was more reliance on mentorship instead of formal training. I would like to see that kind of information and practices formalized. What do they want supervisors to know? What style of supervision is important? There is some of that coming, but again our agency states that we rely more on mentorship, which can be helpful and should be part of it but leads to inconsistencies throughout our province and our agency; so I’d like to see more standardized practices that are communicated in written documents… I’d love to see a reading list, here’s some of the updated information that we have, and I always like the most MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 135 recent information… in the last few years we’ve been noticing in briefings that past practices were not as effective as new supervisory techniques—I would like that to be updated as well. Sometimes they lump everybody into the course because they sometimes want to save money thinking that everybody should benefit from it, and some people end up taking the same course twice. It almost feels like a poor use of time—those over-generalized or over-simplistic courses, you know, instead of something a little more inspiring, more targeted, more tailored, more inspiring, more realistic, practice-related courses. (S17 – MCFD) Commenting on education and training in rural and remote regions, another participating supervisor explained the following: When you become a supervisor in the north it’s more challenging because there are probably a lot more educational opportunities in Vancouver or Surrey… down south is the hub, and it’s hard not to feel discriminated just because you live in the north. If I go to any of the recommended training I’ll be paying for travel. Being a manager in Prince George is much different than being a manager in Vancouver or Surrey. Their staffing numbers are much higher because they’re working in a metropolis, but they don’t know what it’s like for us. A prime example is we had a client living on a reserve outside of Quesnel… he was so unwell, but he didn’t want to go to the hospital but he had family support, so we decided to give him one week to take medication every day and… follow up with family members to ensure he was keeping up. One week later his mum who had said she was living with him, wasn’t actually living with him—we therefore had no way of confirming that he MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 136 was taking his medication, so our doctor certified him. It took us five days with the help of the RCMP to get him into the hospital. Mainly because where he lived we didn’t have any community resources. The family told us that he lived with them, which was not true, the family lived in Quesnel and he was residing on the reserve. It was very complicated. Whereas, in Vancouver they call the RCMP, they pick him up, they take him to the hospital the same day. It took us five days to get him hospital. It’s different work environment with different challenges. (S18 – NH) Levelling of Professional Ability and Mentorship. One participating supervisor expressed the need for progressive levelling of workers to ensure that expertise and experience are recognized and utilized. as one progresses… I was mentioning about skill-mix because the way nursing is done in Canada, you’re employed into a line and you stay in that line. Then, say somebody new comes along—they will own the line, and if your skill levels are the same, you’re not going to learn from each other, and if you’re constantly working together; so where and when do you develop additional skills experience. I will try to phrase it so that it makes sense…. So you can have two inexperienced people working together constantly—their skill levels are not going to develop faster unless they’re attending some training and educational outside work, or else if you have two people that have got different skill-mix they can learn from each other. This is a form of mentorship. (S13 – NH) The Essence of Clinical Education. According to one supervisor, clinical education and support help avoid vicarious trauma and burnout. The supervisors observed that, if education is not provided, people get MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 137 frustrated very quickly within the early years of doing their jobs, and quit their jobs. Then it becomes a recruitment and retention issue. The supervisor observed that: you can retain staff and maybe even recruit staff if people hear that they’ll be offered the best work environment, and in health care especially mental health people burn out quickly, and you lose staff very quickly if you don’t support them well. Clinical supervision should be mandatory (like in United Kingdom) but it’s not only from the organization though—it should also be emphasized by legislative bodies of nurses or social workers because I believe that some aspects of what we do should be made mandatory like clinical supervision, for example. I keep on mentioning it because it does have an impact on what people believe is expected of them and putting some accountabilities to either the organization and individuals, but if it’s not mandatory and doesn’t have to be offered, it does infringe on some progress. Also, when you bring in disciplinary issues that come alongside that—it poses a challenge because some performance issues can be avoided if clinical supervision is offered. (S13 – NH) Maintaining Competency in Practice. Three participating supervisors expressed the challenges of supervising underqualified workers. One of the supervisors observed that it is important to get the right people for the right job to avoid the common attrition in northern rural remote settings. As much as this is a hard to recruit area, just employing people to fit into this space is not the answer because you find that, with time, what you’re expecting a person to do if they were not a fit, you’re constantly addressing performance issues, and then you run into the contractual difficulties—you put learning in place and it’s making no difference because maybe this person is just not the right fit for the work. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 138 But the length of time it takes to just address the issues and not come into a resolve can be frustrating, and that takes a lot of time. When I’m spending more time with one member of staff than doing what I should be doing with the rest of the staff—it’s a big problem. I’m not so sure how some of this happened—I wasn’t part of the interview panel and the short-listing panel—I do sometimes question how the decision was made to employ a particular person in a position. (S16 – NH) Cultural Training. A supervisor expressed the need for cultural competency training for supervisors due to the diversity of needs and clientele in northern communities. The participant also observed the diversity of Indigenous groups all over northern BC: there should be more training just in terms of being a supervisor but also a cultural piece on top of that… although at a certain point it could be on the job training especially because every hundred miles you drive in northern BC there’s a new culture. I do reckon that it can difficult to teach this at the university or something like that, but I do believe that collecting culture related information resources and making them available to people who want to go into leadership can be done… that would be a good inexpensive start. (S10 – NGO) 10. Multidisciplinary Responsibilities/ Interdisciplinary Conflict/ Lack of Appropriate Management Expertise for Multidisciplinary Teams Most mental health organizations in rural northern BC have multidisciplinary teams with operating differences and commonalities, while the differences are mainly between governmental and not-for-profit organizations. Multidisciplinary teams are sometimes difficult to manage due to personal and professional differences in practice. In the three MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 139 examples below, participating supervisors provide examples of bureaucratic challenges within mental health disciplines in northern BC. In the first example, a senior manager explains the complex bureaucratic composition of multidisciplinary teams at Northern Health Authority. Maybe I’ll go back a little bit more on the organization structure and the current shift… historically, the mental health and addictions staff reported to mental health addictions team leader who reported back to mental health addictions manager who reported to mental health addictions director... these services if they’re community based… were moved over to the interprofessional teams; so the interprofessional teams have a team leader… who then reports to a new position called the community service manager. The same… manager has responsibility for the different interprofessional teams, but they’re geographically-based, and they report to the health service administrator… that is the hierarchy. (SM1 – NH) Lack of Appropriate Management Expertise for Multidisciplinary Teams. Participant supervisors expressed the lack of mental health leadership within their organizations. The lack of leadership was mainly within interdisciplinary teams, some of which were not directly involved in mental health services. Good examples from two participants were, one, Mental Health Services within the Ministry of Children and Family Development and, two, training for multidisciplinary work at NH. A supervisor from MCFD expressed frustration around funding decisions for mental health services: MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 140 Most of the managers of Child Protection Services have no familiarity with child and youth mental health; so they’re often looking at our services through the lens of child protection. For example, our regional manager had an opportunity to get one and a half FTEs for our team through the recent release of funding in the province, and I was told that they wanted to dedicate a significant portion of those new FTEs towards services for children in care... but if services to children in care receive priority over services to CYMH within communities, who may have more pressing mental health needs… that’s an unfortunate decision in my mind. I think we should always deliver services to the children who need them most, rather than whether or not they happen to be working with a social worker or with a child protection social worker. Unfortunately, we don’t have any managers in our region who have child and youth mental health expertise, and that’s a disadvantage when it comes to program development and planning and prioritizing resources and so forth. (S7 – MCFD) Training for Multidisciplinary Work. Below, one senior manager explained multidisciplinary training complications related to ongoing introduction of primary care services not only in NH, but also with other health authorities in British Columbia. Interior health is definitely wrestling with this as well; in fact, all of the health authorities… Vancouver Island even has four different models… maybe Fraser… would probably be the health authority that have moved the least. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 141 All of them are going through the process of setting up interprofessional teams and still trying to sort out that clinical supervision…. Northern Health has taken it on as a major shift. In the other ones they still have a lot of specialized programs… but they’ll have interprofessional teams in specific areas. When it comes to overall training needs for staff, and part of it is with the interprofessional teams… a balancing act… you’re trying to keep the skill level up for the people who have specialty knowledge in areas of public health or home support, senior home support care, and mental health/addictions, but then the flip side is you want to provide training for that whole team… So, it’s how do you generalize your training for people who are not practicing in the same program plus expanding it so all people are aware of it. (SM1 – NH) 11. Collaboration Challenges in Interdisciplinary and Multidisciplinary Teams/ Managing Team Dynamics Between Disciplines/ Power Struggles Between Professional Disciplines/ Preference of Discipline-specific Supervision Interdisciplinary and Multidisciplinary Collaboration and/or Challenges. Mental health services in northern BC incorporate frontline worker from several disciplines including, but not limited to, nursing, social work, counsellors, etc. Employees of these disciplines who are under multidisciplinary supervision sometimes find it cumbersome when seeking alternative supervision. Alternative supervision is sought when a multidisciplinary supervisor is not conversant with some clinical or non-clinical procedures. There are also other challenges such as power struggles, multidisciplinary and interdisciplinary conflict within organizations, or the region as whole. A good example is MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 142 when a supervisor is in charge of experienced workers from several disciplines. Participant supervisors gave the following examples. certainly the role of supervising individuals who are more experienced than I am in some areas bring forth power struggles. It’s difficult—the content of our work… the types and levels of offences that we are dealing with… which is part of the difficult decisions that we make each day—there’s often not a clear right answer when it comes to some of the places where supervisors get called in—it’s because the situation is… affecting our community or affecting our other agencies that we work with, and there’s not usually an easy answer… there’s a lot of energy put around the cases that we manage. (S12 – NH) Managing Team Dynamics (Between Disciplines). Below, a senior manager explained the complicated clinical consultations between disciplines resulting from the introduction of primary care services at NHA. Well, this is where Northern Health is in the process of shifting; so, to support the mental health staff and in this time of change—what they’ve done… an example—so, if it’s a smaller community where there was one mental health team, and now within that community, by creating these primary care interprofessional teams, they’ve now got two of them; so they put the mental health and addiction staff on each of the teams. Usually the mental health team leader would’ve ended up being a team leader of one of the two teams, and so, there’s… more of an informal understanding—but if the mental health staff on either of those two interprofessional teams have questions… clinical questions, then they could go to that supervisor who had been the mental MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 143 health addictions supervisor—even though they’re now interprofessional team supervisor. SM1 – NH) Collaboration. One participant supervisor explained a need for collaboration not only between mental health related disciplines, but also with other supportive organizations. Working with the Salvation Army is a good example: My role, because this is a new program, is to inform the other program the criteria for admitting clients or patients in our program and to work collaboratively in terms of how we make sure that transfers occur seamlessly and nobody falls through the cracks. As well as… another example—I think organizational change also takes place by breaking some of the silos that we’ve had; so partnering with our colleagues… so, we had clients in the Salvation Army in the shelter who required wound care, but typically a nurse wouldn’t go in because it’s not a safe place to go by yourself; so we partnered and said, “How about if we go together… you can come and we’ll be there and the client will be seen.” So that’s kind of the role—I think it’s a very specific role that I play by identifying the need, seeing the barriers and removing them by partnering. (S9 – NH) Expert Leadership in Remote, Rural, Multidisciplinary Settings. Participant supervisors expressed the lack of mental health leadership within their organizations. This lack was mainly within interdisciplinary teams, some of which were not directly involved in mental health services. A good example provided by two participants MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 144 was Mental Health Services with the Ministry of Children and Family development: one participant supervisor from MCFD, and another from NH. Most of the managers of CPS have no familiarity with child and youth mental health; so they’re often looking at our services through the lens of child protection. For example, our regional manager had an opportunity to get one and a half FTEs for our team through the recent release of funding in the province, and I was told that they wanted to dedicate a significant portion of those new FTEs towards servicing children and care… but if services to children in care receive priority over services to children… not in care, who may have more pressing mental health needs… that’s an unfortunate decision in my mind. I think we should always deliver services to the children who need them most, rather than whether or not they happen to be working with a social worker or with a child protection social worker…. we don’t have any managers in our region who have child and youth mental health expertise, and that’s a disadvantage when it comes to program development and planning and prioritizing resources and so forth. (S7 – MCFD) After the above review of the manifest (surface meaning) themes, the next section will address the five latent (deeper meaning) themes. During the interview process outlined in chapter three, participants talked about their experiences which were captured by surface meaning themes manifest (emergent) above. The 11 manifest (emergent) themes included verbatim illustrative excerpts from the interview transcripts, which provided consistency and coherence. Through careful consideration and filtering through manifest (emergent) themes for deeper or hidden meaning, five latent MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 145 (superordinate) themes were identified (Boyatzis, 1998). This second phase included a clear interpretation of data which went beyond paraphrasing or description. Table 6: Latent Themes (Superordinate) Latent Themes (Superordinate) Researcher Reflections 1 Incessantly difficult and overwhelming responsibilities A glance at the participant supervisors’ portfolios leaves little doubt that tedious juggling of various tasks is inevitable. Without exception, all participant supervisors view their job as either demanding or stressful. 2 Stressful and complicated decision making It makes work life very difficult for supervisors whose superiors are unable to provide clinical or management support. However, mental health supervisors have to make decisions—some of which may be difficult and stressful. 3 The endless campaign for rural remote professional leadership support Rural remote employment is unique and therefore requires unique policy considerations such as adequate funding for resources. 4 Mentorship in remote practice: A critical fallback It is unfortunate that mentorship is largely inconsistent in rural remote regions due to attrition challenges. There is no doubt that mentorship is a critical part of career development. A trained workforce and minimal attrition encourage mentorship. 5 Multidisciplinary rural remote supervision: A struggle in collaborative plurality I see an increase in multidisciplinary teams with positive aspects; on the other hand, they are a recipe for disputes due to issues such as power struggles in larger northern communities. Latent Themes 1. Incessantly Difficult and Overwhelming Responsibilities All participants expressed various levels of stress due to work demands and responsibilities emanating from upper management. According to supervisors and some MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 146 frontline workers, the numerous tasks over-extended the responsibilities of the supervisors. One FL worker with experience in interim supervision proposed the provision of administrative help for supervisors in areas that did not require decision making. Another FL worker proposed the sharing, among team members, of some procedural supervisory responsibilities. Participating supervisors were concerned about the sizes of their teams and how smaller teams may be an answer to some of the overwhelming mental health supervisory work. 2. Stressful and Complicated Decision Making Three supervisors discussed the discomfort of working through difficult tasks and sitting in ambiguity. According to participating supervisors, the discomfort persists as you make your way to a conclusion or decision until an answer or solution is reached. One supervisor explained: but you do not know what the answer is at the beginning of your engagement of the problem—there may be a serious conflict, and people will make accusations, and you have to sit down and talk about this, and you think you have to be open-minded, but you can’t come to conclusions, you have to stay neutral and balanced and objective, and sometimes you have to conduct an investigation, talk to, you know, at least two people if not more before you can come to a conclusion (S8 – NH) Decision making is a critical aspect in supervisory work, and more critical in rural remote regions where material and human resources are scarce. In one example from a participating mental health supervisor, supervisors’ decision making may sometimes result in cognitive dissonance, where decisions such as retrenching of staff may be in conflict with organizational needs for downsizing. Mental health supervisors often have to consider the MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 147 repercussions from some of their decisions. As discussed earlier in the literature review, the administration, education, and support functions defined by Kadushin and Harkness (2002) capture the main supervisory activities. However, in what Feldman (1999) described as the “Middle Management Muddle” (p. 281), some supervisors are unclear about their roles. 3. The Endless Campaign for Rural Remote Professional Leadership Support Two aspects of loneliness and isolation were brought up by some participating supervisors. One aspect related to lack of personal relationships or the loss of relationships after the assumption of supervisory duties. Many supervisors are promoted to supervisory positions where they will already have developed relationships with fellow frontline workers. In their new capacity, mental health supervisors are prone to isolation and loneliness as they to seek to maintain appropriate supervisor–supervisee relationship. The second aspect of loneliness and isolation brought up by some supervisors related to the remoteness of some work locations, characterized as small-sized communities, hence limited human interaction. However, amidst the gloom of rural remote mental health supervisory practice, those who choose to live and work in the north enjoy life with the magnificent landscapes and seasonal sports, not forgetting enjoyment of the rich diverse culture of northern Indigenous populations. 4. Benefits of Mentorship Propagation and Mentorship in Remote Practice: A Critical Fallback In addition to the need for education and training, all participant supervisors acknowledged the necessity of mentorship in rural remote regions. The majority of participant supervisors shared their positive experiences of mentorship, and only three had negative experiences as mentorees. However, all participants supported the idea of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 148 appropriate mentoring of frontline workers, considering the challenges of practicing in the rural north. Some participant supervisors emphasized the need for mentorship given the limited in-service training opportunities for northern remote rural practitioners. Scott et al. (2006) observed that it is unfortunate that supervisors working in rural settings, who do not receive initial training, often continued to provide supervision without additional training. The majority of participant supervisors also expressed their wish for more training opportunities both within and away from their work stations. Rural supervisors do face many challenges which require specific supervisory training and support. The importance of initial supervisory training is broadly documented: this includes the work of Beddoe and Davys (2016), who emphasized the importance of supervisors being supervision-trained rather than falling into the role through professional maturation. 5. Multidisciplinary Rural Remote Supervision: A Struggle in Collaborative Plurality The importance of multidisciplinary work in the rural remote north cannot be underestimated. Northern rural remote communities are small, with fewer human resources. Various professionals who work in the north tend to form clusters of multidisciplinary teams for each small community. Participant supervisors raised three challenges that they face in rural remote multidisciplinary practice: lack of appropriate management expertise for multidisciplinary teams; lack of appropriate training; and complex collaboration for interdisciplinary teams. The lack of appropriate management expertise was raised by a few participant MCFD supervisors who specifically cited the lack of experienced CYMH managers. Introduction of primary health care by health authorities in British Columbia came with the challenges of MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 149 training multidisciplinary teams. A senior manager explained that training of multidisciplinary teams was complicated by the need to provide ongoing individual professional training while also ensuring the provision of some form of general training for the multidisciplinary team. According to participating supervisors, collaboration within interdisciplinary teams was hampered by FL workers’ supervisory needs. As an example, some FL workers had to choose between a supervisor from their discipline or one who was not. Summary Chapter five has presented the findings from this study with the goal of reporting and reviewing the responses and examples from participants’ stories. This chapter included: participant demographic information; manifest (emergent) themes; latent (superordinate) themes; as well as the researcher’s reflective journal entries. In chapter six, the above findings will be discussed in greater detail. Chapter Six: Discussion General Implications of Findings This research sought to explore the nature of multidisciplinary supervision in rural remote regions of northern British Columbia by posing the following research questions. 1) What challenges and opportunities do mental health supervisors experience in northern British Columbia? 2) How do frontline workers, supervisors, and senior managers perceive the roles and activities of mental health supervisors in northern British Columbia? 3) How are supervisory approaches in various mental health disciplines different or similar in northern British Columbia? The purpose of this chapter is two-fold: First, to reflect on the three research questions by critically analyzing various aspects of the research findings discussed in previous chapters that directly shed light on them. Second, to extrapolate the analysis of findings by placing them within the context of the extant literature and, by so doing, accentuate this study’s central theoretical and empirical contributions to knowledge. Previous studies (e.g., Burns, 2001; Jefferies & Chan, 2004) have examined multidisciplinary mental health supervision and there are a number of models of supervision. Examples of the models are: Social work’s Kadushin and Harkness (2002); nursing’s Faugier (1992); counselling and psychotherapy’s Bernard and Goodyear (2009), and Hawkins’ et al. (2012). However, the unique nature of multidisciplinary rural mental health supervision in northern BC has barely been addressed in previous studies and models. The opportunities for quick career advancement and the pristine and attractive rural lifestyle were overshadowed by participants’ revelations of persistent, dynamic, and complex challenges to multidisciplinary rural mental health supervision. As pointed out earlier in chapter four, a MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 152 review of leadership theories as part of the overall theoretical framework for this study was necessary due to the close relationship between supervision, leadership, and management. The complex nature of multidisciplinary mental health supervision demands dynamic supervisory skills that incorporate the three related terms. Ludwig Wittgenstein’s “family resemblance” theory on closely related categories provided a realistic descriptive view of the tripartite relationship of supervision, leadership, and management (Nyström, 2007). The three terms are necessary in the discussion because mental health supervisors tend to assume the three roles in rural remote settings. Also important for the same setting is whether leadership is learned or taught, a debate central to multidisciplinary rural mental health supervision. According to trait theory, leaders have superior qualities that differentiate them from their followers (Marquis & Huston, 2009), while Drucker’s (1974) management by objective theory purports that leadership can be taught. My assumption in approaching this study was that, although leadership can be innate, it can also be taught, which was consistent with Kouzes and Posner’s (2003) emphasis on allotting resources to leadership development, since leadership is learnable. Despite the confidence of participant supervisors in their innate leadership abilities, prevailing challenges and lack of training in multidisciplinary mental health supervision were evidently overwhelming from the participants’ point of view. The following two-prong review of the manifest and latent themes extrapolate the need for a reexamination of supervisory skills beyond our current understanding. The first part will include a discussion of the research questions and the manifest themes. The second part will address the latent themes to provide an in-depth discussion of the findings that takes into account the study’s theoretical perspectives. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 153 A focus on this study’s manifest themes contextualizes the contemporary views from my study’s participants, which provide a better understanding of the challenges and opportunities of multidisciplinary rural mental health supervision. Since qualitative research interpretation requires going beyond simply describing the data, a review of existing literature will be incorporated (Patton, 2002). Two important factors complicate our understanding of rural remote mental health in northern BC: First is the lack of research studies specific to mental health supervision, and the second factor is the overwhelming assemblage of governance entities involved in the provision of mental health services. The few disciplinary studies including nursing, social work, and counselling that have focused on northern rural remote practice bring to light some internal and external factors that define the uniqueness and challenges of mental health practice in the north (Lenthall et al., 2018; Macleod et al., 2017; Schmidt, 2017; Hanlon & Kearns, 2016; and O’Neill, 2016). The internal factors include: leadership and management; organizational structure, and organization culture, whereas the external factors include: policies and regulations; rural location; funding; and the nature of mental health work (Moore et al., 2010). Although the above factors are acknowledged within various disciplinary studies on rural remote practice, little is known about their impact on multidisciplinary mental health supervisory work. The detailed specifics of the manifest themes in chapter five provide a new, unique, and more detailed understanding of the reality of multidisciplinary mental health supervision in the north. Secondly, the context within which mental health services are carried out in northern BC is bureaucratically challenging and complex due to a substantial assemblage of governance entities. In BC, the administration of mental health services covers several MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 154 ministries including: Health, Children and Family Development; Mental Health and Addictions; and Attorney General. However, as explained in chapter three, most of the province’s mental health services fall under the Ministry of Health and the recently created Ministry of Mental Health and Addictions. Further fragmentation of mental health services is evident in the six health authorities, numerous non-governmental organizations, and a workforce composed of professions from several disciplines (Appendix T). Bearing in mind the above two factors, below are the answers to the three research questions contextualized using the manifest themes. 1 What challenges and opportunities do mental health supervisors experience in northern British Columbia? While the internal and external factors from previous studies provided views and assessments on the nature of rural remote practice, the results from this study indicated specific challenges experienced by mental health supervisors, some of which align with previous research. The complex issues raised in this study included perpetual challenges relating to policy implementation, challenging daily responsibilities, and persistent lack of administrative support. Although some worked for different organizations, the majority of participating supervisors experienced somewhat similar challenges. These findings provide an additional level of complexity to our understanding of rural remote mental health supervisory work. This knowledge on supervisory complexities facing practicing supervisors is critical to the largely elusive solutions on rural remote mental health supervisory practices. Improved mental health multidisciplinary supervisory work in northern BC would potentially enhance truly holistic mental health care, considering that the majority of participant supervisors have to deal with various stakeholders (Jefferies & Chan, 2004). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 155 In what some participant frontline workers and supervisors described as a pull from above and below, participants from both groups described the situation as a sandwich between upper management and frontline work—a simultaneous pulling of supervisor between conflicting expectations, according to Kadushin and Harkness (2002). Dissatisfaction on either side of the sandwich increased as the tasks multiply, leaving frontline workers feeling unsupported. Frontline workers expressed frustrations that their supervisors spent much time in meetings away from their workplace, which compromised team interaction and collaboration. Schmidt (2017) observed that, despite facing many of the same issues as frontline workers, supervisors also faced unique challenges. In additional to external factors related to their rural location, the majority of supervisors voiced challenges in addressing internal factors, such as the numerous task implementation expectations from various levels within a highly hierarchical and pluralistic environment. One supervisor observed that there was always something happening in the higher level that ended up becoming a supervisor’s responsibility. Unfortunately, a vicious cycle of internal and external challenges in rural remote regions is inevitable given the persistent practice challenges voiced by all participant supervisors: mainly, the unequal distribution of tasks and responsibilities. The tasks included dealing with various multidisciplinary and interdisciplinary work requirements, depending on the client’s needs, be it medical or psycho-social; dealing with collective agreements in matters pertaining to supervisees’ support and/or disciplinary actions; continuous training and recruitment of new staff due to high attrition; coordinating various travel requirements for both supervisees and clients; and attending numerous multidisciplinary or stakeholder MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 156 meetings in person or by phone. Notably, the challenge repeatedly brought up by the majority of supervisors was the frustration of dealing with labour unions (collective agreements), mostly when there was a need for a change in working policies/conditions, and/or when taking disciplinary action on a frontline worker. The participant supervisors found the labour union involvement particularly challenging and time-consuming. In addition to the few northern BC rural remote studies, administrative support concerns were addressed in earlier findings from Australia and Canada by Cramer (1995) and Misener et al. (2008). The authors emphasized the significance of administrative management functions in support of rural remote nursing. In contributing to this existing scholarship on administrative support issues, my research found that the majority of the supervisory tasks outlined above includes administrative clerical, procedural, and other components that further overwhelm the overworked mental health supervisors. Also, while carrying out various administrative tasks, professional competency and pecking orders (mentioned in chapter two) are also rife among mental health supervisors whenever they encounter other mental health practitioners in multidisciplinary settings (Lee & Everett, 2004). Also, due to worker attrition, northern rural remote regions rely on maximizing the skills and abilities of the available workforce. The majority of the supervisors, most of whom worked for NHA and MCFD, expressed frustrations due to lack of appropriate management and clerical administrative support. This lack of support leads to difficult decision making, and additional responsibilities with no easy solutions. One supervisor expressed that, whenever challenges arose, the middle management position bore the wrath of supervisees, MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 157 the clients, and upper management. Additionally, there is an unrealistic expectation that supervisors have answers to every problem, if they don’t, they are blamed for it. 2 How do frontline workers, supervisors, and senior managers perceive the roles and activities of mental health supervisors in northern British Columbia? While the roles and conduct of the northern remote mental health workforce may differ, many of the common challenges and opportunities fall under most of the internal and external challenge factors that face northern rural professionals. Given the common experiences, frontline workers and the senior managers understood and empathized with the challenges facing mental health supervisors. Since many of the challenges and views from supervisors are reiterated earlier in this chapter, the following analysis focuses on the views of frontline workers and senior managers. While describing the work of the supervisors, the frontline workers expressed concerns that supervisors had to support teams that were in many cases composed of new and inexperienced frontline workers. They also described directives from upper management as a “shovel down effect” by frontline workers, who expressed concerns that supervisors spent more time addressing other tasks; hence limited availability at the workstations. Senior managers, on the other hand, expressed that directives from upper management to supervisors were bureaucratically typical, but acknowledged the disproportionate amount of responsibility for supervisors. One senior manager expressed that mental health supervisors face additional responsibilities whenever restructuring occurred, providing the example of the introduction of primary care policies at NHA. The concern regarding additional work during restructuring had also been raised by participant supervisors, who had to take on MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 158 additional supervisory responsibilities. Supervising two teams with limited time and support was one example given, a view that resonated with the majority of the participants throughout the study. According to another senior manager, balancing of multiple responsibilities left the supervisors little time to complete required tasks; hence the supervisors’ endless crises mode. The concerns raised by the three participant groups have appeared in the media as communities grapple with inadequate services due to shortages of mental health professionals. A CBC news article by Kurjata (2018), citing the BC Auditor General’s report, observed that poor management and lack of training in northern BC was an obstacle to recruitment and retention of nurses. Despite all the challenges, there are many career and cultural opportunities for those who choose to live and work in the north. Employment opportunities are mostly available due to high attrition and, for those who choose to remain in the north, there is the advantage of quick career advancement. Even with the numerous challenges, majority of participant expressed their appreciation of the rich Indigenous culture, the attractive winter sports, and other northern wilderness adventures. There is consensus around the views on mental health supervisory work among this study’s three participant groups. The majority of the participants alluded to the dire need for the review of rural remote supervisory responsibilities. The participants expressed the need for well-defined responsibilities for multidisciplinary rural remote mental health supervision, and the consideration of a horizontal organizational teams structure. 3 How are supervisory approaches in various mental health disciplines different or similar in northern British Columbia? MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 159 The majority of supervisors from mental health disciplines in northern BC work for two main employers, NHA and MCFD. Many have Social Work or Nursing backgrounds. A few other participating supervisors work for not-for profit organizations and/or educational institutions. Participant supervisors who worked for NHA expressed the lack of support from upper management despite the availability of adequate senior management staff. The participant supervisors further expressed that the NHA management hierarchy is composed of experienced upper management with varied disciplinary backgrounds. The opposite is the case at MCFD since, according to MCFD mental health supervisors, the management hierarchy of MCFD is composed of experienced mental health supervisors but very few people in upper management with experience in mental health and mental health supervision. Supervisors from MCFD expressed frustration that they had difficulties accessing consultative support from upper management, which impacted mental health related policies. Due to a largely multidisciplinary approach to mental health supervision, the differences have more to do with disciplinary practices than leadership. Leadership, including from mental health supervisors, usually accommodates and oversees workers from several disciplines. One difference related to skill set allows supervisors with a nursing background to perform medical functions, such as dispensing medicine if necessary. This kind of support happens more often at in-patient settings. In my experience as a mental health clinician, the majority of mental health supervisors oversee multidisciplinary teams, and consult other team leaders whenever there is a need to address treatment or medical complications beyond their scope of practice. There are several mental health supervisory similarities between disciplines. Absolutely none of the participant supervisors had any kind of formal supervisory training MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 160 before becoming supervisors. The majority of supervisors, however, reported varied levels of in-service training. A second similarity was the requirement of cultural safety or competency training, which supervisors were expected to extend to frontline workers. Thirdly, due to the overrepresentation of women in helping professions, the majority of participating supervisors and generally those in the field were women. A fourth unifying similarity was that all mental health supervisors, regardless of disciplinary background, talked of the overwhelming nature of their workload and high expectations from both frontline workers and upper management. The final similarity raised by a senior manager and supervisors from NHA and MCFD was the lack of appropriate management expertise in multidisciplinary supervision. Mental health is multidisciplinary in nature and more so in rural remote regions; hence the difficult challenge of identifying appropriate leaders with the required expertise and experience. Due to limited competition, for the few who qualify to supervise multidisciplinary teams, rural remote work provides opportunities for fast career advancement. The above differences and similarities are consistent with the complexity of multidisciplinary mental health supervisory work in an administratively fragmented and pluralistic northern BC, and other comparable regions. The remaining part of this chapter will address the latent themes. Latent Themes Incessantly Difficult and Overwhelming Responsibilities One of the noticeable differences from this study, as compared to existing studies, was its uniquely multi-faceted review of multidisciplinary mental health supervision in the rural remote north. In addition to multidisciplinary mental health supervision, this study reviewed supervision within social work, nursing, and psychology. Other related studies that MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 161 have been cited in this study have mainly focused on targeted supervision research within specific disciplines. From a social constructionist perspective, the limited scope of supervision research in rural remote regions has propagated the persistent challenges facing supervisors and, by extension, challenges in rural mental health practice. The essence, needs, and possibilities for broader interaction by the supervisors with the majority of significant and relevant mental health professions are paramount in remote rural settings. According to Gergen (1995), social constructionism purports that a great deal of human life exists as it does due to social and interpersonal influences. Limited human interaction was evident as the supervisors described their typical tasks as follows: challenging responsibilities; balancing of multiple priorities; working with unions; supervising and carrying caseloads; and a lack of administrative support, while constantly receiving tasks from senior managers (shovel-down effect). All of the above were indicative of limited human interaction opportunities. A majority of the participants in all the three participant groups acknowledged that, due to their heavy responsibilities and time constraints, supervisors were unable to add their voices to meaningful communal discourse. An expectation that the status quo in multidisciplinary rural mental health can improve by focusing on the individual aptitude of supervisors remains inadequate and unrealistic. In the absence of social constructionist collective meaning making that abides in ongoing interaction with all professional stakeholders, the challenges facing the supervisors are bound to persist. In a recent study on mental health care in rural regions, Hoeft et al. (2018) proposed task-sharing as a way of leveraging mental health specialists to work together, in both primary care and within communities. Task-sharing would reduce a contentious workload in multidisciplinary rural mental health supervision. The authors observed that although task- MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 162 sharing can help to reduce the burden on some professionals, confidentiality issues would have to be addressed. Similar concerns were raised in interprofessional mental health practice where social knowledge of patients may be helpful but can also lead to negative influence; hence the need for professional ethical requirements (Goodwin et al., 2016). Mental health services in northern BC are based on vertical organization with a topdown organizational structure compared to a horizontal structure that provides employees autonomy and shared responsibilities. This study’s participant supervisors as well as some frontline workers suggested that some supervisory responsibilities could be redistributed by changing team structures. One frontline worker proposed a horizontal structure as opposed to the commonly used vertical structure (Williams & Wilson, 2010). A horizontal structure would reduce the supervisory workload with the delegation of work to other team members. A horizontal structure allows for more interaction between supervisors, supervisees, and senior managers as they work together towards team goals. Horizontal organizational structures do not appear to be particularly supportive of interdisciplinary supervisory processes that are more typical of rural environments. In fact, I posit that the prevailing horizontal structure may be an important determinant of the perpetually high rate of worker attrition in the mental health sector in northern BC. Stressful and Complicated Decision Making The findings from this study also depict supervision in the rural remote north as a distinct role devoid of sufficient interaction with the critically complementary entities of frontline work, senior management, and multidisciplinary partners. To meet their supervisory responsibilities, participant supervisors described persistent and overwhelming struggles with limited collaboration and/or brainstorming. Symbolic interactionist theory as articulated by MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 163 Blumer (1969) may help explain the missing links to promoting appropriate supervision in the rural remote north. Consistent with Blumer, supervisors’ work should happen inclusively within interactive processes with other employees, whereby modifications and decision making by the supervisor are carried out in an informed interpretive process. Participant supervisors discussed the nature of various functions and the lack of certainty in most of their decision making. The supervisors noted the lack of clear guidance from senior managers which resulted in frequent cognitive dissonance. Studies by Kadushin and Harkness (2002) observed that supervisors face the frustrations of the limits of autonomy, which is somewhat related to the concerns expressed by supervisors in this study. The authors pointed to constraints around administrative policies, various regulations, and client advocacy organizations. Although previous studies were generally compatible with some findings in this study, some participants in this study raised additional concerns related to the discomfort of working in an environment that is shrouded in ambiguity. The majority of supervisors expressed frustration that, on many occasions, they had to be comfortable working in ambiguity due to the lack of clinical or management support from senior management. An example was a supervisor who worked for the Ministry of Children and Family Development. He explained that there was a shortage of senior consulting managers with mental health background at the MCFD’s headquarters. Due to a lack of timely responses or support from senior managers, as well as staffing challenges, many supervisors suffered internal cognitive dissonance when making some critical decisions. This led to some supervisors making decisions that were against official policies but in the best interest of clients. The lack of interaction with senior managers relates to symbolic interactionism MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 164 theory where, according to Greene and Ephross (1991), interaction is a “reciprocal perspective because it involves the transfer of meaning between and among people” (p. 208). A supervisor described adherence to the fatigue policy (maximum hours of work per day) as another example of difficult decisions. This supervisor explained that, due to attrition challenges in northern rural communities, some supervisors faced difficulties filling required shifts, and some workers had to work more hours, contrary to policies. The presence of ambiguity results in complexity of decision making, which has implications for the relationship between supervisors and frontline workers, as well as productivity. A reciprocal relationship between supervisors and senior managers can help address some of the difficult challenges that have no clear answers since, according to Blumer, (1969), meaning can be created during an interpretational process as people interact. The Endless Campaign for Rural Remote Professional Leadership Support As indicated by participant supervisors, there appears to be a lack of recognition by policymakers of the uniqueness of rural remote employment. There have been some proposals for redress; however, the need for more policies and resources tailored specifically for the rural remote work environment reverberated throughout this study. The majority of supervisors who had been promoted or grandparented to supervisory positions after several years as mental health workers expressed that persistent challenges, such as worker attrition and lack of collegial and/or upper management support, were common. Yet not much has been done to address the issues. The deficiency negated the spirit of individual and group participation in the creation of knowledge and/or social realities (Burr, 2003). According to Burr, the nature of socially constructed reality is an ongoing dynamic process whereby reality is reproduced by individuals acting on the knowledge and interpretations. An example is MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 165 found in the studies of Ducat et al. (2016) where the researchers observed that professional isolation is a persistent challenge in rural settings. There is therefore a need for organizational responsiveness to, and redress of, the current culture and structure that complicates the work of rural mental health supervisors. There were, however, some supervisors who expressed their attraction to and/or enjoyment of the remote adventurous lifestyle. Although the supervisors described the nature of work and the lifestyle as a doubleedged sword, citing severe climate and other factors, many had lived in remote environments long enough to weather challenges such as loneliness and isolation and they expressed their attraction to the northern lifestyle. However, the ability to weather challenges such as loneliness, isolation, and severe climate came at a price because, from a social constructionist perspective, the social context is at the centre of ‘meaning making’ and the attention on the ‘knowing’ that is created through shared production (Burr, 2003). One participant cited the lack of collegial commitment by multidisciplinary supervisory colleagues. Perhaps due to busy schedules, some supervisors would commit to attending social events but failed to honour promises to attend; hence continued isolation. Dual relationships within smaller communities were also cited as a reason for a lack of socializing opportunities, and a cause of loneliness. On another note, the same supervisors expressed frustration in how common rural remote challenges, such as attrition, and lack of resources and training, persisted in spite of policymakers’ awareness. Expressions by supervisors of feeling ill-equipped to tackle the above challenges are consistent with previous studies by Bernard and Goodyear (2004), Calise et al. (2007), Gellis et al. (2004), and Kuhn (2009). These authors raised the issues of supervisors’ unpreparedness due to a lack of initial training and in-service training, as well as MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 166 ongoing support. The authors also observed that supervisors in rural remote settings are less likely to receive ongoing in-service training, as compared to urban supervisors. The majority of the supervisors in this study expressed that, due to their experience and long service in the north, some job stressors were less challenging than the stress caused by the lack of organizational support. There are current efforts to address worker attrition training challenges which are in line with social constructivist views. A recent Australian study came up with a strategy to address retention challenges in rural workplaces, one consistent with the wishes of participants in this study. The strategy Whole-of-Person Retention Improvement Framework includes three domains: workplace/organization; role/career; and community/place. Workplace/organization involves working in a friendly and supportive environment while role/career involves opportunities for professional development. Thirdly, community/place involves being socially connected and having a sense of belonging (Cosgrave, 2020). The study is yet another relevant attempt to remedy rural remote workforce challenges but falls short of addressing supervisory challenges. While the Australian study addresses the poor relationship between workers and managers in relation to rural remote retention challenges, this study has addressed the relationship further based on a constructionist viewpoint (Burr, 1969). Even though positive supervisor/supervisee relationships improve working conditions, supervisory challenges in rural remote regions require much more. They require a combination of collaboration and more horizontal organizational relationships which, from a constructionist perspective, are cocreative and transparent. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 167 Mentorship in Remote Practice: A Critical Fallback Mentorship has been cited in general terms in other studies as part of supervisory professional development. In this study, mentorship was elevated to a level akin to apprenticeship, with the majority of participant supervisors embracing mentorship as absolutely necessary in rural remote multidisciplinary supervisory work. Although not specifically meant for rural remote regions, Bass et al. (1990) proposed the Supervisor In Training program (STI), meant to support newly hired supervisors. At the core of the mentorship discussion is the realization of the importance and influence of the social construction theory, where the ongoing interaction between a supervisor and a mentor provides an opportunity for knowledge construction. According to Gergen (1985), social constructionism places great emphasis on everyday interactions between people and how language is used to construct their reality. Since the majority of supervisors in this study had less than five years’ experience, many were newly promoted and had not received leadership training. The supervisors were expected to acquire skills on the job from their senior colleagues. Many supervisors observed that mentorship was more reliable than formal leadership training. One supervisor expressed disappointment in that their colleagues in urban areas could access much of the leadership training available in their city while, due to travel costs, a rural remote mental health supervisor would have to cover the costs of some of the training offered at the same city. Despite the persistent lack of training opportunities, the majority of supervisors and frontline workers expressed appreciation for the mentorship they had received earlier in their career. According to some participant supervisors, mentorship was what sustained the skills and morale of many rural remote workers who lacked the support and training that was MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 168 critically required. Participant supervisors expressed that they learned how to manage many tasks by emulating their mentors since there are still no initial formal training opportunities for supervisors. This research found that, even though initial training is needed for new supervisors, an apprentice style in-service training for preparing new rural remote supervisors was necessary. Consequently, both theoretical training and mentorship will be combined to prepare future supervisors. A previous study by Spence et al. (2001) found that, in the initial six months to three years following clinical training, the majority of practitioners could not continue using techniques they had been taught, necessitating refresher courses. Therefore, being a mentee to a more experienced professional, akin to apprenticeship, provides sustainable learning experiences. This is consistent with Blumer’s (1969) symbolic interaction theory’s assertion that humans make decisions about action based on the symbolic meanings ascribed to these actions, which are learned through social interactions and reflection on the self from the imagined perspective of others. Furthermore, according to Spence et al. (2001), the lack of appropriate supervisors has been linked to failure of some program implementations. Therefore, to avoid occupational stress and burnout, ongoing professional support in the form of apprenticeship or mentorship may be helpful to maintain the skills learned during the initial theoretical and/or clinical training. Mentorship is also critical to the multidisciplinary nature of supervision in rural remote settings, given the additional learning required for collaborative work. This is also consistent with Blumer’s ideas that meanings are continuously created and recreated through interpreting processes during interaction with others. In the case of multidisciplinary supervision, mentorship provides the apprentice supervisor with the opportunity to learn the nuances of dealing with professionals from other disciplines. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 169 Multidisciplinary Rural Remote Supervision: A Struggle in Collaborative Plurality For practical and logistical reasons, mental health supervision is essentially multidisciplinary. Professionals from various disciplines regularly serve the same mental health patients, and therefore collaborate to integrate and co-ordinate holistic mental health services within rural remote regions. This is consistent with social constructionism theory’s insistence on an individual’s awareness of the culture within workplaces, which helps in developing collaboration (Burr, 1995). As noted earlier in this study, there are tensions between mental health professionals which arise for a number of reasons, such as pecking orders (Gazzola et al., 2009), gender aspects (Glauser, 2018), and blurred job boundaries (Kreitner & Kinicki, 2010), for example. These tensions are related to three critical challenges raised by participant supervisors in this study: 1) lack of appropriate management expertise for multidisciplinary teams; 2) lack of appropriate training; and 3) complications in collaboration for interdisciplinary teams. Due to the lack of expertise in multidisciplinary leadership mental health supervision, collaboration remains a challenge. According to participant supervisors from the Ministry of Children and Family Development, the need for both individual professional training and general training for multidisciplinary teams is critical for rural mental health supervisory work. MCFD mental health supervisors also reiterated the lack of senior mental health leadership within the ministry. Another challenge to supervisees was the choice of supervisors that some frontline workers had to make in collaborative work within interdisciplinary teams, given the varied skills and training. Avoiding conflict in interdisciplinary work requires knowledge of antecedents in personality difference (Patton, 2014b), and can be addressed by prior awareness of past differences. The realization that there are competing demands and practice MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 170 paradigms associated with mental health supervision is critical to collaborative work. The three functions observed by Kadushin and Harkness (2002)—administration, education, and support—are a case in point. Supervisors who were involved in regular interdisciplinary work voiced a lack of professional expertise to address some functional requirements, such as education. In addition, two other challenges are the complex bureaucratic composition of multidisciplinary teams in rural northern BC, and training complications for multidisciplinary professionals. According to a participant senior manager with the Northern Health Authority, the organization structure and hierarchy of the mental health leadership has been undergoing frequent changes which have been destabilizing mental health supervisors and other employees. The frequent changes in leadership have led to lack of consistent collaboration and cohesion within the interdisciplinary teams since it is through consistent social interaction that human beings become aware of what others are doing or about what they are willing to do. There have been frequent changes to the medical model and leadership within the five British Columbia’s health authorities, the most recent being the introduction of primary care services at NHA, resulting in a major reorganizational in mental health services delivery. In my experience as a mental health clinician, there are challenges in the fostering of skills levels for specialty mental health supervisors and frontline workers while simultaneously providing interdisciplinary worker training; a challenge that was articulated by my study participants. Subsequently, generalizing training for professionals from various disciplines remains a challenge for BC’s Health Authorities. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 171 Summary A major finding from the study involved the perception by participants of the acquisition, maintenance, and application of supervisory knowledge in multidisciplinary mental health supervision, and the critical role of social constructionism. Previous studies have focused on common rural remote challenges, such as lack of resources, worker attrition, and isolation. However, the critical and complex supervisory challenges in multidisciplinary rural mental health supervisory work have been overlooked. The analysis in this chapter reveals a few things that are important contributions to extant knowledge on the topic of multidisciplinary mental health supervision in northern BC. First, this study has shed light on some internal and external rural remote challenges unique to multidisciplinary supervisory practice. The challenges are discussed at length within the latent themes. Second, throughout the study, it is clear that the governance complex, which entails the plethora of regions, departments, units, and other jurisdictions in charge of mental health, adds to the complexity around decision making. Finally, within northern BC, governance gaps prevail in an environment where policy spaces exist but are often not well managed to resolve the complexity surrounding the relationship between supervisors and frontline workers and the senior managers. Chapter Seven: Recommendations, Limitations, and Conclusion In chapter six the general implications of this study were discussed. This final chapter provides some recommendations, research limitations, my personal reflections, and the conclusion. In the following subsection, practice recommendations in support of multidisciplinary rural mental health professionals are discussed. Practice Recommendations for Multidisciplinary Rural Mental Health Professionals To expand upon the widely recognized internal and external rural remote professional challenges, results from this study zeroed in on the challenges of multidisciplinary middle management of rural mental health. Based on this study, the following recommendations can be made: The need for task offload; ease of decision making; addressing collegial isolation; and alternative training options. Overwhelming Task Load This study demonstrated that mental health supervisors in rural regions can benefit from task offload. Creating opportunities and avenues for sharing workplace responsibilities is critical to improving multidisciplinary supervisory work in rural remote regions. The use of creative management strategies such as horizontal management should be considered to address the overwhelming task overload that involves the tedious juggling of various tasks. Redress examples include the formation of: disciplinary committees, promotion committees, occupational safety committees, mentorship groups, assistant supervisors, and technologically effective administrative support. All these suggestions are consistent with a constructionist approach as all involved unite in joint progressive endeavours. The findings from this study were consistent across samples on the need for task and role review of middle management operations in the rural remote north. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 174 Easing of Decision Making While problem solving is a basic supervisory responsibility, a rural mental health supervisor should not struggle with cognitive dissonance and ambiguity in decision making. This calls for systematic ways of addressing complex organizational challenges in a supportive and collaborative manner that involves consistent interaction between all management levels, both within the organization and between disciplines. In line with the theory of symbolic interactionism, joint problem solving will achieve jointly deliberated action plans. Another Kind of Isolation In addition to the widely acknowledged rural remote physical isolation, collegial isolation was raised in this study. Given the multidisciplinary nature of rural mental health supervision, linking supervisors from common geographical rural regions can alleviate the supervisors’ isolation. Upon assuming supervisory responsibilities, rural remote supervisors lose the collegial networks since they cannot continue or maintain their previous relationships with their new supervisees. Given the limited pool of collegial connection opportunities, supervisors in rural remote regions end up in solitary enclaves. The advent of internet technological connections may make it easier for supervisors to interact virtually or by phone. Much of the required technological requirements are readily available, necessitated by the advent of the Covid 19 pandemic. Examples of such technology are Zoom and Microsoft teams. Alternative Training Within the Assemblage of Governance Entities Mental health supervisors should strongly encourage mentorship as an apprentice, alternative, or complementary training strategy. Designing training for multidisciplinary rural MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 175 mental health supervisors is complicated. There are several mental health governance entities under different administrative jurisdictions and managements, rendering the provision of formal training difficult. Therefore, fostering training that is tailored for multidisciplinary rural remote supervisory work is critical. Recommendations for Future Research Future research should consider two comparative studies. First, a comprehensive study should compare multidisciplinary training/professional development needs and opportunities between rural and urban multidisciplinary mental health supervision. The majority of participants in this study raised the issue of a lack of training, purporting that supervisors in urban areas have access to more and better training opportunities than rural remote supervisors. Secondly, a jurisdictional comparison on the challenges and opportunities for rural remote multidisciplinary supervision is necessary, bearing in mind that there are common internal and external factors involving rural remote supervision. A comparison between multidisciplinary supervisory experiences targeting two or more jurisdictions can therefore provide insight on possible developmental and functional improvement to multidisciplinary rural remote supervision. To address the above studies, I recommend multiple-case designs (Yin, 2014) for the comparative aspect. Regarding the first example above, there would be a case each for rural and urban supervision whereas, in the second example, there would be two or more cases for each of the targeted remote rural jurisdictions. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 176 Limitations of the Study This qualitative exploratory study involving frontline workers, supervisors, and senior managers examined the nature of multidisciplinary rural mental health supervision in northern BC. Due to the overrepresentation of women in the helping professions, the majority of participants were women. Also, the majority of participants were Caucasian. The lack of gender and cultural diversity in both circumstances was a limitation to this study in terms of representation of the three rural participant groups. Potentially, researcher bias due to preconceived ideas may have had an impact on my data collection and analysis. However, the awareness that researcher bias is inherent in qualitative research informed my use of a reflective journal (Patton, 2002). Keeping track of my thoughts in reflexive recording ensured that my values, beliefs, and preconceptions did not influence the data or the eventual findings. Finally, other limitations were related to personality impressions, also known as the halo effect. During the interviews, some participants may have suffered performance anxiety, while others may have avoided disclosing some of their work-related weaknesses. Others may have simply wanted to impress me. Personal Reflection I embarked upon my PhD journey with great hope and determination to complete the process within four years. I had been in school as a mature student for just over 10 years when I started my PhD course work. I have always been dedicated to my family, my fulltime employment, and my friends. I also enjoy formal learning, for which my friends nicknamed me a career student. I appreciate learning, which became even more appealing when I was hired to teach my first university course after my Master’s—nine years ago. No MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 177 wonder that, two years into my university teaching, I embarked on my PhD journey. I had to restructure my employment commitments to achieve a life balance. When I started my PhD coursework, I gave up some hobbies to ensure that I was not neglecting any of my responsibilities. It also meant that I had to work harder than most of my friends to fit in my studies. I had good support from my family and friends and within the first three years successfully defended my proposal. My supervisor and the entire committee were very supportive, and I hoped to complete my studies within the next two years. It took much longer than that, true to the saying—“things happen.” My will, perseverance, and determination were strong in spite of the highly demanding and exhausting pursuit. The journey has been long and sometimes hard for me, my family, and my friends, most of whom have not given up on me. During my high school years, my late father often reminded me that “giving up on one’s passion is a tough option,” hence my sustained endurance and commitment to the very end. Along the way, I have learnt the following life lessons. In a world where human relationships are sometimes unpredictable, my research journey reaffirmed that human kindness and selflessness still abide. This study’s research participants’ collaboration and selflessness left me humbled during data collection. I had to travel to smaller towns within our province and, without exception, the reception from all participants was very encouraging, given that the interviews were voluntary and took between one and two hours on average. Also, in addition, in sharing their experiences with a few phone calls, some of the participants kept in touch with updates thereafter. As I mentioned earlier, the saying “things happen” taught me the need for mental preparedness at all times. Since we can only control the present, there were times when I MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 178 thought certain roadblocks were too overwhelming for me to continue my PhD journey. However, as I embarked on writing and teaching, I learnt how to weather the challenges that I came across. With mental preparedness and self-care, I managed to stay the course. Reaching out to my committee, fellow doctoral students, fellow teaching staff, family, and friends kept me going. The sheer amount of work sometimes kept me away from human interaction while completing the required chapters. Although there were some in my support network that sometimes reached out to me, towards the end I really appreciated the relief that came from reaching out to others. The importance of patience has taken on a profoundly new meaning during my dissertation writing and in my personal life commitments. I have learnt to appreciate the small wins without stressing too much about outstanding tasks. Despite taking longer than I expected, I have appreciated each stage of my PhD journey. I truly enjoy learning and I hope to continue to be a lifelong learner. Finally, my teaching experiences while pursuing my PhD have increased my passion for sharing knowledge and a commitment to lifelong learning. I have come to appreciate that teaching is not a one-way process but a reciprocal undertaking that increases our knowledge exponentially. Conclusion This study provided frontline workers, supervisors, and senior managers an opportunity to share their view on the challenges and benefits of rural supervision. The answers to the three research questions provide a better appreciation and understanding of the crucial role of multidisciplinary rural mental health supervision. The purpose of this study was met through the valuable insight to challenges and struggles shared by the three MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 179 participant groups which included: Stressful and overwhelming work demands; difficult and complicated decision making; collegial isolation; much needed mentorship; and the struggle in collaborative plurality. The findings from this study also emphasized the need for practical and specific ideas for much needed support for rural remote supervisors. This study identified: the need for specific training that caters to an assemblage of governance entities that characterizes mental health jurisdictions in northern BC; the need for a horizontal management to offload overworked multidisciplinary mental health supervisors; and the easing of decision making responsibilities to avoid or reduce cognitive dissonance and ambiguity among the supervisors. The results of this study imply that concerned governments should no longer assume that addressing the widely accepted internal and external rural remote profession functional challenges will cater to all rural professionals. Multidisciplinary mental health supervisors face unique challenges that require specific solutions appropriately tailored. From a theoretical perspective, this study has also illuminated the essence and effective multidisciplinary rural mental health supervision. Interaction between supervisors and other stakeholders during interpretive processes at work helps in the creation and recreation of meaningful ideas that are jointly achieved by various professionals (Blumer, 1969). The results of this study provide an important step forward in the research of rural remote multidisciplinary supervision. In addition to northern BC, I also had Kenya, my country of birth, in mind while conducting this rural remote study. 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MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Appendix A: Approval for Study 2018—Ethical Approval Certificate 203 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 205 Appendix B: Approval for Study—Ministry of Children and Family Development Email: From: Leveque, Jeremy MCF:EX Sent: Thursday, March 30, 2017 10:00 AM To: Muturi Kariuki Cc: Lloyd, Sarah MCF:EX; Chartrand, Kim MCF:EX; Gabriel, Cindy MCF:EX Subject: Project Approval Good morning Anthony, On behalf of the Strategic Policy, Research and Engagement branch, I am pleased to inform you that your research study, An Examination of the Challenges and Opportunities in Mental Health Supervision: Focusing on Northern British Columbia, has been approved having met the following requirements: 1. Ministry sponsorship has been confirmed as Cindy Gabriel (EDS Northeast), Kim Chartrand (EDS Northcentral), and Sarah Lloyd (EDS Northwest). 2. Ethics Approval was received from the University of Northern British Columbia dated January 06, 2017. 3. Privacy/Security Approval was received from MCFD’s Modelling, Analysis and Information Management Branch on March 28, 2017, subject to the following caveats – you must: 4. o Revise recruitment materials to clarify that interested participants are to contact you if they wish to participate, not that you will contact them directly to solicit participation Please contact your ministry sponsors copied here to provide them with the revised recruitment materials for them to distribute to their MCFD CYMH staff. The sponsors may indicate in that distribution whether they support their staff to participate in the interviews during work time. As a reminder, any recorded information obtained from the Ministry or collected from participants should meet government security standards. When using USB Memory Sticks, a personal computer, audio tapes, you should secure research data as follows: • ensure USB Memory sticks are encrypted • ensure personal computer’s hard drive, if it is a laptop, is encrypted. • if using audio tapes, as encryption of audio tapes is unlikely, researchers must ensure audio tapes are never left unsecured (e.g., never leave unattended unless they are locked in a home office filing cabinet), and • don’t leave laptops in a car even if locked. You may now proceed with your research. Best of luck, Anthony. Jeremy Leveque | Research Analyst Strategic Policy, Research and Engagement Branch Policy and Provincial Services | Ministry of Children and Family Development Phone (778) 698-3611 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Appendix C: Approval for Study—Northern Health Authority 207 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 209 Appendix D: Informed Consent Form An Examination of the Challenges and Opportunities in Mental Health Supervision: Focusing on Northern British Columbia INFORMED CONSENT I understand that Anthony Kariuki, Ph.D. student in the Health Sciences Program at the University of Northern British Columbia, is conducting a research project on mental health supervision in northern British Columbia. I understand that the purpose of this study is to identify the knowledge, skills, and needs of mental health supervisors in northern British Columbia. Also, the study will seek to determine the supervisory differences and/or commonalities among adult mental health supervisors in various disciplines. I understand that I was chosen because I am a supervisor in the mental health field. The researcher, Anthony Kariuki, will use an interview guide to explore my experiences in the supervision of frontline mental health workers. 1. This consent is given on the understanding that Anthony Kariuki will use his best efforts to protect my identity and maintain my confidentiality. 2. I understand that all citizens are required by law to report situations of a child in need of protection due to suspected neglect/or physical, sexual, or emotional abuse to the Ministry for Children and Family Development (MCFD). Any disclosure of failure to report a child in need of protection overrides any promise of confidentiality, and the information about suspected abuse must be reported by the researcher to MCFD. 3. I give my consent freely and understand that I may end the interview, refuse to answer questions, and/or withdraw from the research process at any time. 4. I understand that I am being asked to represent my own perspective and not the perspective of the agency that employs me. 5. I understand and agree that the information I have given to Anthony Kariuki in our interview will be treated in the following manner: a) I will be assigned a random code to protect my identity, this code will be stored separately on the UNBC secure shared drive and deleted at the end of the research project; b) The interview will be audio recorded and transcribed; hand-written notes will be taken during the interview; c) During the study, this non-identifying data will be stored by Anthony Kariuki, in a locked filing cabinet, in a locked office, in his personal residence. Electronic files will be stored on his personal computer using a secure log-in, password protection, and anti-virus software; d) The data will be used only by Anthony Kariuki for his thesis research, presentations, and publications regarding this research; e) Relevant statements made by me during the interviews may be used in presentations of the research however all identifying information will be removed to protect my anonymity; f) Following completion of the research project, all paper copies will be burned, audio recordings will be deleted, and electronic MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 210 files will be deleted from Anthony’s personal computer. The code linking the data to participants will be deleted at that time. A password protected electronic copy of the data will be stored by a member of Anthony’s committee on his UNBC computer, which is a secure system with password protection. Five years after the study is completed, the stored electronic copy will also be deleted. 6. I understand that if I have any comments or concerns, I can contact the UNBC Office of Research at 250-960-6735 or reb@unbc.ca. _____________________ _____________________ ________________________ Participant (please print) Signature Date Signed _____________________ _____________________ _________________________ Researcher (please print) Signature Date Signed MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 211 Appendix E: Transcriber Confidentiality Agreement This study, An Examination of the Challenges and Opportunities in Mental Health Supervision: Focusing on Northern British Columbia, is being undertaken by Anthony Kariuki at the University of Northern British Columbia. The study has two main objectives: 1. To identify the knowledge, skills, and needs of mental health supervisors in northern British Columbia. 2. To determine the supervisory differences and/or commonalities among adult mental health supervisors in various disciplines. Data from this study will be used to write a PhD dissertation. I, (name of transcriber), agree to: 1. Keep all the research information shared with me confidential by not discussing or sharing the research information in any form or format (e.g., disks, tapes, transcripts) with anyone other than the Principal Investigator(s); 2. Keep all research information in any form or format secure while it is in my possession; 3. Return all research information in any form or format to the Principal Investigator(s) when I have completed the research tasks; 4. After consulting with the Principal Investigator(s), erase or destroy all research information in any form or format regarding this research project that is not returnable to the Principal Investigator(s) (e.g. information stored on computer hard drive). Transcriber: ________________________ (print name) __________________________ ________________ (signature) (date) Principal Investigator: ________________________ (print name) __________________________ ________________ (signature) (date) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 212 If you have any questions or concerns about this study, please contact: Anthony Kariuki UNBC School of Social Work 3333 University Way Prince George, BC V2N 4Z9 (250) 552-4545 kariukia@unbc.ca or Glen Schmidt UNBC School of Social Work 3333 University Way Prince George, BC V2N 4Z9 (250) 960-6519 Glen.Schmidt@unbc.ca This proposed study has been reviewed by the Research Ethics Board at the University of Northern British Columbia. For questions regarding participant rights and ethical conduct of research, contact the Office of Research by email at reb@unbc.ca or telephone at (250) 960-6735. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 213 Appendix F: Interview Guide—Frontline Workers 1. Please can you tell me a bit about your education and training background? 2. Could you summarize how you came to take up your current appointment? 3. What do you think is the purpose of your supervisor’s position in your agency? 4. What do you value most about yourself, your job, and your organization? 5. What activities do you think take up your supervisor’s time? 6. What roles or activities do you think your supervisor should spend more time on? 7. What prevents this from happening? 8. Do you find your organization supportive of supervisors? 9. Are there factors that could facilitate/ease the supervisory role? 10. How could supervisors be more helpful to you at work? 11. Are there times when your values, and/or beliefs have impeded on the relationship between you and your supervisor? 12. Can you tell me about your best experience while working with a supervisor so far? 13. What would be your advice to anyone thinking of applying for a supervisory position? 14. What makes you come to work each day? 15. If you had three wishes for your organization, what would they be? MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 215 Appendix G: Interview Guide—Supervisors 1. Please can you tell me a bit about your education and training background? 2. Could you summarize how you came to take up your current appointment? 3. Was it always your wish or intention to progress to a supervisory position? 4. To what extent does your current post differ from your previous experience? 5. What do you think is the purpose of your role/position? 6. What do you value most about yourself, your job, and your organization? 7. What do you wish you had known before you took up the supervisory position? 8. What supervisory activities require most of your time? 9. What supervisory roles would you like to spend more time on? 10. What prevents this from happening? 11. Do you find your organization supportive of your work? 12. Are there factors that could facilitate/ease your supervisory role? 13. Do you have a specific role to play when organizational change is taking place? 14. Where do you turn to for support? Do you feel the support that is available is sufficient? What would help you feel more supported in your supervisory work? 15. Have you previously held any other supervisory position in another organization? If you have, what are the differences and commonalities between your current position and previous one(s)? 16. Are there times when your values, and/or beliefs have impeded on your supervisory work? 17. In what ways do you think your approach to supervision aligns (or does not) with the approach/outlook/orientation of the agency/organization in which you are employed? How or does this impact your supervisory role and practice? 18. What have been your biggest joys and/or accomplishments? Can you tell me about your best supervisory experience so far? 19. What would be your advice to anyone thinking of applying for a similar position? 20. What makes you come to work each day? 21. If you had three wishes for your organization, what would they be? Thank you, for your willingness to participate in this study. I will leave you with these questions in preparation for the interview. I can be reached at kariukia@unbc.ca MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 217 Appendix H: Interview Guide—Senior Managers Please, can you tell me a bit about your education and training background. 1. Could you summarize how you came to take up your current appointment? 2. Was it always your wish or intention to progress to management? 3. To what extent does your current post differ from your previous experience? 4. What do you think is the purpose of your role/position? 5. What do you value most about yourself, your job, and your organization? 6. What do you wish you had known before you took up the supervisory position? 7. What supervisory activities require most of your time? 8. What supervisory roles do you think you could spend more time on? 9. What prevents this from happening 10. Do you find your organization supportive of your work? 11. Are there factors that could facilitate/ease your supervisory role? 12. Do you have a specific role to play when organizational change is taking place? 13. Where do you turn to for support? Do you feel the support that is available is sufficient? What would help you feel more supported in your supervisory work? 14. What have been your biggest joys and/or accomplishments? Can you tell me about any of your best supervisory experiences so far. 15. What would be your advice to anyone thinking of applying for a similar position? 16. What makes you come to work each day? 17. If you had three wishes for your organization, what would they be? Thank you, for your willingness to participate in this study. I will leave you with these questions in preparation for the interview. I can be reached at kariukia@unbc.ca MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 219 Appendix I: Mental Health and Substance Use Related Organizations Alzheimer’s Disease and Other Dementias Alzheimer Society of British Columbia: A non-profit organization that provides education and support to people with Alzheimer’s disease, and their families, physicians, and health care providers. Anxiety Anxiety Disorders Association of British Columbia (AnxietyBC): A non-profit organization formed to increase awareness of anxiety disorders, promote education of the general public, affected persons, and health care providers; and increase access to evidence-based resources and treatments. Anxiety Disorders Association of Canada: A non-profit organization whose aim is to promote the prevention, treatment, and management of anxiety disorders, and to improve the lives of people who suffer from them. BC Alliance Membership • Association of Addiction Specialists and Allied Professionals (ASAP) of BC • BC Association of Clinical Counsellors • BC Association of Social Workers • BC Psychiatric Association • BC Psychogeriatric Association • British Columbia Psychological Association • British Columbia Schizophrenia Society • Canadian Mental Health Association, British Columbia Division (CMHA) • Consumer Development Project, Kelowna • Community Legal Assistance Society (CLAS) • Federation of Community Social Services • First United Church Mission • From Grief to Action • John Howard Society of British Columbia • Keeping The Door Open • Mood Disorders Association of BC • Psychosocial Rehabilitation BC • Royal Canadian Mounted Police—“E” Division • TheFORCE • Society for Kids’ Mental Health MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 220 • Vancouver Police Department • Vancouver and Surrey FASD Collaboration Roundtables: A non-profit association that provides information, leadership, advocacy, and support services to its members. • Community Action Initiative: An organization that supports communities that identify and seek to address mental health and substance use concerns. Children and Youth Al-Anon/Alateen Family Groups BC/Yukon Assembly: Al-Anon, known as Alateen for younger members, is an international organization that offers self-help programs for families and friends of alcoholics, within a policy of anonymity. Alcohol-Drug Education Service: An agency which promotes healthy lifestyles by preventing and/or reducing the problem use of alcohol and other drugs through education and advocacy. Child and Youth Mental Health—BC Ministry of Children and Family Development: This ministry provides a wide range of community-based specialized mental health services to children and their families. HeretoHelp: Website of the BC Partners for Mental Health and Addictions Information—groups working together to help people better manage mental health and substance use problems, and live a healthier life. Kelty Mental Health Resource Centre: A resource for children, youth, and families related to mental health and substance use issues (located at the BC Children’s Hospital site). Sunny Hill Health Centre for Children: As part of Children’s and Women’s Health Centre, this provincial facility offers specialized services to children (birth to age 19) with disabilities, their families, and communities throughout British Columbia. The F.O.R.C.E Society for Kid’s Mental Health: A society which provides information and resources for parents of children with mental illness. Criminal Justice British Columbia's Forensic Psychiatric Services Commission (FPSC): FPSC is a multi-site health organization providing specialized hospital and community-based assessment, treatment, and clinical case management services for adults with mental health disorders in conflict with the law. Canadian Association of Elizabeth Fry Societies John Howard Society of BC Depression and Mood Disorders Mood Disorders Association of British Columbia: Provides support and education to people with a mood disorder, their families and friends. Mood Disorders Society of Canada: A non-profit organization committed to improving the quality of life for people affected by depression, bipolar disorder, and other related disorders. Eating Disorders Academy for Eating Disorders: Professional organization that promotes excellence in research, treatment, and prevention of eating disorders. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 221 Jessie’s Hope Society: A non-profit organization which educates, supports, and advocates for services around the issue of eating disorders in British Columbia. Kelty Eating Disorders information Looking Glass Foundation for Eating Disorders National Association of Anorexia Nervosa and Associated Disorders National Eating Disorder Information Centre (NEDIC): A non-profit organization which provides information and resources on eating disorders and weight preoccupation. Provincial Specialized Eating Disorders Program Provincial Adult Tertiary Eating Disorders Program Fetal Alcohol Spectrum Disorder Asante Centre: Website provides information and resources on fetal alcohol spectrum disorder, autism spectrum disorder, and other complex developmental needs, as well as details on the Asante Centre and its services. FASD Information Service: This service provides links to support groups, prevention projects, resource centres, and experts on fetal alcohol spectrum disorder. FASlink: Canadian Fetal Alcohol Disorders Society provides support, information, advocacy, and a discussion forum. Indigenous Organizations (Aboriginal) • • • • • First Nations Health Authority Metis Nation BC BC Association of Aboriginal Friendship Centres Health Canada First Nations and Inuit Health BC Aboriginal Network on Disability Society Professional Colleges • B.C. College of Family Physicians • B.C. College of Social Workers: regulatory body for the practice of social work in British Columbia • College of Dietitians of British Columbia • College of Licensed Practical Nurses of British Columbia • College of Naturopathic Physicians of B.C. and Naturopathic Physicians Regulation under the Health Professions Act • College of Occupational Therapists of British Columbia • College of Pharmacists of BC • College of Physicians & Surgeons of British Columbia: mandate is to protect the public through the regulation of medical practice by licensed medical practitioners • College of Psychologists of British Columbia: college’s role is to protect the public interest by regulating the practice of psychology and monitoring the practice of psychology practitioners) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 222 • College of Registered Nurses of British Columbia • College of Registered Psychiatric Nurses of British Columbia: the college is responsible for assuring a safe, accountable and ethical level of psychiatric nursing practice • College of Traditional Chinese Medicine Practitioners and Acupuncturists of B.C. • Royal College of Physicians and Surgeons of Canada Psychosis British Columbia Schizophrenia Society: A non-profit organization dedicated to supporting families, educating the public, and advocating for better services for people with schizophrenia and other serious and persistent mental illness. Schizophrenia Society of Canada: An organization whose mission is to improve the quality of life for those affected by schizophrenia and psychosis through education, support programs, public policy, and research. Early Psychosis Advanced Practice: Website provides unified resources about Early Psychosis Intervention (EPI) for the province of British Columbia. Research Institutes Canadian Centre on Substance Abuse: A national agency that informs decisions, actions, and the public debate on substance abuse issues. Centre for Addiction and Mental Health: An Ontario public hospital providing direct patient care for people with mental health and addiction problems. The centre is also a research facility, an educational and training institute, and a community-based organization providing health promotion and prevention services. Centre for Addictions Research of British Columbia: A partnership between the University of Victoria and BC’s four other major universities, with a mission to create an internationally recognized centre dedicated to research and knowledge exchange on substance use, harm reduction, and addiction. Centre for Applied Research in Mental Health and Addiction: A research centre within the Faculty of Health Sciences at Simon Fraser University. Their mandate is to conduct research that can be applied to enhance the effectiveness, efficiency, and quality of mental health and addiction services in British Columbia. Children’s Health Policy Centre: An interdisciplinary research group in the Faculty of Health Sciences at Simon Fraser University. Human Early Learning Partnership: A collaborative, interdisciplinary research network based at UBC. McCreary Centre Society: A non-government not-for-profit committed to improving the health of B.C. youth through research, education, and community-based projects. Michael Smith Foundation for Health Research: Supports a vibrant research community in BC, recognized worldwide for innovative discoveries that improve health and save lives. Self-Help and Support Organizations Al-Anon/Alateen Family Groups BC/Yukon: Al-Anon, known as Alateen for younger members, offers self-help programs for families and friends of alcoholics, within a policy of anonymity. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 223 Alcohol-Drug Education Service: An agency that promotes healthy lifestyles through education and advocacy. Alcoholics Anonymous BC/Yukon: Describes AA program’s philosophy and provides contact information. Cocaine Anonymous—British Columbia Area: This website describes the Cocaine Anonymous program and philosophy, and provides contact information for local support groups. FASlink Fetal Alcohol Disorders Society: FASlink is a national non-profit organization that provides support, information, advocacy, and a discussion forum. Kelty Resource Centre: Online resources on child youth mental health and substance use. http://www2.gov.bc.ca/gov/content/health/managing-your-health/mental-health-substanceuse/organizations LifeRing: LifeRing support groups provide access for women and men to community-based mutual self-help support groups for those who self-identify with problematic substance use. MADD-BC—Mothers Against Drunk Driving (MADD): An organization that is committed to stopping impaired driving and supporting the victims of this violent crime. Narcotics Anonymous (BC Region): The site describes the program and provides a list of meetings throughout British Columbia. Vancouver Area Network of Drugs Users (VANDU): A group of users and former users who work to improve the lives of people who use illicit drugs through user-based peer support and education. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 225 Appendix J: Job Description—Team Leader Child Protection and Guardianship (MCFD) Posting Title SPO 27R - Team Leader Child Protection & Guardianship Position Classification Social Program Officer R27 Union GEU Location Creston, BC V0B1G6 CA (Primary) Salary Range $68,530.07 - $78,226.68 annually effective February 3rd 2019 Close Date 2/17/2019 Job Type Regular Full Time Temporary End Date Ministry/Organization BC Public Service -> Children & Family Development Ministry Branch / Division Child protection Job Summary Team Leader, Child Protection and Guardianship Social Program Officer R27 An eligibility list may be established Please Note: this is an ongoing posting without scheduled closing date. This posting may be open for up to 6 months. Posting closing date will be added to the posting minimum 2 weeks prior to the scheduled closing date. Applications will be reviewed on a bi-weekly basis. The Ministry of Children and Family Development (MCFD) promotes and develops the capacity of families and communities to care for and protect vulnerable children and youth, and supports healthy child and family development to maximize the potential of every child in B.C. The Ministry is responsible for regional and province-wide delivery of services and programs that support positive and healthy outcomes for children, youth and their families. As Team Leader you supervise Child Protection and Guardianship social workers that deliver statutory MCFD services in Creston and outlaying communities. Your duties will include supervision of staff, tracking of key priorities, monitoring of contracts, human resources, labor relations and other duties. Results and detailed oriented, you ensure integrated case management practices are current and meet required service levels and standards, and provide leadership, support and professional development activities to your team improving professional and integrated services delivery. Employing superior collaborative skills, you are expected to establish productive working relationships with other MCFD teams, community partners and provincial, federal and non- MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 226 governmental agencies, and act as a liaison and participate on internal and external committees as designated by the Community Services Manager. Opportunity to work with families facing challenges which may occasionally involve exposure to unpleasant dealings with angry, abusive, or abused clients; exposure to hazards from frequently working around volatile parents and/or children in crisis. If you are ready for a leadership role and an exciting new career, we look forward to your application. The BC Public Service is an award-winning employer and offers employees competitive benefits, amazing learning opportunities and a chance to engage in rewarding work with exciting career development opportunities. For more information, please see What We Offer. The BC Public Service is committed to creating a diverse workplace to represent the population we serve and to better meet the needs of our citizens. Consider joining our team and being part of an innovative, inclusive and rewarding workplace. For complete details about this opportunity, including accountabilities, please refer to the attached job profile. For specific position related enquiries, please contact Lori.Simpson@gov.bc.ca. DO NOT SEND YOUR APPLICATION TO THIS EMAIL ADDRESS. For more information about how to complete your job application, add/edit your resume and for more useful tips when applying for jobs, please refer to the Your Job Application page on the MyHR website. If you are still experiencing technical difficulty applying for a competition, please send an e-mail to BCPSA.Hiring.Centre@gov.bc.ca, before the stated closing time, and we will respond as soon as possible to assist you. NOTE: Applications will be accepted until 11:00 pm Pacific Standard Time on the closing date of the competition. Job Qualifications In order to be considered for this position, your application must clearly demonstrate how you meet the education and experience qualifications as outlined in the attached Job Profile. • Bachelor of Social Work or a Bachelor of Arts in Child and Youth Care; or a Master of Social Work, Educational Counselling or Clinical Psychology, to include the completion of a practicum in Family and Child Welfare. NOTE: If your Degree was obtained outside of Canada, you need to confirm it has been assessed for equivalency through the International Credential Evaluation Services (ICES). You must request from ICES to be provided with both a comprehensive report and the MCFD supplemental report to be considered for this competition. • • • • Minimum 3 years of social work experience in child welfare. Minimum 6 months of supervisory experience of child welfare. Preference may be given to applicants with over one year supervising/leadership experience in a Child Welfare setting. Possess Full (C6) Child Welfare Delegation or be immediately eligible for Full (C6) Child Welfare Delegation, as per the Child, Family and Community Service Act. Applicants selected to move forward in the hiring process may be assessed on the Knowledge, Skills, Abilities and Competencies as outlined in the attached Job Profile. A Criminal Record Check and a Criminal Record Review Act check are required. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 227 APPLICATION REQUIREMENTS: Cover letter required: YES - cover letter is required as part of your application. Clearly identify how you meet the qualifications necessary for this position. The content and/or format of your cover letter may be evaluated as part of the assessment process. NOTE: Please ensure your resume/cover letter clearly demonstrates your supervisory experience (employment history and if you have acted the month/year). Resume required: YES - Please ensure your resume provides detailed information about your education and employment history as it relates to the required job qualifications, including the month and year(s) for each job in your employment history and job-related responsibilities. Online Questionnaire: YES - As part of the application process, you will be prompted to complete an online questionnaire to demonstrate how you meet the job requirements. Job Category Leadership and Management MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 229 Appendix K: Job Description—Standard Form (Northern Health Authority) Job Title: Facilities Sites: Program Leader / All Sites Across Northern Health Department: Nursing Reports to: Manager or designate Bargaining Unit: BCNU/HSA Classification: Date: DC3/CH3 Developed: Revised: Job Code: 20300-RN (BCNU) – MOS 20330-RN (BCNU) – MOS 20310-RN (BCNU) – UPP 20320-RN (BCNU) – UPP 21300-RPN (HSA) October 2012, November 2012 JOB SUMMARY: In accordance with established vision and values of the organization, the Program Leader practices in accordance with the standards of professional practice and code of ethics as outlined by the College of Registered Nurses of British Columbia (CRNBC) or the College of Registered Psychiatric Nurses of British Columbia (CRPNBC) as well as within a patient/client/resident and family centered care model. The Program Leader is responsible for the provision of excellence in the delivery of a patient/client/ resident and family centered approach to care within a designated program/clinical area(s). Administers, oversees and coordinates the delivery of health services for direct patient/client/resident care in accordance with the established mission and goals of Northern Health. Provides leadership and supervision to staff, coordinates resources, determines workforce plans, establishes work assignments, and monitors activities in order to enable the delivery of quality patient/client/resident care, effective utilization of resources, and overall effectiveness for the designated program/clinical area(s). Makes selection decisions in hiring new staff, conducts performance reviews, and determines training, orientation and development needs. Facilitates solutions to work problems and issues. Provides direct patient care as required. TYPICAL DUTIES AND RESPONSIBILITIES: 1. Administers, oversees, and coordinates the delivery of care/services for the designated program/ clinical/resident area(s) by planning, developing and implementing programs and services for patients/clients/residents. Provides leadership through the organization, coordination and evaluation of patient/client/resident mix and patient/client/resident needs within the designated program/clinical area(s). Evaluates care to ensure program/service needs are met. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 230 2. Ensures appropriate levels of staffing are maintained by communicating with schedulers. Establishes work assignments. Monitors, delegates and adjusts work activities to enable the delivery of quality patient/client/resident care/services and effective utilization of resources to meet operational needs. Resolves work problems and establishes priorities. 3. Coordinates requests for vacation, education and leaves of absence; ensures vacancies are filled, communicates scheduling changes, ensures resources are available. Reviews staffing levels to determine operational requirements, seniority, etc. Grants or denies leave requests in accordance with operational needs. Reviews timekeeping records for accuracy. Establishes and maintains a system for analyzing and reporting trends and their impact on resources and service delivery (includes Worksafe BC, sick time, overtime, casual utilization, turnover, staff mix, vacation utilization, relief, vacancies, etc). 4. Identifies, in collaboration with designated stakeholders, the educational needs of the staff in the provision of direct patient/client/resident care and ensures the appropriate mechanisms are in place. Updates own knowledge by reviewing relevant literature, consults with other clinical staff, evaluates clinical practice and participates in professional development. 5. Assumes overall responsibility for the supervision of staff. Conducts individual performance planning and feedback sessions. Monitors and evaluates staff performance and provides constructive feedback through formal and informal opportunities. Provides ongoing coaching and mentoring to facilitate performance improvement and the achievement of individual objectives. Works with the Manager to manage individual performance involving corrective action or discipline. Ensures the overall effectiveness for the designated program/clinical area(s). 6. Provides leadership for clinical practice by identifying best practices within the designated program/ clinical area(s). Ensures the structure, system processes, culture and patient/client/resident and family centered care model are in place to facilitate ongoing recognition of the needs for a best practice model by developing, implementing, interpreting and maintaining policies and procedures and standards of care. Reviews and revises policies, procedures and standards related to the care provided to ensure they are current and evidence-based. Communicates and distributes information to staff. 7. In collaboration with the management team, plans, develops, implements and monitors the goals and objectives for the program/services in accordance with the mission and purpose of the designated program/clinical area(s). Liaises with representatives from shared services to develop and/or revise methods, processes and procedures to support and/or improve the delivery of patient/client/resident care, the quality of life of the patients/clients/residents, and the quality of work life of the staff and staff development initiatives. 8. Participates in the recruitment and selection of staff by conducting interviews, assessing clinical skills and making hiring decisions. Ensures the orientation of new staff to their role by familiarizing the staff with the existing policies, procedures and standards. Utilizes educational resources such as self-assessment and teaching modules in order to ensure staff are able to demonstrate the integration of the knowledge, skill and ability in order to meet the needs of the assigned patient/client/resident population. 9. Manages the financial, technical and human resources through planning processes and developing, monitoring, adjusting and implementing the budget. Takes corrective action to maintain a balanced budget. Oversees the collection of statistical, budget and performance data and ensures reporting requirement/submissions are met. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 231 10. Promotes the development of nursing research by guiding staff in the testing of new ideas and approaches to care, and by participating in continuous quality improvement activities by utilizing evidence based patient/client/resident care research to assist staff to promote patient/client/resident care based on best practice. 11. Develops and implements Quality Improvement and Risk Management initiatives in accordance with Northern Health standards. 12. Ensures a safe and healthy workplace for patients/clients/residents and staff through the maintenance of effective orientation and training procedures, promotion and monitoring of safe work practices and enforcement of health and safety requirements. Ensures all unsafe situations are reported; investigates and initiates corrective action. Ensures incident reports are accurately completed and reported. 13. Liaises with colleges and other educational organizations to arrange student practicums. Coordinates or delegates the facilitation of the placements of students in the designated program/clinical area(s). 14. Represents designated program/clinical area(s) on committees as required. 15. Provides direct patient/client/resident care for nursing areas as required in accordance with CRNBC/CRPNBC Standards of Practice. 16. Performs other related duties as assigned. QUALIFICATIONS: Education, Training and Experience: Bachelor’s Degree in Nursing, advanced preparation in the designated clinical specialty area(s), three year’s recent related experience in a management/leadership position, and four years recent clinical experience in designated clinical specialty area(s); or an equivalent combination of education, training and experience. Current practicing registration with the College of Registered Nurses’ of BC (CRNBC) or the College of Registered Psychiatric Nurses’ of BC (CRPNBC). Valid BC Driver’s License. Skills and Abilities: Leadership – Promotes staff morale, cooperation, assertiveness and risk-taking, creative planning for change and innovations, implementation of NH policies or other protocols, and ongoing professional development of self and others. Management – Manages time and resources, implementing activities to promote cooperation among relevant others, supervising responsibilities of others, collaboration across disciplines and related activities. Knowledge Integration – Using factual information, prior learning and basic principles and procedures to support decisions and actions with relevant research-based evidence. Integrates best practice from nursing and health-related disciplines and the humanities, arts and sciences disciplines into professional practice. Human Caring and Relationship Centered Practice – Ability to promote client-focused care that demonstrates care for and with clients and significant others, sensitive to diverse cultures and preferences, client advocacy and social justice concerns. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 232 Communication – Demonstrated ability to communicate effectively with the clients, families, the public, medical staff and the members of the interdisciplinary team using verbal, written and computer communication means. Critical Thinking – Demonstrated ability to integrate and evaluate pertinent data (from multiple sources) to problem-solve effectively. Innovation: Demonstrated ability to challenge conventional practices; adapt established methods for new uses; pursue ongoing system improvement; and evaluate new technology as potential solutions to existing problems. Tolerance of Ambiguity: Able to deal with unresolved situations, frequent change, delays or unexpected events. Teaching – Ability to transmit information intended to instruct clients and others about topics essential to health care and well-being. Assessment and Intervention – Demonstrated ability to complete initial and ongoing client assessments (clinical and diagnostic reasoning) and provide nursing care through appropriate/ prescribed technical, therapeutic, safety type interventions. Ability to operate related equipment including proven ability to utilize computer technology. Physical ability to perform the duties of the position. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 233 Appendix L: Generic Supervisory Expectations Various disciplines follow laid down principles; for example, clinical counselling in family therapy emphasizes the following basic principles/expectations: 1. Supervision must be respectful. 2. Supervision, like therapy, must be a safe place. 3. A working alliance must be developed. 4. A supervisor does not offer therapy to the clinical family. 5. A supervisor does not offer therapy to the therapist in training. 6. Supervision operates within a clearly defined clinical training system that includes intergenerational subsystems and dynamics. 7. The dynamics of supervision include hierarchy and power. 8. Supervision develops through predictable stages. 9. Supervision interventions are driven by theory. 10. Supervision should be competency based. 11. The supervisor has simultaneous responsibilities to the therapist, the clinical family, the clinical setting/ institution, and the self. 12. The supervisor, like the therapist, follows clear ethical principles of conduct and practice. 13. Supervision is unique within each training system. (Lee & Everett, 2004, p. 4) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Appendix M: Types of Professional Supervision 235 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Source: Professional Supervision Guide for Nursing Supervisors (2011, pp. 13–14) 236 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 237 Appendix N: Social Work Supervision Model Kadushin et al (2009) outlined the social work supervision models as follows: § Individual supervision is te most widely used model of supervision, particularly for unlicensed or inexperienced (less than two to six years of practice in the same setting) workers (Kadushin & Harkness, 2002). It is delivered in a one-on-one tutorial session scheduled weekly for at least an hour. The demands of time and effort required by this model may be challenging to hospital-based social work supervisors who have corporate or wideranging administrative responsibilities. § Group supervision is the second most widely adopted model of supervision. It is characterized by the presence of a formal social work supervisor who performs the functions of supervision—administrative, educational, and supportive—in a group format. Group supervision is a supplement to, not a substitute for, casework supervision. § The introduction of group supervision is ideally preceded by worker preparation for the change and agreement by the staff. The advantages of the group modality are conservation of time and resources; lateral peer learning; and sharing and normalization of job-related stress (Bogo & McKnight, 2005; Kadushin & Harkness, 2002; Sulman, Savage, Vrooman, & McGillivray, 2004; Tsui, 2005). § Peer supervision is supervision led by a peer group; in this situation, no supervisory oversight or authority exists. All participants hold equal status in terms of accountability and responsibility for their own practice. The purpose of peer group supervision is to provide educational—clinical supervision through case conferences and the exchange of clinical expertise and guidance. Peer supervision is a supplement to, or a substitute for, educational— clinical supervision (Brashears, 1995; Barretta-Herman, 1993; Hardcastle, 1991; Kadushin & Harkness, 2002; Sulman et al., 2004; Tsui, 2005). Team supervision is led by a team leader who may or may not be a social worker. § In team supervision, intradisciplinary workers may exercise autonomy, collectively make decisions about work assignments, case dispositions, performance checks, and professional development, providing educational=clinical guidance and oversight and allocating work assignments. The supervisor is a team member but retains administrative accountability for team performance (Kadushin & Harkness, 2002; Tsui, 2005). On interdisciplinary teams, the leader may be a physician, nurse, or other medical professional who assumes supervisory authority over the other team members (Kadushin & Harkness, 2002). (Kadushin et al (2009, pp. 183–184 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 239 Appendix O: Supervisory Training for Child and Youth Mental Health (MCFD) The MCFD Provincial Model of Supervision, which also supports the child-centred and strength-based practice, forms the foundation of all services in British Columbia (MCFD, 2011). Child and Youth Mental Health (CYMH) is a department within MCFD which manages mental health services for children and youth. Supervisors are therefore included in MCFD’s provincial model of supervision. The following is an overview of MCFD’s clinical supervision model, introduced in 2011. The model includes the following: client-centred, professional, and supportive elements of practice. Client-centred: elements of practice include the skills used to direct practice of assessment, planning and service delivery to the client. These may be the basic skills of engagement connecting with and interviewing clients, and accurate case formulation, or more specialized skills relevant to the areal of practice of the practitioner. The practitioner’s capacity to understand and implement specific skills is reviewed in a context of service delivery with their specific clients, and may lead to decisions for specialized assessments, consultation or further training or other sources of knowledge. Professional: elements of practice include institutional and organizational aspects delivering services to families. Clinical supervisors ensure the necessary resources, roles, and industry and organizational standards are applied and adhered to ensuring professional integrity and ethical practice. As well they help the practitioner recognize the significant impacts professional systems have on the lives and functioning of the clients they serve. Supportive: elements of practice include the practitioner’s experience of providing direct service to their clients, and ensure they have the capacity and support necessary to make accurate and comprehensive assessment and service decisions. The supervisor helps to ensure an informed and emotionally grounded team capable of providing the necessary supports to MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 240 children, youth and families experiencing multiple needs and challenges. (Ministry of Children and Families, 2011) The model’s guiding principles: The model acknowledges that a supervisor’s experience is not enough, hence the need for a skill set for providing support to supervisees. The skill set is based on: 1) Research-informed practice that focuses on the level of supervisor-supervisee satisfaction as the desirable outcome. 2) Effective engagement that builds trust and caring relationship between supervisor and worker. 3) Clinical supervision process aims at creating an effective and relevant plan of service which includes exposing possible bias and gaps in knowledge on the part of the practitioner. (Ministry of Children and Families, 2011) The following are the model’s key relational skills principles: Relationship, reciprocity, reflection, accountability, capacity, and ongoing learning (see Appendix ?). Specific Skills for Effective Supervision for this model include: § Mindfulness: An intentional, non-judgemental awareness of moment-to-moment experience. Ssiege, D. & Hartzell, M. (2003) § Emotional intelligence: Is the ability to understand one’s emotional make-up and emotional make-u of others and to use insight for this knowledge to effectively manage and regulate one’s own emotions to make good decisions and to act effectively. Coleman, D. (1995) § Relationship and trust: Trust = Credibility + Vulnerability. Credibility is not only doing the right thing but doing things the right way. It is being seen as both ethical as well as competent, on the other hand, Vulnerability is most easily associated with your team knowing what you are thinking – what your motivations and intentions are. It is closely tied to frequent, open and honest communication. Brandon smith 2011. § Self-Reflection: Is the act of analyzing our actions, decisions, or products by focusing on what we did or are doing and learning lessons that can be applied to new situations. Killon and Harrison, 1992 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC § 241 Learning Styles: i.e. Clinical supervision supports ongoing learning; Supervisees have diverse learning styles; Determine what is best for supervisee; Mismatch in clinical supervision can lead to poor outcomes; Supervisors need to work effectively across a range of learning styles. § Coach approach and Mentoring: A set of skills and tools that supervisors can draw from. 1) Asking questions with the primary intention of supporting the coachee’s learning 2) Asking questions with an open form to invite exploration by the coachee 3) Asking questions that invite the coachee to look beyond problems and obstacles 4) Asking questions that invite a personal response to truly engage the coachee 5) Ask questions that will move the coachee towards commitment and action. (Ministry of Children and Families, 2011) The Mechanics of Supervision § Establishing the Supervision Agreement (See appendix) § Continuous Feedback (Quality Improvement Cycle) § Policy, Standards, and Guidelines: The ministry’s common policy for supervision and consultation is an overarching/common policy across all MCFD programs. § Case Practice: e.g. Using a scenario - a group of four people (2 supervisors, 1 supervisee, 1 observer) (see appendix) (Ministry of Children and Families, 2011). Commitment to On Going Learning 5. Learning Organization § (We can…. build “learning organizations” …where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together) Senge, P. M (2006). The fifth discipline. The art of learning and practice organization. Toronto, ON, Canada: Currency/Doubleday. § Personal Learning Plan: What do I want to do; how will I do it; and how will I evaluate the results. (BC Ministry of Children and Families, 2011). § MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 243 Appendix Oa: Objectives of MCFD Supervisor Training § Understand the definitions, domains and functions related to clinical supervision. § Support practitioners in developing comprehensive case formulations and subsequent child and family plans. § Identify clear roles and responsibilities for all team members providing services to children and families. § Demonstrate how to use the supervisory relationship, increase the transparency of the decision making process. § Demonstrate how to increase professional expertise through self-reflection and increased awareness of one’s own values, strengths and biases. § Demonstrate coaching and mentoring approaches that enhance professional capacity (BC Ministry of Children and Families, 2011). MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 245 Appendix P: Supervisory Training at Northern Health Authority A generic form of leadership training known as Leadership LINX that is available to all six BC health authorities was developed by Public Health Services Authority (PHSA) for the BC Health Leadership Development Collaborative (BCHLDC). Following are excerpt overviews of the modules available to Northern Health’s middle and upper management staff: Introduction to leadership The first module in the Leadership Track for New Managers. It’s a big move from being an individual contributor where you are responsible for your own work to a position such as supervisor or manager where you are responsible for a broader scope of work that is accomplished with and through others. Sometimes the move to management is made because you’ve been recognized as capable in your role as an individual and you have the ability to work well with others. Other times the move to management comes as part of a personal career plan. Either way, working in a formal leadership role requires new ways of thinking and acting with others. The aim of this module is to explore the similarities and differences between leadership and management and to support you in developing habits of learning from your experience that will help you improve your practice as a leader and manager. Appreciative enquiry This module examines the application of the Appreciative Inquiry approach to re-framing issues and engaging stakeholders toward a common purpose. The module defines Appreciative Inquiry (AI) in the context of healthcare management. It explores the difference between a “problem-based” versus a “strengths-based” mindset. The implications of this mindset will be considered in the context of engaging stakeholders and building relationships. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 246 The module will introduce the AI model, an appreciative structured process of Discovery, Dream, Design, and Deliver. Cross-functional teams This module addresses cross-functional team collaboration in service to patients, either directly, or serving internal functions or public-facing functions in non-clinical settings. The biggest customer service issue a new manager faces is how different programs/ departments handle a particular patient. This module introduces several strategies for enhancing crossfunctional team collaboration. Four strategic approaches are presented: (1) optimizing member composition; (2) maximizing collaboration; (3) understanding team role balance; and (4) determining the organizational context. Developing others This module complements the module Healthy Work Environment and its discussions on creating a healthy workplace culture. In this module the focus is on learning. We begin with a discussion of learning in the workplace and working with different generations of employees. The first part of this module enhances the leader’s awareness of ways to foster learning – of both individuals and teams – in the workplace. The second topic is a more specific look at giving learning oriented feedback and builds on the transactional competencies of performance management that are covered in the Management Track workshops. Emotional Intelligence In this module, the concept of emotional intelligence (EI) and its role in personal leadership are addressed. The first half of the module focuses on defining emotional intelligence in the context of the demands experienced by a health care manager. To promote emotional awareness, participants will obtain a sense of their current emotional functioning by conducting an emotional intelligence self-assessment. The second part of the module focuses MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 247 on specific strategies and skills to further build emotional awareness as well as emotional management and regulation. Facilitating a healthy work environment This module is based on building positive workplace relationships and creating a safe and healthy organization through engagement of employees and stakeholders. We begin with a broad discussion of culture in the workplace and the role of leaders in creating a psychologically and environmentally safe work environment. The second half of the module builds on culture by introducing the concept of engagement. Participants will practice facilitating conversations about Q12 results. Fundamentals of system thinking and change This module contains two main topic areas: a) system terms and types, and b) types of workplace change and the relationship to transitions. In the first part of this session, through brief content inputs and experiential activities, participants will explore and apply basic systems thinking terminology, identify five basic types of systems, and examine work activities through a set of system lenses designed to bring clarity to transformation conversations. The second part of the session is designed to take system concepts to the next level by discussing and applying basic types of change – developmental, transitional, and transformational; the various criteria for determining each type; and how leadership strategies for managing transitions differ according to the type of change. The module will conclude with participants applying their learning to real-time workplace changes they face. Interpersonal communication A key developmental task for new leaders is to build a managerial relationship with direct reports. Communication is the primary means of building relationships. This module begins with practice in being open to the points of view and concerns of others by listening. It complements and builds on the work done in Coaching out of the Box. The second part of the MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 248 module is about core speaking skills, both when responding in conversations and when presenting ideas to others. Introduction to conflict resolution This module is a basic introduction to the topic of conflict in the workplace, beginning with an exploration of the leader’s mental models and habits related to conflict. The module aims to broaden the participants’ perspectives on difference and the value of diversity and help them understand the often deeply ingrained attitudes and approaches to conflict. The second part of the module will introduce a model for dealing with 1:1 and group conflict, with skill practice. Dealing with conflict is an enduring challenge in the workplace. This module is an introduction to positive ways of seeing and resolving differences in the workplace. Personality styles This module examines the important role personality styles, or psychological preferences, play in personal leadership development (the Lead Self domain of the LEADS framework). A self-assessment personality tool will be required for this module, such as the Myers-Briggs Type Indicator® (MBTI®). Personality styles have been shown to impact a wide range of leadership behaviours, including: decision-making, problem solving, stress tolerance, communication, and team dynamics. The first half of the module focuses on identifying the role perceptions play in creating assumptions and their relationship to personality type. The second part of the module debriefs the participant’s self-assessment personality profile, linking the results to their decision-making, problem-solving and communication styles with the goal of creating greater adaptability for the new manager. Principle-centred leadership In this module, principled-centered leadership is addressed from the perspective of core personal values, which impact how one spends and manages one’s time. The first half of the MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 249 module focuses on identifying the participant’s personal core values, with an emphasis on differentiating between espoused values and values we use on a daily basis (the difference between what we say and what we do). Values are also connected to integrity and ethical decision-making. The second half of the module addresses basic time management skills, since values impact how we spend our time. This section also introduces Stephen Covey’s work around importance versus urgency. Reframing for results In this interactive module, participants will be oriented to Lee Bolman and Terry/Terrance Deal’s “four frames analysis.” The model asks leaders to examine organizations through four basic frames: political, structural, symbolic and human resources. Participants will then apply this model of analysis to a CBC “Current” or “White Coat, Black Art” podcast or other healthcare example. As part of their pre-work, participants will be asked to identify a work project to which they will apply their learning during and immediately following the session. Participants will be asked to examine both the podcast example and their work project through each of the four frames and consider how this process applies to their own leadership and management decision-making processes elsewhere. Setting direction In this module we will explore the broad topic of organizational vision specifically as it is applied to healthcare in BC at the Provincial and local levels. Building on some Health Authorities’ use of “Celebrate What’s Right With the World” with Dewitt Jones, we will view the sequel “Focus Your Vision,” applied to department and team-level vision for direction. From here, participants will apply the SMART goal-setting framework directly to the vision and values at the local team, department, organization or Health Authority levels. MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 250 Team development New managers are confronted with the difference between succeeding as an individual contributor (doing the work yourself) and being a manager (accomplishing the work through the work of others). This module is essentially a starter kit for leading groups or teams. The curriculum plan is based on the minimum content necessary for new managers to confidently facilitate collaboration. Although the module speaks in several instances to working with a team in meetings; it is the concepts of trust, creating shared agreements, facilitating diverse perspectives, and decision making that are the core processes of teamwork that enable the leader to work well with others, whether there is a formal, ongoing team in place or not. Coaching out of the Box Coaches focus on goal setting. Outcome creation and personal change management with individuals and teams. Coaching most often takes place when: § There is desire to accelerate § There is something at stake (a challenge, stretch goal or opportunity) § There is high degree of change requiring rapid adjustments and additional resources or skills. § There is a gap – in knowledge, skills, confidence, resources § There is a lack of clarity and complex choices need to be made § There is a need to identify core strengths to leverage them. Coaching is self-directed growth. Allowing an individual or team the freedom and choice to map out their own growth and development trajectory through challenges and obstacles and into what can be and is possible, empowers them with the recognition that they are creative and resourceful versus being dependent on leadership for the map. It is how leaders develop other leaders around them. (Core LINX: A Leadership LINX Program, 2011) MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Appendix Q: Supervision Agreement (MCFD) 251 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 252 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Appendix R: Performance Appraisal (MHAS) 253 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 254 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 255 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 256 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Appendix S: Provincial Health Services Authority (PHSA) • BC Cancer Agency • BC Centre for Disease Control • BC Children's Hospital & Sunny Hill Health Centre for Children • BC Emergency Health Services • BC Mental Health and Addiction Services • BC Renal Agency • BC Transplant • BC Women's Hospital & Health Centre • Cardiac Services BC • Perinatal Services BC 257 MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC 259 Appendix T: Regulatory Colleges (BC) Health Professions Act • British Columbia College of Nurses and Midwives • College of Chiropractors of British Columbia • College of Dental Hygienists of British Columbia • College of Dental Technicians of British Columbia • College of Dental Surgeons of British Columbia • College of Denturists of British Columbia • College of Dietitians of British Columbia • College of Massage Therapists of British Columbia • College of Naturopathic Physicians of British Columbia • College of Occupational Therapists of British Columbia • College of Opticians of British Columbia • College of Optometrists of British Columbia • College of Pharmacists of British Columbia • College of Physical Therapists of British Columbia • College of Physicians and Surgeons of British Columbia • College of Psychologists of British Columbia • College of Speech and Hearing Health Professionals of British Columbia • College of Traditional Chinese Medicine Practitioners and Acupuncturists of British Columbia Social Workers Act • BC College of Social Workers MULTIDISCIPLINARY MENTAL HEALTH SUPERVISION IN NORTHERN BC Appendix U: NHA Mental Health and Addiction Services Acquired Brain Injury (ABI) Adolescent Psychiatric Assessment Unit (APAU) Adult Addictions Day Treatment Program (AADTP) Adult rehabilitation and recovery services Assertive Community Treatment (ACT) Clubhouses and activity centres Community Mental Health and Addiction (Generalist Teams, used to be known as CAST, COAST, CRU) Developmental Disabilities Mental Health (DDMH) Early Psychosis Intervention (EPI) Eating Disorders Clinic (EDC) Elderly Services Intensive Case Management Team (ICMT) Opioid Agonist Therapy (OAT) Prevention services Provincial resources Rehabilitation Services Supportive Independent Living Program (SILP) Supportive living / Supportive recovery beds Suspected Child Abuse and Neglect (SCAN) Clinic Youth Community Outpatient Service (YCOS Prince George) 261