Clinical supervision in positive behaviour support: A brief report on the perspectives of practitioners in Australia

ABSTRACT

Purpose

To examine current practices and recommendations regarding clinical supervision from the perspective of Positive Behaviour Support (PBS) practitioners in Australia.

Methods

A qualitative study design consisting of semi-structured interviews with 14 PBS practitioners.

Results

Positive supervision experiences revealed the importance of “a supportive relationship”, “supporting reflective practice”, and “different supervisors fulfilling different needs.” Challenges experienced included “a focus on operational matters’, “lack of clinical PBS expertise” and “sourcing and funding own supervision”. Recommendations included the need for supervision standards and trained supervisors with PBS expertise and knowledge of registration requirements and practice obligations. Questions were also raised to whether specific supervision training should be mandated.

Conclusion

Clinical supervision provides critical oversight to ensure quality PBS practices, especially given research reporting inexperienced, unregulated, and untrained behaviour support practitioners in Australia. Results suggest, however, that some clinical supervisors have limited PBS expertise, and that further practice standards and guidance are required.

KEYWORDS:

• Intellectual disability
• clinical supervision
• positive behaviour support
• practitioners

Behaviour support provision for people with intellectual and developmental disability is gaining attention in Australia. The Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (2023) has revealed reports of abuse, neglect, and over-reliance on restrictive practices (e.g., the use of physical and chemical restraint and seclusion) to manage challenging behaviour. These findings align with concerns regarding skill deficits in the behaviour support workforce in Australia (Dowse et al., 2016; Hayward et al., 2019) and evidence of poor-quality PBS plans (NDIS Quality and Safeguards Commission, 2021). A recent national survey also revealed behaviour support practitioners to be largely inexperienced, unregulated and untrained (Fisher et al., 2024; Kelly et al., 2024). These concerns emphasise the importance of clinical supervision in guiding evidence-based and ethical practices (Bayley et al., 2022; Fisher et al., 2024).

The National Disability Insurance Scheme (NDIS) specifically funds positive behaviour support (PBS) from specialist providers. These providers must register with and are regulated by the NDIS Quality and Safeguards Commission (the “Commission”). In a recent national survey reporting the experiences of 392 NDIS-funded practitioners (Fisher et al., 2024), supervision was reported as a key enabler of good practice, but was also identified as an ongoing support need. The Commission specifies the requirement for registered behaviour support practitioners to receive regular supervision. The requirements of clinical supervisors and the supervision framework/s to be used, however, are not clearly articulated within the current NDIS guidelines (NDIS Quality & Safeguards Commission, 2018; NDIS Quality & Safeguards Commission, 2019; NDIS Quality & Safeguards Commission, 2020; NDIS Quality & Safeguards Commission, 2021).

The current study builds upon existing research by examining current supervision practices from the perspective of NDIS-PBS practitioners, including their positive experiences, challenges and recommendations for good practice. This is an important step towards building effective practice supervision for behaviour support practitioners under the NDIS. It also has relevance for international audiences involved in building workforce capabilities and supervisory practices and systems in behaviour support for people with disability.

Method

A qualitative phenomenological approach, consisting of semi-structured interviews, was used to examine the experiences of PBS practitioners receiving clinical supervision. A hermeneutic approach (Neubauer et al., 2019) allowed the researchers to consider and provide commentary on the emerging themes. Proctor's model (Proctor, 2000) was used to inform the development of interview questions and interpret results. This model includes restorative, formative, and normative approaches and is recognised for guiding clinical supervision practices and analysis (Dawson et al., 2013). This research project was approved by the Flinders University Human Research Ethics Committee (ID: 5238).

Participants

Inclusion criteria included NDIS-PBS registered practitioners who are or have received supervision. Participants were recruited via the Association for Positive Behaviour Support Australia (APBSA). At the time of this study, APBSA consisted of a disability and community service network and was a key affiliation for PBS practitioners, with over 1,400 members. A snowball sampling approach was utilised, with members asked to share information about this study with PBS colleagues and networks (Noy, 2008). NDIS-PBS practitioners supervised by the first author were excluded from the research project to reduce conflict of interest.

Data collection

All interviews were conducted online (via Microsoft Teams or Zoom), lasting around 60 minutes, with the time and mode of participation organised around participant preferences. At the commencement of each semi-structured interview, demographic information was collected, followed by seven open-ended questions to gather information on positive experiences (e.g., Can you describe any supervision experiences that have had a positive impact on your work?), any experiences they found challenging (e.g., Can you describe any supervision experiences that you have found challenging?), and recommendations for good practices in clinical supervision (e.g., Can you tell me what makes a good supervisor? How could supervision be best supported within your practice, organisation and service system?).

Data analysis

Inductive thematic analysis identified themes from the interviews (Braun & Clarke, 2022). Interviews were transcribed verbatim and were then independently reviewed by two researchers using NVivo software. This included line-by-line coding to label segments and generate codes that were then grouped into broader conceptual themes within the three focus areas (i.e., positive experiences, challenges, and recommendations). The reviewers (SG and AF) refined codes and agreed on final themes through reflective discussion, and then independently assessed the validity of initial codes according to final themes.

Results

Interviews were conducted with 14 NDIS-PBS practitioners (11 women and three men). Demographic data are presented in Table 1. Participants came from diverse professional backgrounds (with different regulation requirements), with various durations of experience (1-5 + years) and employment type (e.g., within organisation, subcontracted or self-employed).

Table 1. Participant demographics.

	Profession	PBS training/qualification	Employment	Experience^a
1	SW^b	No specific PBS training	Sub-contracted	1–2 years
2	DE^c	Graduate program^e	Self-employed	3–5 years
3	DE	Graduate program^e	Self-employed	3–5 years
4	SW	1–5 d workshop	Organisation	3–5 years
5	OT^d	1–5 d workshop	Self-employed	3–5 years
6	SW	1–5 d workshop	Self-employed	5 + years
7	Psych	1–5 d workshop	Organisation	3–5 years
8	DE	1–5 d workshop	Sub-contracted	3–5 years
9	DE	Graduate program^e	Organisation	1–2 years
10	DE	Grad Cert in PBS^f	Sub-contracted	7–12 months
11	OT	Grad Cert in PBS^f	Organisation	1–2 years
12	DE	1–5 d workshop	Organisation	0–6 months
13	Teacher	1–5 d workshop	Organisation	3–5 years
14	Teacher	1–5 d workshop	Self-employed	7–12 months

^a Time working as a NDIS-PBS Practitioner

^b SW = Social Worker; ^cDE = Developmental Educator; ^dOT = Occupational Therapist

^e Four year bachelor degree in disability studies (includes PBS-specific training)

^f Graduate Certificate in PBS with four PBS-specific topics (in disability, PBS assessment, analysis and implementation)

Four participants who provided NDIS-PBS support for 3–5 years also reported being in a supervisory role. For six participants, clinical supervision was funded by organisations. Five reported receiving a combination of self-funded and organisationally funded supervision; three were self-employed and funded their supervision. Most participants (n = 9) had one clinical supervisor, and the remaining five received support from two separate clinical supervisors. Half of the participants (n = 7) were based in South Australia.

Positive experiences

The following three themes were identified: The importance of “a supportive relationship”, “reflective practice”, and “different supervisors fulfilling different needs.” All participants noted the importance of a strong, open relationship with their clinical supervisor based on common goals and supervisee needs. Twelve of the 14 participants (86%) noted trust as essential in the supervisory relationship. The majority (n = 13; 93%) of participants described the value of having clinical supervisors who challenged their practice and supported them through difficult situations that encouraged professional growth. For example, one participant reported:

[My supervisor] constantly challenged me to be more rigorous … they’re there to be supportive, to help you recognise it and grow (P7).

Almost all participants (n = 12; 86%) reported receiving clinical supervision and mentoring from multiple sources (including five who received formal supervision from two supervisors, and others reporting support from multiple peer mentors). Participants valued the ability to move between clinical supervisors to benefit from their diverse strengths and skillsets. For example, it was reported that:

… having different supervisors brings a different lens, different levels of ideas, understanding and even opinions … (P1).

Challenges

The following three themes were identified: “A focus on operational matters’, “lack of clinical expertise’ and “the need to source and fund own supervision”. Participants reflected that supervision sessions often focused on navigating systems and operational processes (e.g., administrative issues and reporting requirements) rather than clinical skills and person-centred practice. Two participants (14%) also reflected on the challenge of working within the Commission’s compliance expectations and their work expectations and beliefs regarding good PBS practice. For example, one participant reported:

[My supervisor] was very focused on our regulations and … what we have to get done, our timelines … where I was more concerned about … the plan I am producing, who am I writing my plan for? (P10).

In addition to the focus on operational and compliance processes, seven participants (50%) reported their clinical supervisors having limited clinical PBS skills and knowledge. For example, one participant stated: “I still don't even have entire confidence that I'm doing the right thing because I don't have entire trust in the capabilities of my supervisor … ” (P12), and another said their supervisor told them to “Google” the answers to their questions (P13).

Nine participants (64%) reported availability of expert supervisors was also a challenge. Eight participants (57%) sourced their own clinical supervision, and some reported the desired frequency of supervision was unattainable due to affordability.

Recommendations

Key themes extracted included “the need for supervision standards and training”, “the question of mandating training”, and the importance of “supervisors with PBS expertise” and “supervisors who understand registration requirements and practice obligations.” All participants reported needing suitably credentialed, experienced, and skilled clinical supervisors to support NDIS-PBS practitioners. However, although all participants reported the need for minimum standards and skilled supervisors, there were varying views on the level of training required and whether this should be mandated. For example, several participants raised concerns that if supervision training was mandated it may have a negative impact on an already thin market. All 14 participants reported the need for clinical supervisors to have PBS expertise and demonstrated experience in providing PBS, with nine (n = 64%) specifically recommending that PBS clinical supervisors should have formal PBS-specific qualifications or training. Further, eleven of the 14 participants (n = 11; 79%) said they would not choose a clinical supervisor who was not a currently practicing NDIS-PBS practitioner with a strong knowledge of the regulatory system in which NDIS-PBS practitioners operate.

Discussion

This research has provided preliminary insights into experiences of NDIS-PBS practitioners receiving clinical supervision. The results emphasise the value of supervision that provides supportive and expert oversight to guide quality practice. They also raise concerns regarding the competencies of current clinical supervisors and a focus on compliance, rather than clinical skills and person-centred practice with clear role expectations. This prompts important considerations regarding mandating appropriate credentials (e.g., qualifications) and supervision standards.

Participants provided several recommendations to improve clinical supervision for NDIS-PBS practitioners, including the need for supervisors to received specific training and the importance of supervisors having both PBS expertise and good understanding of registration requirements and practice obligations. The findings of this research also emphasised the importance of all three functions of Proctor’s model of clinical supervision (Dawson et al., 2013). The “restorative” function was highlighted with emphasis on a supportive and trusted supervisory relationship, which helped to address stress levels and practitioner burnout, in addition to more technical practice guidance. The “formative” function was emphasised by the need for supervisors who provided clinical guidance and opportunities for skill development through constructive feedback and reflective practices. The “normative” function related to the desire for supervisors to be able to support compliance activities, with good knowledge of legislation, registration requirements and practice obligations under the NDIS. One concerning finding, however, was the focus of current supervision on these compliance activities over supporting (and having the skills to support) clinical practice. This reflects findings from a recent national survey of NDIS-PBS practitioners, where “limited PBS expertise across the sector” was identified as a key barrier, and “access to clinical support and practice guidance” was identified as an ongoing support need (Fisher et al., 2024). In this survey, practitioners also emphasised barriers relating to the service system and current focus on compliance activities. The current research also supports current literature emphasising the organisation’s role in enabling professional growth and development by supporting quality clinical supervision practices through valuing these restorative, formative and normative functions (Martin et al., 2014; Snowdon et al., 2020).

A limitation of this study was the lack of representation of NDIS-PBS practitioners from regional areas across Australia, in addition to practitioners working within aged care, forensic and correctional settings. Although a significant proportion of practice occurs within metropolitan areas, further research is needed to capture the experiences of practitioners and the nature of clinical oversight in these settings, including rural/remote areas and culturally diverse communities (e.g., Aboriginal and Torres Strait Islander communities). This recognises Australia’s vast rural/remote areas with limited access to services and expertise.

The findings of this research provide important insights and recommendations for practice and research. In practice, the value of supportive and reflective supervision is emphasised by those who also bring PBS expertise and good working knowledge of current service systems. To facilitate this in practice, however, it is important to: (1) determine the role of clinical supervisors and recommended supervisory framework for NDIS-PBS practitioners (e.g., core functions/features, what is and is not in their purview); (2) establish practice standards for clinical PBS supervisors, including minimum expectations regarding the PBS skills and qualification required, with a staged plan for introducing these standards; and, (3) to support access, choice and flexibility in seeking quality supervisors, it is also recommended that a formal network of skilled supervisors is established.

Conclusion

Quality supervision for NDIS-PBS practitioners is essential, with the need to upskill practitioners and improve behaviour support practices in Australia widely acknowledged. This research provides important insights and recommendations relating to PBS supervision from the perspective of practitioners, which will help as we continue to shape evidence-based PBS practices in Australia and, ultimately, achieve best outcomes for those receiving behaviour support.

Disclosure statement

No potential conflict of interest was reported by the author(s).