Through my work in the medico-legal sector, I have the privilege of working with a particularly amazing group of professionals, who provide essential, close and constant support to my clients who have an acquired brain injury (ABI). Their title might vary – carer, buddy, support worker, personal assistant or rehabilitation assistant (RA to be used generically for all titles) but at the heart of it, all of them are enabling their clients to live their lives to the full. Their role is wide ranging but from a communication point of view, an RA requires a deep understanding of cognitive communication. They need to have sophisticated communication skills that allow them to facilitate effective communication with the person who has cognitive communication difficulties (CCD), both for their personal interactions and when supporting the person with ABI to achieve communication competence in a variety of environments.
To support RAs, I routinely provide training, starting with an induction using the Model of Cognitive Communication Competence (MacDonald, 2017) as a foundation for our conversations about the client’s cognitive communication skills. Thereafter, we explore the person with ABI’s communication competence, delving into topics, such as, pragmatics and social cognition with increasing depth as we both gain understanding of the communication support needs of the person we are working with. Collaboration with RAs is essential; even though I arrange community visits with my clients and meet them in a range of settings, these provide snapshots compared to the complete perspective the RA gains from their work.
Training RAs tends to follow a typical pattern. Early on, I share information about CCD that is relevant to the person with ABI but over time a conversation evolves about the communication challenges the RAs observe and experience. The training space can become a more reflective space where the RA talks about their work with the client and I find myself asking different questions about how the work makes the RA feel or what they need to sustain them in the role?
This kind of conversation feels more like supervision than training and the skills I am using allow us to create a space where the RA can pay attention to all their needs relating to the work. I draw on supervisory skills that allow for a formative, restorative or normative experience (Proctor, 1986).
The fact that supervisory needs exist is not surprising. The role of an RA is extremely challenging. Many of the RAs I work with have long shifts. Some provide live-in care from anything between forty-eight hours to six weeks at a time. This creates an intensity in their work life, in which they are required to maintain a high level of care, rehabilitation and support with the client and sometimes in the face of challenging behaviour and communication. The importance of supervision for people in these roles is acknowledged in the CQC regulation 18. This regulation states that CQC registered organisations must have a ‘systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service’, including the supervision needs of the workers. This seems straightforward, but working in the medico-legal sector means that teams are gathered from several organisations. Professionals might be sole-traders, associates or employees of an organisation. RAs might also be employed through an agency or can be directly employed by the client, putting them outside a formal management structure. The way in which a multi disciplinary rehabilitation team is formed creates the potential for the RA’s supervisory needs to be missed because so many organisations are involved. Roles and responsibilities with regards to supervision might be assumed rightly or wrongly to be taken by others. Within this medico-legal context, as a speech and language therapist (SLT) I do not have direct responsibility for the supervision of RAs but my relationship could be considered analagous to that of a SLT and speech and language therapy assistant because I delegate tasks and responsibilities to the RAs in relation to the support they give as professional conversation partners. From this perspective, it might be wise to pay to heed to the RCSLT supervision guidance even though the RA is not directly my responsibility. This guidance explains the SLT’s responsibility, i.e. that:
- “You must continue to provide appropriate supervision and support to those you delegate work to” (HCPC, 2016b, p. 7)
- “RCSLT (2009) … stipulates that the qualified SLT holds the ethical and legal ‘duty of care’ for the client and consequently for the standard of duties delegated to an assistant practitioner”
What this means in my context is that in knowing the challenges and complexity of the work the RA is undertaking, I have a professional responsibility (and a personal desire) to support them in their role. Communicating with a person who has CCD is difficult because, as the communication partner you generally do more of the work, which can be tiring. Over the long term this can create emotional strain, especially if the nature of the communication is inappropriate or misjudged. These challenges exist not only in the one-to-one relationship with the client, but also when supporting them in the community where challenges can be unpredictable and require quick thinking in tense and possibly uncomfortable public scenarios. In addition, I know that when unsupported, RAs can reach burn out, which is obviously difficult for them but also, switching focus to my legal ‘duty of care’ to the client, burnout of RAs leads to difficulties for the person with ABI too. It is beneficial for the client if support through supervision can mitigate communication breakdown with their RAs and/or burn out because it brings greater stability for the person with ABI and reduces the need for expensive recruitment and training of successive RAs.
Over the years, there have been times when it felt natural and useful to adopt a supervisory style with an RA, but I have also learnt that even if I am willing and have the skills and training to supervise it does not mean that I should be the one to supervise! Some thought needs to be given to the challenges that arise when working in this context.
There can be conflicts when working with a client who has more than one RA. By comparison, in my supervisory practice, I no longer supervise speech and language therapists who are in the same team because this can limit the freedom that one or both supervisees feel about topics they can bring to supervision. From the other point of view, the RA might be offered supervision from several professionals within the team, or from their agency so being clear about what supervision they are receiving and from whom can make it clear about when I do or do not need to think about supervisory needs.
An RA might have no experience or a negative perception of supervision from previous experiences. I do not think that it is my role to establish or insist upon supervision in that scenario, although advocating for the benefits might open new doors for the RA.
There will be a cost for supervision and supervision is unlikely to be the priority for funders. When supervision is requested or needed, thinking about how to plan for that through the quoting system will remove one barrier to finding the time to meet with the RA.
I have concluded that there are compelling reasons for attending to the supervision needs of RAs and every member of the team can share the responsibility of doing so. In writing this post, I have found the space to consider how I might develop my practice:
- There is no doubt that the RA role is challenging and will raise supervisory needs to the surface. It can be helpful to name the fact that ‘supervision’ is happening, especially if an RA has limited experience of supervision
- I want to take any opportunity to invite RAs to consider supervision and advocate for the benefits of supervision to raise their skills through reflective practice, improve the quality of their work and provide a space for restoration and support. I think this approach keeps the person with ABI at the heart of our team practice and raises the standard of care for them
- I have come to the view that any SLT or rehabilitation professional with supervision training in the team can provide supervision but having a conversation about the best option for supervision within each unique circumstance will be helpful. I have now experienced many different structures, each with pros and cons, such as, group supervision with one professional supervising a group of RAs, supervision with two professions reflecting with one RA or looking for external supervision outside the team. This could either be signposting RAs back to their organisations or networking with other rehabilitation professionals outside the team who understand brain injury and its challenges but can provide supervision from outside the team, reducing conflict
- I am now keen to model a culture of supervision and raise the profile of supervision with RAs with the aim of encouraging RAs to invest in their own supervision skills
From my conversations with colleagues, both speech and language therapists and other rehabilitation professionals, I have the impression that whilst all are in favour or supervision and some will offer this to RAs there is no wider framework about how to deliver supervision to RAs at the team level. Perhaps we can all share the responsibility to raise the profile of supervision, keeping the wellbeing of our clients and colleagues at heart and start to explore creative ways to offer excellent quality supervision through our networks.
As ever, I am really interested to hear what others’ think and am open to correspondence on this topic.
Mary Ganpatsingh
References:
Proctor, B. (1986). Supervision: A co-operative exercise in accountability. In A. Marken & M. Payne (Eds.), Enabling and Ensuring Supervision in Practice. University of Chicago Press.