Clinical supervision brings a different vision or focus to a problem or situation. It can be one to one with a supervisor or a supervisor might facilitate a supervision group. Often in teams issues overlap between individuals and while one person might bring a particular issue this usually resonates with the majority of the team. While all health professionals have experienced supervision in training not all have access to it on a regular basis. Spending time learning from when we are up against our limits is a hugely rewarding  process that can have a huge impact on our effectiveness and wellbeing. Imagine how it would feel to be able to work through your issues with those most difficult patients or clients without your heart sinking.

Supervision is ‘super’ (enhanced) – ‘vision’ (perception), it is part professional tool to explore challenges and part a way of looking after ourselves, supporting our ongoing personal and professional development. It provides space to reflect on practice, a place to develop knowledge, the opportunity to identify ‘blind spots’, a place to re examine difficult issues, giving time to think through ethical issues, to try out new ideas and a space to develop new skills.

One of us, David Owen has developed a model of supervision looking at 5 different realms (see below). David co-edited a book on clinical supervision in the medical profession, and has contributed to other texts on supervision. He offers training to health professionals in supervision.

---

The Five Realms in Supervision coaching and mentoring

David Owen

In every clinical relationship the doctor and healthcare team hold an extraordinary position in relation to the patient. When, as doctors, we find ourselves in challenging situations, it often appears that the problem is due to the patient or their illness. We understandably try to ‘fix it’, often without really taking on board the impact of the problem on ourselves or our teams. Failing to pay attention to what is evoked in us and what we evoke in others, is a major cause of patient and doctor dissatisfaction that may, in some cases, erode the wellbeing of both parties. This can go on and undermine the health care teams and organisations upon which we rely to treat patients and support ourselves.

The model of the five realms is something that I have found useful when supporting doctors and teams. It allows us to focus on things with five different perspectives. Those of the problem, the patients, the doctor, the team and the broader organisational and cultural context.

The Five Realms are:

1. The realm of the problem; including diagnosis and management.
2. The realm of the patient, customer or service user; in medical context this includes the patients subjective experience of the problem or service.
3. The realm of the doctor; including the doctor-patient relationship, their work and home environment, the doctor’s professional needs and personal well being.
4. The realm of the team and interpersonal dynamics with colleagues.
5. The broader organisational, cultural and socio-economic context in which we practice.

This model provides a practical ‘map’ to view the wider issues that so often accompany any problem. Each realm has associated tools for exploring the issues evoked. Often with individuals and teams the deepest problem, stuckness or ‘point of pain’ is not the one that the individual or team initially identifies as the problem. The same principles apply whether providing supervision, coaching or mentoring but for easy of reading I will refer to them collectively as supervision from here. The five realms model allows the exploration of the relationship between different parties such as the doctor – patient – team and allows the supervisor and supervisee to explicitly focus on the different expectation, agreements and resources available in each realm. It may include disease management strategies, frequent reoccuring problems in clinical settings, patient communication (and satisfaction), doctor wellbeing, team cohessiveness and peer support, practice policies and assumptions and organisational and funding constraints. It very much includes the interpersonal relationships that are mirrorred through the lens of the supervisor – supervisee relationship. In addition it empowers doctors to look at, and if appropriate, challenge, unhelpful cultural, social and professional beliefs and norms.

Each of the five realms invites a different way of looking at an issue, giving five different perspectives to understand and explore a doctor’s professional relationships. These five realms can be represented as sitting one inside the other like Russian dolls,.

While some issues appear to focus mainly in one realm, my experience is that the five realms or perspectives do not exist independently from each other but are dynamically intertwined. Different supervisees will often have a personal preference about how they work, and will find the perspective offered by looking into some of these realms easier than others. In my experience, often the deepest insights and most profound changes come when the supervisee is able to explore one of their less preferred ways of working. One of the most important aspects of the supervisor’s role is to help the supervisee feel safe enough to see things from a different perspective and support the supervisee with looking at how they might do things differently.