Supervision in New Zealand: Professional Growth or Maintaining Competence?
Herkt, Jackie, Hocking, Clare, New Zealand Journal of Occupational Therapy
Supervision has been part of occupational therapy practice in New Zealand for more than two decades. Engagement in supervision is expected by the New Zealand Association of Occupational Therapists (NZAOT, 2005) and mandated by the profession's regulatory authority, through its Code of Ethics (Occupational Therapy Board New Zealand, 2004a). However, little is known about current supervisory practices in New Zealand, or therapists' experiences of providing or receiving supervision. Even less is known about what outcomes supervision achieves. This article raises questions about the outcomes occupational therapists in this country want from supervision, arguing that a single process cannot accommodate all the differing expectations of key stakeholders. The discussion is informed by findings of a small-scale qualitative study undertaken to explore the phenomenon of supervision as it is currently implemented.
Because supervision has been incorporated into the professional, organizational and regulatory structures in New Zealand, an overview of how this happened, the various stakeholders in this country and their differing perspectives is provided. Following that, a more general discussion of local and international literature is presented to clarify the key issues.
The New Zealand context
In the health and disability sector in New Zealand today, there is a dual emphasis on ensuring organisations provide quality services that are effective and efficient, while also ensuring practitioners are competent and accountable for the quality of service they provide (Ministry of Health, 2000). The Health Practitioners Competence Assurance Act (HPCAA) 2003 addresses the latter. The Act has resulted, for occupational therapists, in greater emphasis being placed on supervision. Two mechanisms set up by the Occupational Therapy Board of New Zealand (OTBNZ), which administers the Act, have been influential.
Firstly, the HPCAA (2003) requires regulatory authorities to protect the public by ensuring registered health professionals are competent to practice. The Continuing Competence Framework for Recertification (CCFR) developed by the OTBNZ was designed to achieve this purpose, enabling therapists to demonstrate their ongoing competence for annual recertification. The framework specifies that therapists receive supervision and maintain a supervision log detailing "the nature and frequency of professional development" (OTBNZ, 2004b, p. 8). The CCFR requires identification of professional development activities undertaken to maintain competence, and makes provision for supervisors to comment on these. A declaration is required from a third party attesting to a therapist's fitness and competence to practice. This person may or may not also be a supervisor. The third party has access to supervisor comments to inform the declaration (OTBNZ, 2004b). These requirements are given further weight by the Board's Code of Ethics (2004a) which specifies that occupational therapists should "receive effective professional supervision relevant to the work setting" (p. 3).
Secondly, the HPCAA (2003) empowers regulatory authorities to require individual, or indeed all health practitioners, to undertake a competence programme "for the purpose of maintaining, examining or improving" (p. 36) competence to practice. One form such programmes might take is a period of supervised practice (HPCCA, 2003, Section 40(f), p. 37). In the context of this governmental expectation, NZAOT recommends supervision for all therapists in the belief that it "enhances professional development, clinical competence and safe practice. It reduces risk to the client and clinician" (NZAOT, 2005, p. 1).
The New Zealand occupational therapy profession's current understandings of the process and purpose of supervision has evolved over the last three decades. Based on a search of published documents and speaking with therapists who have practiced for some time, it appears that most occupational therapy departments in New Zealand had introduced supervision by the mid 1980s. The early focus was on the support and development of new graduates as they commenced practice. The provision of supervision slowly crept up through the departmental or service hierarchy, with managers being the last to be seen to require and potentially benefit from supervision.
Supervision was initially provided by the charge, head, or a more senior therapist to less experienced therapists (S. Milligan, personal communication, February 4, 2005) and was perceived to be a joint process, whereby supervisee and supervisor shared responsibility for both process and outcomes (Campbell, 1982-3). By 1988, supervision was described as providing therapists with support and feedback on their work, enhancing supervisees' skills, thus facilitating competence and reducing the risk of burnout (Hocking ,1988). These views have persisted through to the present. For example, a decade later Christie (1998) drew attention to the importance of supervision, asserting that it was "an essential element in our professional role development" (p. 12) and thus crucial to the profession's growth. Similarly a recent study of supervision in a mental health service, which included occupational therapists as participants, concluded that supervision was perceived as a "largely private arrangement sanctioned by the organization; it is not a managed process; quality of service to clients is paramount" (Cooper, 2006, p. 21).
However, whilst occupational therapists describe a supportive, shared process, supervision has been operationally linked with staff appraisal systems and annual goal setting, and since the late 1980s has been incorporated into performance management processes. Perhaps recognising the tensions between these professional and operational purposes, the literature reveals a shift from advocating the provision of supervision, to acknowledging it as complex and potentially problematic for supervisors (Moulder, 2000a & b). Nonetheless, despite the importance it was accorded by the profession, the first evidence of formal training in supervision processes and skills targeted to occupational therapists was not until the early 1990s. At that time, the Central Institute of Technology began regularly offering a seven-day 'Training in Clinical Supervision' course.
In the early to mid 2000s, supervision was 'claimed', first by NZAOT and then the OTBNZ. Both professional bodies defined supervision, but each had its own agenda and thus emphasis. Recently the agencies and organisations that provide supervision to their employees have begun responding to internal and external pressures by introducing policies and procedures related to supervision, defining and clarifying the supervision they offer and the philosophy behind it (Ministry of Education, 2005; Simmonds Carlsson, Coups, Mueller, Neads & Thornley, 2007). This study was therefore situated in a time when there is confusion about the role, purpose and the most effective delivery style of supervision in New Zealand.
The literature reveals supervision to be a complex term, often poorly understood (Hawkins & Shohet, 2000; Proctor, 2000). Viewing the process of supervision from multiple perspectives helps in unravelling the complexities. From a counselling perspective, supervision is defined as a relationship that is evaluative, with a strong emphasis on monitoring the quality of the service and gate keeping entry to the profession (Bernard & Goodyear, 1998). Consistent with the emphasis on monitoring and checking, the Occupational Therapy Board of New Zealand's Code of Ethics (OTBNZ, 2004a) defined professional supervision as "a structured intentional relationship within which a practitioner reflects critically on his/her work, and receives feedback and guidance from a supervisor, in order to deliver the best possible service to consumers" (p. 7).
In contrast, the American Occupational Therapy Association (AOTA) defined supervision as:
A process in which two or more people participate in a joint effort to promote, establish, maintain, and/or elevate a level of performance and service. Supervision is a mutual undertaking between the supervisor and the supervisee that fosters growth and development; assures appropriate utilization of training and potential; encourages creativity and innovation; and provides guidance, support, encouragement and respect while working toward a goal. (AOTA, 1999, p. 592)
Here, a supportive relationship that empowers and encourages is stressed in a way that is not evident in other definitions. The perspective taken by an organisation or agency is important, not least because placing emphasis on different aspects might lead to supervision having a very different flavour.
Further clarity is gained by considering the purpose of supervision. Kadushin (1992) identified three distinct functions: administrative, supportive and educative. However, professional ideas and expectations of supervision are still evolving. Representative of current thinking and consistent with the AOTA definition, McMahon (2002) outlined three concepts underpinning supervision. Firstly, supervision is a relationship. The quality of the relationship is seen to be an important component in the ultimate success of supervision. Secondly, supervision is a developmental process, addressing a wide variety of issues. How they are addressed will evolve over time and will be dependent on the developmental stage of the supervisee. For this reason, it is important to monitor the process. Lastly, McMahon proposed that supervision is a learning opportunity, where supervisors are encouraged to create an environment that challenges and supports the supervisee. Additionally, McMahon advised of the need to ensure the work done in, or facilitated by, supervision is integrated into practice.
Whilst discussions about the purpose of supervision are ongoing, less attention has been paid to the way it relates to more recently developed processes such as performance-management, consultation, and mentoring. Performance management is often confused with supervision. It is important to differentiate between the two, as both processes are usually mandatory. Whilst there is overlap, there are three key differences between performance management and supervision. Firstly, the initial focus is different; performance management is about the organisation's needs, whereas supervision focuses on support for the individual. Secondly, issues of power are more overt in performance-management. As Blackburn and Cornelius (2001) argued, "at the heart of organisational performance management systems lies the use of power by managers on behalf of the company to control employee behaviour" (p. 179). Thirdly, line managers are expected to take the lead in performance-management whereas, in supervision it is the supervisee that leads (Cornelius & Gooch, 2001).
The Auckland University of Technology Ethics Committee granted ethical approval for this interpretative study. Grounded theory was chosen as the methodology for the study as it ensures that the voices of the participants are heard and that the study remains focused on their understandings and the meanings that they make of the process of supervision. The study had 11 participants with some of the participants agreeing to be interviewed in both capacities; as supervisee and supervisor. This resulted in 12 hours of interview data, from interviews with eight supervisees and five supervisors. Two participants were interviewed twice. Five interviews were conducted face to face with the remainder conducted by telephone. All interviews were audio taped, with the permission of participants.
The participants were recruited via advertisements placed in OT Insight, the monthly magazine published by NZAOT, which invited therapists to contact the first author if they were interested in participating. They came from a variety of large and small cities throughout New Zealand. They represented a wide range of work-places, from the traditional hospital settings to community, education, and private practice settings, in both mental and physical health. They were broadly representative of the occupational therapy workforce, ranging from new graduates, through to individuals who had been in the profession for up to 30 years. Participant confidentiality was protected by offering the option of being interviewed away from their workplace, by storing participant contact details separate from interview data, and carefully ensuring participants were not identified to employers or colleagues. The privacy of employing organizations and the other parties involved in supervisory relationships was protected by asking participants not to name others, and by removing names of all organizations from transcripts.
The research used theoretical sampling, choosing the participants based on their likely ability to contribute to the evolving theory (Creswell, 1998, Glaser & Strauss, 1967). Grounded theory process asks that the researcher collects, codes and analyses the data as the research occurs. During this process the researcher decides what data to collect next and where to find it, this process is called theoretical sampling. Undertaking this process helps to develop the theory as it emerges and results in the emerging theory controlling data collection (Glaser & Strauss, 1967).
Interview data was transcribed verbatim by a professional transcriber, who had completed a confidentiality agreement, and transcripts checked for accuracy against the audiotapes. Data analysis involved reading and rereading transcripts to ensure that key themes were identified and developed. From this painstaking, iterative process, a number of important issues emerged for the profession to consider. Member checking and triangulation of supervisee and supervisor perspectives were used to ensure trustworthiness.
The findings reported here focus on issues pertinent to supervisory practices in New Zealand that we believe need to be debated. Those are the nature and process of supervision, the supervisory relationship, and power in supervision.
The nature of supervision
To discover how participants conceptualised supervision, they were asked to define it in their own words. Participants' definitions were often hesitant, with one stating, "Our code of ethics says we should be in supervision, but we don't even know what supervision is". Nonetheless, three key purposes of supervision with associated activities were apparent.
Firstly, participants identified that a crucial purpose of supervision was gaining knowledge. For new graduates, and at times for other therapists who were under pressure or new to their position, it was about being given the information they needed to fulfil role requirements. A new graduate stated: "I see supervision as a chance to get questions answered, to clarify specific things like how to go about doing something that I perhaps don't have the knowledge how to do." It was clear that this period, even with new graduates, lasted only a few weeks. Participants with greater experience, or who felt confident in their role rarely spoke of being given information but rather of gaining knowledge through the opportunities supervision offered to weigh up different perspectives and consider whether their practice or actions needed to change.
Secondly, supervision was an opportunity to reflect on practice. This occurred in relation to clients, peers and the organisation in which they worked, as well as different contexts of practice. Reflecting on practice involved looking at what they did and how they did it. Supervision provided:
An opportunity for supervisees to look over or reflect on the work they are doing for an organisation with clients. A place to look at oneself as a practitioner and to look at the work that one does and reflect on it, develop from it and gain insights and question.
Within the task of reflecting on practice participants, particularly those with more experience, viewed supervision as an opportunity to raise and develop their self-awareness. They valued feedback as one of the steps towards achieving this.
Thirdly, the supervisees in the study perceived supervision as keeping them safe, in situations where their skills, decisions and competence might be questioned.
It's a protective device for me to keep myself up to speed with other things that may be going on ... [Supervision] is to keep me safe ethically so it provides me with an outlet to discuss ethical issues that I might have and to get some feedback.
Supervision provided an opportunity to express concerns and to receive advice, feedback and support that would protect them from this risk. Keeping safe necessitated having someone to help supervisees determine whether what they were doing was acceptable and current practice, and was strengthened by reflection on practice.
Process of supervision
Participants held expectations of supervision in terms of how it would be conducted. They described using dialogue as a means to explore a subject or gain resolution of a problem. Raising issues was a significant activity, in that it defined a starting point from which things could happen. It involved the process of bringing things to supervision; whether that was looking at their own skills and limitations, conflicts within their work, or exploring their role as an occupational therapist within their particular setting.
I see supervision as a chance to ... discuss any issues that might be of concern to me, either related to elements of my practice or perhaps difficult situations I've been in that have caused an unusual emotional response in myself or the patient I am working with--or it might be around issues of conflict with staff members.
Participants initially talked about supervision as a means of problem solving. However, when explored this was not about providing answers so much as talking through possibilities, which enabled them to generate their own solutions. Supervisees wanted the locus of control to be theirs, by deciding which of the potential solutions to use.
It's about helping the person do their own problem solving. It is not necessarily giving people answers. It is about helping them to find the best way to work though their own issues.
In their hesitancy to articulate the purpose and activities of supervision, both supervisees and supervisors identified insufficient training in supervision. They felt strongly that it should not be 'occupational therapy', but in not being trained in supervision, there was a danger of slipping into a therapeutic relationship. The data showed emerging skills in setting up supervision contracts but inability to use the contract effectively, and a paucity of skills to call on in supervision sessions.
Participants were clear that the relationship between supervisor and supervisee is a central feature of supervision. They all described it as a one-to-one relationship, in effect describing their current mode of supervision. The nature of the relationship was perceived to be one of mentoring, with emphasis on it being supportive and trusting. They understood that a mentoring relationship may not develop quickly; being something they would grow into over time. It seemed that a supervisor might start as something akin to a coach, and become something better - a mentor, meaning an advisor, guide, guru, counsellor, coach or teacher. Participants' use of the term mentor is interesting from the perspective that mentoring relationships have no biting edge. Specifically, mentoring would not usually encompass line supervision and being accountable to one's mentor. This suggests that issues of power implicit in supervisory relationships with line supervisors have a consequence for the relationship itself.
The words used to describe the qualities of a supportive and trustworthy supervisor, reflected someone non-judgemental, encouraging and caring, almost friendly, a confidant. Furthermore, supervisees wanted their supervisor to be a person they respected, someone able to give guidance, and for new graduates and in some instances those new to a practice area, someone who has more knowledge about the practice area than the supervisee. The features the participants highlighted appear to be those that allow them to feel safe about disclosure when raising issues that involve challenges, concerns and conflicts.
It's time out for an employee where they can be with a person who they would trust [zvho has] a degree of knowledge and skill, whereby /supervisees] can express themselves, their concerns, their abilities. An open ended process of caring.
Just as raising issues was a starting point of the supervisory process, getting the relationship right in terms of being supportive and trusting appears significant in both supervisees' participation in supervision and its potential outcome. Importantly for the participants, supervision seems to be a process directed at providing opportunities for learning and feedback that will ensure others view their practise positively, and enable them to give a good account of their actions. Notions of accountability, however, were noticeably absent from the data, with only one new graduate including the evaluative, oversight aspect of supervision in her definition. Accountability indicates a relationship that has a degree of being called to account, introducing the possibility of therapists being held liable for their practice and the attribution of blame. Along with accountability comes the need to measure up against others or against set criteria for practice.
It's about getting an idea of how the person is practicing ... to give them some guidelines as to what is accepted practice.
Power in supervision
Inherent in participants' accounts of the supervisory relationship was the issue of power and it was here that the strongest feelings emerged. Participants described power in a number of ways, ranging from the capacity supervisors have to influence supervisees, to their delegated authority to ensure accountability and competence. Supervisees wanted foremost to be seen in a good light. They wanted to be viewed positively, seen to be coping well and capable of doing their job. As such, supervisees also felt the need to protect themselves, and their willingness to explore any weaknesses depended on how safe they felt to disclose.
Interestingly, the difference between acknowledging weaknesses and working to improve knowledge and skills, versus being seen as incompetent was constantly raised as an issue by supervisees who had line managers as their supervisors. These supervisees were very wary of the boundary between being judged competent or incompetent. This influenced what they would bring to supervision, as any disclosure was thought to have a potential impact on them within the workforce. What is clear is that supervisees were not willing to take risks.
I'd like [the supervisor] to be an occupational therapist who wasn't going to be the person approving or disapproving my next application for a pay rise ... I would want someone who wasn't going to be doing my annual performance appraisal. It would mean that I would feel more comfortable about bringing up any issues of incompetency on my part, without thinking this is going to reflect badly when my annual appraisal comes up. Because you have to try to sell yourself in one way and it would be nicer to feel that you could just come out and go 'I don't feel that I dealt with that well--I think I need to work on this, how do I go about doing that?' Whereas that's kind of like saying 'I'm not performing as well as I should be' and so there is a direct conflict.
The sense of needing to protect themselves calls into question the effectiveness of having a line manager as a supervisor. It was clear that supervisees believed that supervisors in line management positions had power over them, in having the ability to negatively affect performance appraisals and salary reviews, or initiate disciplinary actions. This belief influenced both what supervisees were willing to bring to supervision, and the depth to which they were prepared to explore issues. As a result, a number of the supervisees in the study chose or found themselves using a range of actions characterised here as guarding. This involved supervisees consciously or unconsciously protecting themselves by using cognitive avoidance strategies, or physically avoiding supervision by not making time for it. It was clear from the data that when participants used guarding, there was a strong negative impact on the outcome of supervision.
The occupational therapists who participated in this study clearly identified the developmental possibilities inherent in professional supervision, and recognised dialogue and self-disclosure as mechanisms supporting such development.
Simultaneously, their reports of being guarded in how much and what they say reveals an acute awareness that their self-report might be used against them. Rather than openly disclosing concerns, some knowingly hide issues and actively avoid supervision. The tension they experience between the extremes of open discussion and guarded self-report reflects the disparate views of supervision that have existed in New Zealand at different times. As discussed earlier, these range from the original emphasis on support and development to the current prominence of risk reduction, maintenance of competence, sign off for recertification, and the possibility of imposed periods of supervised practice. In turn, these findings reflect the divergent views evident in the international literature, where learning (McMahon, 2002), guidance, support, encouragement, and creativity (AOTA, 1999) are espoused alongside evaluative, monitoring, gate keeping (Bernard & Goodyear, 1998) and administrative functions (Kadushin, 1992).
In New Zealand, as in otherWestern countries, it seems the shift away from supportive and educational supervision processes has come about because of the increased "managerialism and economic rationalism" (O'Donoghue, 2003, p. 46) currently being implemented within health care settings. This shift is evident in New Zealand in relation to health policy (Ministry of Health, 2000) and in the HPCAA (2003), where there is a strong push for quality assurance, competence, accountability and oversight of individual practitioners. The implication is that achieving such ends will ensure recipients of health care services are free of risk of serious harm (HPCAA) and health dollars are used to greatest effect.
Against such imperatives, promoting supervision as a supportive, creative process centered on the development of self will inevitably appear less urgent, immeasurable, and perhaps self-indulgent. This critique is aided by lack of clarity about what supervision of this nature means and what its outcomes might be. For example, both Carroll (1996) and Grauel (2002) proposed a widespread belief within the helping professions that supervision goes beyond oversight, yet acknowledged that there is no consensus to show what 'beyond oversight' means.
The implications of the study are far reaching. It seems clear that continuing the present state of confusion over the real purpose of supervision is untenable, because it allows neither supportive and educative nor managerial outcomes to be fully achieved. Instead, therapists' expectations of supervisory relationships characterized by a high level of trust, care and support are unfulfilled and at the same time, organisational and regulatory imperatives of regular participation in supervision are frustrated. To move forward, we suggest that several things need to happen. All involve decisions at a national or local level and take for granted that New Zealanders will have to decide for themselves, since the international literature provides no clear direction.
One given, as we see it, is that the Occupational Therapy Board needs to reach greater clarity about its intent in simultaneously mandating supervision in its Code of Ethics and structuring supervisory mechanisms into its Continuing Competence Framework. It seems that while the ethical code addresses good practice, which comfortably encompasses developmentally focused supervision, the competence framework must closely align with the HPCAA (2003), as such, it is concerned with ensuring competence to practice. Achieving that purpose implies oversight, that is, that someone takes responsibility to monitor or review the adequacy of professional development plans and activities in relation to professional responsibilities. This is a very specific, and narrow function of supervision that aligns more closely with performance appraisal sign off. Rather than suggesting that professional supervisors fill the role, it might be more accurate to align this function with service managers, team leaders or professional development advisors. Similarly, the language surrounding a period of supervision imposed under the auspices of a competence programme might more clearly signal the intent of ensuring competent practice if 'oversight' rather than 'supervision' was specified. The time to seek clarity and influence how the Board might move forward is now, with the formal notification of the review of the HPCAA having been circulated in May of this year. The review will focus on the way the Act has been operationalised, and offers opportunity to influence the scope of the review. Occupational therapists may wish to ensure the review addresses the way the words supervision and oversight are used within the Act. Movement at that level may assist in revision of the Board's structures in ways that allow frameworks of supervision that support therapists' professional development in addition to ensuring a competent workforce.
In contrast to the Board, with its legislative point of reference, NZAOT is charged by its members to advocate on their behalf, albeit with the long term good of the profession and recipients of occupational therapy in mind. If informed by the findings of this study, NZAOT's stance on supervision would lean much more heavily towards supporting occupational therapists to develop into the role, to optimize their potential for being a therapist. Such a stance might bring supervisory relationships, reflective practice, and life-long learning to the fore. It would likely necessitate warning therapists and managers of the risks inherent in deploying line managers as supervisors, and stating a preference for skill-based selection of supervisors. Consistent with the signals participants gave about what they valued in supervision, and the undesirable impact power discrepancies have on supervision, NZAOT might advocate contracts between supervisee and supervisor that focus on developmental processes, confidentiality and trust building. Adopting such perspectives would require re-visiting the association's current supervision position statement, which has adopted the Occupational Therapy Board's definition in its entirety (NZAOT, 2005), and might extend to working with members to identify and describe relevant supervisory theories and skills, and the characteristics of optimal supervisory relationships.
At an organisational level, this study makes evident that employing bodies need to decide and clearly communicate their stance on supervision because oversight, accountability and responsibility functions appear incompatible with developing a professional awareness of self and skill in critical reflection. By unambiguously signalling the purpose for which supervision is provided, employers or managers would empower therapists to negotiate or independently seek any additional support they need. For example, an organisation might determine that its supervisory processes are a cornerstone of safe practice. From this perspective, supervision would be recognized to be a source of information in relation to competent or incompetent practice, and thus individual's prospects for promotion or need for performance management. Therapists employed by such organisations could expect to be supervised by their direct line managers or other senior staff and to be presented with standardized supervisory contracts. They would recognize the need to find other avenues to explore professional development for support with reflection, creativity, and innovation.
The findings of this study also have implications for the occupational therapy programmes in New Zealand, as the bodies charged with preparing graduates for practice. Discharging that responsibility includes teaching students about the different nuances of supervision, and the various purposes of the supervisory functions structured into employment, registration and professional development processes. Along with such knowledge, these future therapists need skills to participate in each process and the vision to recognize supervision as a cornerstone of life-long learning and reflective practice. The question of upskilling supervisors to achieve supervision's potential as a professional development tool is more complex, with responsibility shared amongst all those authorities mandating or endorsing its use.
In conclusion, supervision is recognized internationally as a means of both supporting and monitoring therapists' practice. If supervision is to retain its place as an accepted and essential component of practice in New Zealand, serious consideration of its purpose in our context, and the skills required to achieve that purpose is required. Action by stakeholders in the profession is required, to clarify assumptions about the outcome of supervision. Such action may result in differentiation of a variety of types of supervision to meet different ends. Our hope in the long term is to put an end to expectations deemed unrealistic in the current fiscal climate and to stop creating the circumstances where competent therapists hide aspects of their practice they might more usefully examine and develop.
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Jackie Herkt, MHSc (Hons), Dip(OT), is the Head of the School of Occupational Therapy at Otago Polytechnic in Dunedin. In 2005 she successfully completed her master's thesis through the Auckland University of Technology. It focused on supervisory practices in New Zealand, and provided the basis for this article. Email for correspondence: email@example.com
Dr. Clare Hocking, PhD, MHSc(OT), Adv Dip(OT), Dip(OT), is an Associate Professor at the School of Occupational Therapy at AUT University in Auckland. She guided Jackie's early explorations of supervisory processes in the health professions and was her thesis supervisor.…
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Publication information: Article title: Supervision in New Zealand: Professional Growth or Maintaining Competence?. Contributors: Herkt, Jackie - Author, Hocking, Clare - Author. Journal title: New Zealand Journal of Occupational Therapy. Volume: 54. Issue: 2 Publication date: September 2007. Page number: 26+. © 2008 New Zealand Association of Occupational Therapists. COPYRIGHT 2007 Gale Group.
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