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Translation of the Manchester Clinical Supervision Scale (MCSS) into Danish

and a preliminary psychometric validation

Article  in  International journal of mental health nursing · July 2012

DOI: 10.1111/j.1447-0349.2012.00858.x · Source: PubMed

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Title: The translation of the Manchester Clinical Supervision Scale (MCSS) into Danish and a
preliminary psychometric validation


Running head: Translating and validating MCSS


Authors:

Dr. Niels Buus MScN RN (Corresponding author)

Institute of Public Health.

University of Southern Denmark.

J.B. Winsløwsvej 9B.

5000 Odense C.

Denmark.

Telephone: +45 6550 4400.

E-mail: nbuus@health.sdu.dk.

Dr. Henrik Gonge MSc (Psychology)

Psychiatric Unit Odense - University Function

Sdr. Boulevard 29

5000 Odense

Denmark

E-mail: henrik@gonge.dk

Contributions:

Niels Buus: Design, data collection, analyses, and writing of article.

Henrik Gonge: Design, data collection, analyses, and writing of article.

Declaration of interest:

No authors have any conflicts of interests

All authors have approved the final article. The article has not been published nor submitted

for publication simultaneously elsewhere.

The study conforms to all Danish ethical standards/requirements.

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Abstract

A central challenge for empirical research of clinical supervision is how to measure the
effectiveness of clinical supervision. The Manchester Clinical Supervision Scale (MCSS)
measures supervisee’s perception of the effectiveness of clinical supervision. The aims of this
paper were to account for the translation of MCSS from English into Danish and to present a
preliminary psychometric validation of the Danish version of the scale. Methods included a
formal translation/back-translation procedure and statistical analyses. The sample consisted
of MCSS scores from 139 Danish mental health nursing staff members. The total MCSS score
had good internal consistency, but the analyses identified a number of reliability and
consistency issues. The results were compared with other translations of MCSS and with the
reduced version of MCSS, the MCSS-26. The discussion indicated that MCSS theoretically
refers to a broad conception of supervision, which includes supervision practices ranging
from highly formalised events to more frequent ad hoc sessions. MCSS’s intention to measure
perceptions of supervisees from this variety of practices may be problematic, and it is
suggested that a further reduction of the type of practices MCSS currently aims at measuring
could be beneficial.


Keywords (MeSH): Evaluation Studies, Nursing Education Research, Psychiatric Nursing,
Psychometrics, Questionnaires.

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Introduction

Clinical supervision has a well-established role in nursing practice (Lynch et al., 2008,
Cassedy, 2010). In professional nursing discourses it is most often regarded as a valuable
intervention on practising nurses (Butterworth et al., 2008, Sloan, 2006). Clinical supervision
may increase reflective practice, reduce work-related stress and burnout, and improve the
quality of the care given. However, there is limited empirical evidence supporting the value of
clinical supervision (Buus and Gonge, 2009, Francke and de Graaff, 2011).

A central challenge for empirical research of clinical supervision is how to measure the
effectiveness of clinical supervision. In the present paper, we will account for the translation
into Danish and the preliminary psychometric validation of an instrument for measuring the
effectiveness of clinical supervision, the Manchester Clinical Supervision Scale (MCSS).

Manchester Clinical Supervision Scale

Dr. Julie Winstanley developed MCSS (Winstanley, 2000b), and it is the most widely used
instrument for measuring supervisees’ perceptions of the quality and effectiveness of clinical
supervision. The development of the scale grew out of an extensive evaluation of clinical
supervision in nursing located at the University of Manchester (Butterworth et al., 1997). In
the original design of the scale, Winstanley drew on concepts from three different models of
clinical supervision: Proctor’s three-function interactive model of supervision (Proctor, 1987),
Faugier’s growth and support model of clinical supervision (Faugier, 1992), and Hawkins and
Shohet’s integrative approach (Hawkins and Shohet, 2006).

In a later paper, Winstanley and White refer to a definition of clinical supervision provided by
the Open University: “Clinical Supervision provides time out and an opportunity, within the
context of an ongoing professional relationship with an experienced practitioner, to engage in
guided reflection on current practice in ways designed to develop and enhance that practice
in the future” (Winstanley and White, 2011, p. 161).

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The first version of MCSS had 59 items and was derived from two qualitative studies of
clinical supervision (White et al., 1998, Butterworth et al., 1997). Following explorative factor
analysis and field-testing, the scale was revised/reduced initially to 45 items and finally to 36
items (MCSS-36) (Winstanley, 2000a).

Each item is formulated as a statement about clinical supervision, and respondents answer on
a five-point Likert scale from “strongly disagree” to “strongly agree”. A high score for any sub-
scale reflects a high degree of quality and effectiveness of that particular aspect of clinical
supervision, and a high total score reflects a high overall quality and effectiveness of clinical
supervision (Winstanley, 2000b). The Cronbach α reliability coefficient of the MCSS-36 total
scale was 0.86, and the test-retest reliability coefficient was 0.93 (Winstanley, 2000b).

MCSS-36 comprises seven sub-scales, each concerning a distinct aspect of clinical supervision:
1. Trust/rapport (7 items, α = 0.85). “Level of trust/rapport with the supervisor during
the session/ability to discuss sensitive/confidential issues”
2. Supervisor advice/support (6 items, α = 0.86). “Extent to which the supervisee feels
supported by the supervisor and a measure of level of advice and guidance received”
3. Improved care/skills (7 items, α = 0.91). “Extent to which the supervisee feels that CS
has affected the delivery of care and improvement in skills”
4. Importance/value of clinical supervision (6 items, α = 0.87). “A measure of the
importance of receiving CS and whether the CS process is valued or necessary to
improve quality of care”
5. Finding time (4 items, α = 0.79). “A measure of the time available for the supervisee to
attend CS sessions”
6. Personal issues (3 items, α = 0.70). “A measure of how supported the supervisee feels
with issues of a personal nature”
7. Reflection (3 items, α = 0.83). “A measure of how supported the supervisee feels with
reflecting on complex clinical experiences” (Winstanley, 2000b, p. 9).
The scale is, tentatively at first, related to the three main tasks of supervision outlined in
Proctor’s model: development (the formative task), assessment (the normative task), and
recreation (the restorative task) (Winstanley, 2000b).

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In 2011, the scale was revised on the basis of Rasch item response analysis and further
reduced to 26 items (MCSS-26) (Winstanley and White, 2011). The number of scales was
reduced to six in MCSS-26 by omitting all three items in the sub-scale “Personal issues”
because of low reliability (see their wording in table 1). More, three items were omitted
because of item redundancy (items 14, 28, and 33) and four because of misfit (items 19, 26,
30, and 32). In this 2011 publication, the scales were described and analysed as having
stronger and more definite relations to Proctor’s descriptions of clinical supervision’s three
domains (Winstanley and White, 2011).

Translations of Manchester Clinical Supervision Scale

MCSS has been translated into French, Spanish, Portuguese, Norwegian, Swedish, and Finnish.
The procedure of translating and validating MCSS into Norwegian and Swedish (Severinsson,
2012) and Finnish (Hyrkäs et al., 2003b, Hyrkäs et al., 2003a) has been published. However,
these reports can only be compared with caution, as they examine different versions of MCSS
and employ different statistical tests.

Hyrkäs et al. (2003b) translated the 45-item version of MCSS in to Finnish and computed
internal consistency of the sub-scales (Cronbach’s alpha) and the homogeneity of items
(Spearman rank correlation coefficient). The internal consistency was high for the MCSS total
score (α = 0.92), but three sub-scales had low consistency (α < 0.7). Further, the homogeneity
test indicated that items 9 and 14 were particularly problematic, which was linked to cultural
non-equivalence (Hyrkäs et al., 2003b). In a subsequent study, the Finnish version of MCSS-36
was validated by using an 11 member expert panel (Hyrkäs et al., 2003a). The panel’s
evaluation led to the elimination of sub-scale 5 “Finding time” and to the elimination or
revision of a number of items (or the reintroduction of items only present in the previous
MCSS-45). These items were evaluated as being culturally non-equivalent with Finnish
nursing practice. This was related to the following issues: 1. Time for CS was guaranteed and
asking about finding time was therefore redundant (sub-scale 5), 2. Finnish supervisors were
not continually present in clinical contexts and it was redundant to assume continual
availability (item 14 and 19), 3. Finnish supervisors did not give specific advice and
statements assuming that they did were wrong (item 22), and 4. Personal issues were not

6
addressed during supervision and statements assuming they did were wrong (item 9)
(Hyrkäs et al., 2003a). Hyrkäs et al. (2003a and 2003b) do not make explicit, which items they
included in the final, culturally revised Finnish version of MCSS.

Severinsson (2012) translated MCSS-36 into Norwegian and Swedish and computed internal
consistency of the sub-scales (Cronbach’s alpha) and confirmatory factor analysis (CFA) to
determine the factor loading of each item. The internal consistency was high for the MCSS
total score (α = 0.88), but three sub-scales (4, 5 and 6) had low consistency (α < 0.7). The CFA
indicated that there was low construct validity: the data did not fit the 7-factor structural
model (Severinsson, 2012).

MCSS was translated into Danish as part of a descriptive mixed methods study of clinical
supervision practices among mental health nursing staff in a Danish health care trust (Buus et
al., 2010, Buus et al., 2011, Gonge and Buus, 2010, Gonge and Buus, 2011). The aims of this
paper are: 1. To account for the translation of MCSS from English into Danish and to compare
insight from the translation with other translations of MCSS. 2. To describe the psychometric
properties of the Danish version of the scale and to compare these properties with properties
of other translated MCSSs and the recent MCSS-26.

Materials and methods

A methodological study in which the authors translated the MCSS into Danish and tested
psychometrics properties of the Danish version of the MCSS.

Translation

Our ambition was to enable international comparisons of studies of supervision, so we aimed
at translating MCSS into Danish with the least possible distortion of the scales’ linguistic and
cultural meaning. This meant that we tried to retain MCSS’ original syntax and wording, and
we deliberately avoided improving or deleting problematic items as part of the cultural
adaption, which was done in the Finnish validation of MCSS (Hyrkäs et al., 2003a). We used
Beaton et al.’s (2000) guidelines for cross-cultural adaption of self-report measures. Practices

7
of clinical supervision vary between countries. In Denmark, for instance, clinical supervision
is only offered to qualified nursing staff, whereas it is commonly offered to both students and
qualified nursing staff in the UK. Therefore, the guidelines were chosen because they explicitly
account for socio-cultural differences between words and practices.

The guidelines for translation contain six stages:
Stage 1. Translations into target language. Three translators translated the questionnaire
independently: two informed bilingual translators and one naïve bilingual translator.
Stage 2. Synthesis of translations. The translators compared and discussed the three
translations and created a joint version based on consensus and by drawing on second
opinions from informed colleagues on the wording of a number of ambiguous items.
Stage 3. Back translation into original language. A professional, naïve translator (with a MA in
English) made an independent back-translation.
Stage 4. Expert committee examining the original and the back-translation: a. Semantic
equivalence (meaning of individual words). b. Idiomatic equivalence (meaning of idioms). c.
Experiential equivalence (meaning in relation to everyday practices). d. Conceptual
equivalence (cultural meaning of word and expressions). All translators and the back-
translator discussed cultural equivalency between the original text and the translation on the
basis of a detailed log accounting for the development of the final version, including all
previous/alternative wordings.
Stage 5. Test of pre-final version. The pre-final version of the questionnaire was tested on 20
qualified nurses enrolled in The Advanced Training Course in Psychiatric Nursing at Aarhus
University Hospital, Risskov, Denmark. Beaton et al. (2000) suggest tests on 30-40
respondents, but preliminary analysis indicated that the 20 respondents identified the same
items as problematic, and recruiting was stopped. The nurses responded to the translated
MCSS and wrote down their reflections on responding. They had 55 specific comments, which
were used to challenge the translation and suggest alternatives.
6. Submission of documentation of the developers of the measure. The final version was sent
to the creators of MCSS, Dr. Julie Winstanley and Dr. Edward White, who commented on the
back-translations and the expert committee’s explanations for choosing between words with
almost equivalent meaning.

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Psychometric analysis

A sample of responses to the final Danish translation of MCSS was collected in a survey
conducted at Aarhus University Hospital, Risskov, Denmark (Gonge and Buus, 2010, Gonge
and Buus, 2011). Permanently employed nursing staff from nine general psychiatric wards
and four community mental health centres were invited to participate in the study. In total
139 staff responded (seven did not report on sociodemographic variables). The sample
includes RNs (58.3 %), auxiliary nurses (36.4 %) and occupational therapists/social
educators (5.3 %). 84.1 % of the sample were women. 65.2 % of the respondents were
employed in the general psychiatric wards, while 34.8 % worked in community mental health
centres. The majority worked day shift (85.6%) with only 9.1 % working evening shift and 5.3
% night shift. Mean age of the respondents was 46.3 years (SD 10.0, range 22-65 years).
Four weeks after responding to the survey, 90 respondents working in general psychiatric
wards were asked to answer the MCSS again. 62 Staff returned a second response to the MCSS
(test-retest).

Statistical methods
Internal consistency of the scales and the total MCSS was assessed by applying Cronbach's
alpha statistic. Alpha coefficients indicate the level of inter-item correlations for the items
constituting each scale and the total MCSS. Cronbach’s alpha coefficients were calculated for
MCSS-36 and for the newly revised version MCSS- 26 (Winstanley and White, 2011). Test-
retest reliability was tested through pairwise correlation analyses; Stata IC 10.0 was used for
all tests.

Results

Translation
We were not able to follow the stages of Beaton et al.’s (2000) guidelines in a step-by-step
fashion. When it was put into practice, the translation was an iterative process, where several
steps were repeated, because later steps revealed issues regarding the wording of some items
and suggested alternatives, which had to be examined and validated from the beginning.

9
The back-translation highlighted 30 words or phrases that were not fully equivalent with the
original text. This led to the re-wording of five items that were subsequently back-translated.
In most instances, the expert committee decided which of the nearly synonymous words and
phrasings to use.

In accordance with Beaton et al.’s (2000) reflections on different types of equivalence, we will
highlight three sets of challenging issues in the translation process:
1. Semantic equivalence. Two items were clearly ambiguous and it was not possible to retain
this ambiguity in Danish. Item 26 “My supervisor puts me off asking about sensitive issues” is
ambiguous because it can mean either that the supervisor puts the respondent off by raising
sensitive issues or that the supervisor does not invite the respondent to raise sensitive issues.
We chose to translate it as: “My supervisor inhibits me by asking about sensitive problems”
(cited from the back-translation). Item 10, “CS sessions are intrusive” is ambiguous because it
is unclear in which sense the sessions are intrusive, e.g. it could be a disruption of daily
routines or a violation of personal integrity. The item belonged to the “Importance/value of
clinical supervision” sub-scale, so we chose to translate it as: “Supervision sessions are
urgent/obtrusive” (cited from the back-translation).
2. Idiomatic equivalence. There were only a few idioms in MCSS, which needed adaptation, for
instance, the idiom “to ‘unload’” in item 5 is identical in Danish. There were three professional
idioms that needed attention. The use of acronyms, including CS is less frequent in Danish
than in English, so we changed “CS” to “supervision”. Further, we found Danish equivalents to
“clinical knowledge base” (item 24), and “skill base” (item 34).
3. Experiential and conceptual equivalence. It was difficult to translate the phrase “personal
issue/problem” in item 9 “CS does not solve personal problems” and in item 17 “Having
someone different to talk to about personal issues was a great help”. In Danish, “personal”
entails strong connotations of “privacy” and there is no semantically equivalent word for
“issue”. Therefore the committee decided on “one’s own problems” (item 9) and “my
problems” (item 17) (cited from the back-translations). Finally, item 19 “My supervisor is
never available when needed” was experientially non-equivalent for most of the qualified staff
testing the pre-final version, because supervisors of trained staff are external to the
supervisees’ institutions and they are therefore not expected to be available full time.

10
Psychometric analysis
In table 1, the responses to the Danish translation of MCSS are summarized by descriptive
measures (means and standard deviations) and analyses of internal consistency (Cronbach’s
alpha). The alpha coefficients stated with each individual item are item-rest correlations,
which indicates what the inter-item alpha coefficient would be for the remaining items if the
particular item was removed from the scale.

Accumulated mean score for each of the scales are Trust/Rapport 27.1 (SD 4.8), Supervisor
advice/support 22.7 (3.5), Improved care/skills 26.0 (SD 3.1), Importance value of CS 11.3
(SD 3.2), Finding time 11.3 (SD 3.2), Personal issues 10.9 (SD 2.0) and Reflection 12.6 (SD
2.0). Mean of the total MCSS score (all 36 items) is 138.7 (SD 16.8).

Internal consistency was high in the scales “Trust/rapport” (α = 0.86) and Improved
care/skills (α = 0.84). The scales “Reflection” (α = 0.78) and “Supervisor advice/support” (α =
0.79) also showed satisfactory internal consistencies. However, regarding the latter the item-
rest coefficient for item 14, “If there is something I don’t understand there is always someone
to ask”, (α = 0.82) indicates the internal consistency may be improved by removing this item.
The internal consistency of the scales “Importance/value of CS” (α = 0.61) and “Finding time”
(α = 0.63) is questionable as it is controversial whether alpha levels below 0.7 are acceptable
(Clark-Carter, 1997). However, item-rest coefficients for item 25 “Supervision is unnecessary
for experienced/established staff” (α = 0.67) and item 7 “I find supervision sessions time-
consuming” (α = 0.65) suggest that removal of these items may increase internal consistency
of the two scales respectively. Internal consistency of the sub-scale “Personal issues” (α =
0.46) is far from being satisfactory. Finally, the coefficient for the total MCSS (α = 0.91)
indicates a high level of internal consistency.

Regarding MCSS 26: Leaving out items 19 and 26 from the sub-scale “Trust/rapport” does not
affect the level of consistency (α = 0.86). In line with results from analyses of MCSS-36
mentioned above, the internal consistency of the sub-scale “Supervisor advice/support” has
been improved from α = 0.79 to α = 0.82 by excluding item 14. On the contrary, the internal
consistency of the sub-scale “Improved care/skills” dropped from α = 0.84 to α = 0.80 by the
exclusion of items 30, 32, and 33. Item-rest coefficients from analyses of MCSS-36 suggest it is

11
relevant to exclude item 30, “Without CS the quality of client/patient care would deteriorate”
(α = 0.86), while the item-rest coefficient for item 33, “CS improves the quality of the care I
give to my patients/clients”, (α= 0.80) advocates for this item to be retained. (Omitting item
32 does not affect the α value). Internal consistency of the sub-scale “Importance/value of CS”
has also been negatively affected by leaving out item 28 “CS is for newly
qualified/inexperienced staff only” as it decreased the coefficient from α = 0.61 to α = 0.49.
The findings in the analyses of MCSS-36 support the decision to omit the sub-scale “Personal
issues” from MCSS-26. Reducing the quantity of items from 36 to 26 has little impact on the
internal consistency of the total MCSS with the α = 0.91 only decreasing to α = 0.89.

The pairwise correlation analyses of test-retest reliability indicated despite some low
correlation coefficients, that the majority of the items (29 items) were highly reliable (p <
0.01), another two items met criteria of significance (p < 0.05) while five items (item nos. 11,
13, 14, 24 and 25) failed to reach levels of significance in the analyses. In general test-retest
reliability appears to be satisfactory with only a few items of questionable reliability.


Discussion

Results from the translation to Danish of the MCSS and the subsequent psychometric analysis
of the scale have indicated a number of issues regarding both sub-scales and individual items.

In line with Hyrkäs et al. (2003b), who analysed the MCSS-45, and Severinsson (2012), the
results indicated that the four sub-scales “Trust/Rapport”, “Supervisor advice/Support”,
“Improved care/skills” and “Reflection” had high internal consistency (α > 0.7). Conversely,
the sub-scales “Importance/value of CS”, “Finding time” and “Personal issues” have
unacceptably low internal consistency (α < 0.7).

Sub-scale 1 “Trust/rapport” demonstrated acceptable internal consistency. It included item
19 “My supervisor is never available when needed”. The item-rest coefficient indicated that
the internal consistency would increase if this item was omitted. During translation, and in
line with Hyrkäs et al. (2003a), clinical experts regarded the item as culturally non-equivalent,

12
because supervisors were not expected to be available al all times. The sub-scale also included
item 26 “My supervisor puts me off asking about sensitive issues”, which was found to be
ambiguous in English during the translation to Danish. Furthermore, in Severinsson’s (2012)
CFA, these two items had the lowest factor loadings. In line with these observations,
Winstanley and White’s (2011) Rasch analysis indicated a misfit and led to the omission of
items 19 and 26 from the sub-scale in the revised MCSS-26.

Sub-scale 2 “Supervisor advice/support” demonstrated acceptable internal consistency. It

included item 14 “If there is something I don’t understand there is always someone to ask”,
which was also problematic because of the underlying assumption of availability noted above,
cf. (Hyrkäs et al., 2003a). The item-rest coefficient indicated that the internal consistency
would increase if this item was omitted, Hyrkäs et al. (2003b) found that the item had a poor
correlation coefficient, and in Severinsson’s (2012) CFA, the item had the lowest factor
loading. In line with these observations, Winstanley and White’s (2011) Rasch analysis
indicated redundancy and led to the omission of item 14 from the sub-scale in the revised
MCSS-26. Finally, Hyrkäs et al. found that item 22 “My supervisor provides me with valuable
advice” was problematic in the Finnish context because they emphasized “insightful learning”
(Hyrkäs et al., 2003a, p. 623) rather than concrete and direct advice. However, this issue was
never debated in the Danish context, and the psychometric properties of the item were not
conspicuous, cf. (Winstanley and White, 2011, Severinsson, 2012).

Sub-scale 3 “Improved care/skills” demonstrated acceptable internal consistency and did not
include semantically problematic items. As stated above, Winstanley and White’s (2011)
decision to remove items 30 (misfit), 32 (misfit) and 33 (redundant) from sub-scale 3 in
MCSS-26, was not unequivocally supported by the item-rest coefficients.

Sub-scale 4 “Importance/value of CS” had unacceptable internal consistency, which Hyrkäs et
al. (2003b) and Severinsson (2012) also found. Winstanley and White’s (2011) Rasch analysis
indicated a removal of item 28, “CS is for newly qualified/inexperienced staff only”, because of
misfit. However, the item-rest indicated that removing item 25, “Supervision is unnecessary
for experienced/established staff” would improve the sub-scale more than removing item 28.

13
The same tendency can be observed in Severinsson’s (2012) CFA, where item 25 is identified
as particularly weak.

Sub-scale 5 “Finding time” had unacceptable internal consistency, which Hyrkäs et al. (2003b)
and Severinsson (2012) also found. However, Winstanley and White’s (2011) Rasch analysis
indicated that the sub-scale was uni-dimensional and it was not revised in MCSS-26. Still,
“Finding time” can be considered different from the other MCSS sub-scales, because it is
heavily influenced by time pressure and constrained resources. Therefore it may not be a
clear measure of the effect of supervision (Gonge and Buus, 2011). Such reservations may be
why Hyrkäs et al. (2003a) chose to remove the sub-scale from their culturally adapted MCSS.

Sub-scale 6 ”Personal issues” included two items, that referred to ”personal issues”: Item 9
”CS does not solve personal issues” and item 17 “Having someone different to talk to about
personal issues was a great help”. In both the Danish and Finnish (Hyrkäs et al., 2003b)
translations, it was problematic to refer to such issues because of connotations to private
issues, which are not addressed during supervision in these countries. The rest-item analysis
in the present study, Hyrkäs et al. (2003b) calculation of Spearman correlation coefficient, and
Severinsson’s (2012) CFA identified item 9 as particularly weak, which may be because of
item 17’s reference to “someone different” that makes it less troubling to refer to “personal
issues”. In accordance with the low internal consistency observed in the present study and by
Hyrkäs et al. (2003b) and Severinsson (2012), Winstanley and White’s (2011) Rasch analysis
indicated that the sub-scale’s reliability was not acceptable and it was not included in MCSS-
26.

Sub-scale 7 “Reflection” did not raise concerns during translation and has demonstrated good
psychometric properties in the present study and in Severinsson’s study (Severinsson, 2012).
Winstanley and White’s (2011) Rasch analysis did not indicate that the sub-scale needed
revisions in the MCSS-26.

It is interesting to note, that most of the items with poor psychometrics were identified as
problematic during translation. This could indicate that a strong emphasis on semantics in the
design of items could identify weak items very early in the design of a scale. However, the

14
translation also identified textual ambiguity in item 10, “CS sessions are intrusive”, which
apparently did not cause poor psychometrics in the English version of the scale.

In line with the English and the translated versions of the MCSS, the internal consistency of
the total score of the Danish version of the MCSS-36 was high. However, Severinsson’s CFA
indicated that the data did not fit the model. This finding may be influenced by MCSS’s
relatively large number of sub-scales and Severinsson’s relatively small sample size, but the
finding still raises important questions about the theoretical components of MCSS.

Winstanley (2000b) stated that MCSS-36 was designed to suit all grades of nursing staff in a
variety of settings. Clearly reflecting this ambition, the scale’s items relate to a broad
conception of clinical supervision and to a variety to supervision practices.
First, supervision methods include: “unloading” (item 5), reflection (item 11 and 13), problem-
solving (item 12), learning from supervisor’s experience (item 20), giving advice (item 22),
and offering guidance (item 35). Second, concrete benefits of supervision include: support and
encouragement (item 8), widening of clinical knowledge base (item 24), motivation (item 31),
stress reduction (item 32), and widening of skills base (item 34). Third, most descriptions of
the supervisor indicate a formal role, but item 14 “If there is something I don’t understand
there is always someone to ask” and item 17 “Having someone different to talk to about
personal issues was a great help”, could also indicate informal peer support by a trusted
colleague. Fourth, most items do not indicate the frequency of contact, but two items, 14 and
19, seem to suggest a relatively constant availability of a supervisor. For example, item 19,
“My supervisor is never available when needed”. This could reflect a relatively close
supervisory relationship between a supervisee and a supervisor.

The wide operationalization of clinical supervision and the implicit references to different
supervision practices may, on the one hand, be considered as MCSS’ strength, but, on the
other hand, be considered a weakness, if respondents struggle recognising their supervision
practices in MCSS’ statements. Considering the results from Winstanley and White’s (2011)
Rasch analysis, most of the problems encountered during translation into the Scandinavian
context may not be local, but may be concerned with defining the scope of supervision
practices globally.

15

The revision of MCSS solves some of the issues related to a wide conception of supervision:
the items related to the issues “supervisor” and “frequency of contact” described above, are
removed. However, these restrictions on the scope of practices that are examined by MCSS are
not reflected in the definition of supervision proposed by Winstanley and White (2011). The
definition from Open University includes relatively informal roles and continuous
supervision.

Limitations
Our test of the translated version of MCSS was made on qualified staff in a mental health
setting, receiving primarily group-based supervision. Testing other categories of staff and in
other settings may yield different results. Staff from only one hospital may reflect
organizational practices in this specific hospital rather than a general attitude among staff
working in psychiatric hospitals in Denmark. Finally, a sample size of 139 is insufficient to
reach a conclusive evaluation of the validity of the Danish translation of MCSS.

Conclusion

The purpose of MCSS is to measure the proximal effect of supervision by examining a range of
methods and concrete benefits. Several studies from different countries have confirmed that
the scale’s total score has good internal consistency, but studies have not consistently
confirmed the scales factor structure.

Theoretically, the designers of the MCSS refer to a broad conception of supervision, which
includes both highly formalised and more informal day-to-day supervision. Severinsson
(2012) suggests that the theoretical scope of MCSS may be too limited and that it should also
address more distal outcomes, such as the quality of care and patient safety. On the contrary,
we believe that including such measures in MCSS would compromise MCSS as measure of the
outcome of supervision per se. In contrast to Severinsson, we suggest that a further reduction
of MCSS’ theoretical scope could be beneficial. This could be accomplished by omitting the
“Finding time” sub-scale, which does not identify outcome, but conditions of supervision.
Finally, the MCSS has been linked with Proctor’s three domains of clinical supervision, but

16
scientific and/or educational benefits of these links are not well accounted for by the creators
of MCSS. We suggest making use of the convincing MCSS total scores by combining them with
a new, narrower definition of supervision, which should not aim at including informal types of
supervision practices.

17
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Table 1. Internal consistency of scales in MCCS 36 and MCSS 26 (Cronbach’s α) as well as test-retest correlation coefficients (pairwise
correlation).

MCSS Items / Scales Mean (SD) MCSS-36 MCSS-26 Test-retest
(n=139) Cronbach’s Cronbach’s Correlation
α α coefficients
(item-rest) (item-rest) (n=62)
Sub-scale 1. Trust/Rapport 27.1 (4.8) .86 .86
8. My supervisor gives me support and encouragement 3.8 (0.88) (.85) (.86) .30*
15. My supervisor offers an ‘unbiased’ opinion 3.8 (0.97) (.84) (.83) .56**
16. I can discuss sensitive issues encountered during my clinical casework with my 4.1 (0.84) (.83) (.82) .34**
supervisor
1)
19. My supervisor is never available when needed 3.4 (0.86) (.88) - .49**
23. My supervisor is very open with me 3.7 (0.80) (.84) (.84) .62**
1)
26. My supervisor puts me off asking about sensitive issues 4.1 (0.91) (.83) - .59**
1)
27. My supervisor acts in a superior manner during our sessions 4.1 (1.07) (.83) (.83) .77**
Sub-scale 2. Supervisor Advice/Support 22.7 (3.5) .79 .82
14. If there is something I don’t understand there is always someone to ask 4.0 (0.81) (.82) - .18
20. I learn from my supervisor’s experiences 3.7 (0.75) (.78) (.80) .42**
22. My supervisor provides me with valuable advice 3.7 (0.80) (.73) (.76) .47**
24. Sessions with my supervisor widen my clinical knowledge base 3.9 (0.87) (.72) (.75) .24
34. I can widen my skill base during my CS sessions 4.0 (0.76) (.75) (.79) .38**
35. My supervisor offers me guidance with patient/client care 3.5 (0.92) (.77) (.81) .49**
Sub-scale 3. Improved care/skills 27.6 (4.2) .84 .80
18. My CS sessions are an important part of my work routine 3.7 (0.95) (.81) (.74) .53**
29. Clinical supervision makes me a better practitioner 4.2 (0.77) (.82) (.78) .61**
30. Without CS the quality of client/patient care would deteriorate 3.9 (0.98) (.86) - .45**
31. CS sessions motivate staff 4.1 (0.68) (.82) (.76) .49**
32. I feel less stressed after seeing my supervisor 3.5 (1.00) (.84) - .49**
33. CS improves the quality of care I give to my patients/clients 4.0 (0.75) (.80) - .48**
 36. I think receiving clinical supervision improves the quality of care I give 4.0 (0.76) (.81) (.74) .47**
Sub-scale 4. Importance/value of CS 26.0 (3.1) .61 .49
1)
3. CS sessions are not necessary/don’t solve anything 4.5 (0.77) (.55) (.39) .52**
1)
4. Time spent on CS takes me away from my real work in the clinical area 4.1 (1.02) (.60) (.44) .44**
1)
10. CS sessions are intrusive 4.2 (0.89) (.52) (.33) .30*
21. It is important to make time for CS sessions 4.4 (0.58) (.55) (.40) .64**
1)
25. Supervision is unnecessary for experienced/established staff 4.2 (1.27) (.67) (.61) -.07
1)
28. CS is for newly qualified/inexperienced staff only 4.6 (0.72) (.49) - .70**
Sub-scale 5. Finding time 11.3 (3.2) .63 .63
1)
1. Other work pressures interfere with CS sessions 2.6 (1.24) (.52) (.52) .64**
1)
2. It is difficult to find the time for CS sessions 2.6 (1.20) (.51) (.51) .34**
1)
6. Fitting CS sessions in can lead to more pressure at work 2.7 (1.18) (.54) (.54) .64**
1)
7. I find supervision sessions time-consuming 3.4 (1.08) (.65) (.65) .55**
Sub-scale 6. Personal issues 10.9 (2.0) .46 -
5. I can ‘unload’ during my CS session 3.8 (1.01) (.40) - .53**
1)
9. CS does not solve personal issues 3.2 (1.09) (.46) - .45**
17. Having someone different to talk to about personal issues was a great 3.9 (0.72) (.25) - .52**
help
Sub-scale 7. Reflection 12.6 (2.0) .78 .78
11. Supervision gives me time to ‘reflect’ 4.3 (0.75) (.71) (.71) .03
12. Work problems can be tackled constructively during CS sessions 4.0 (0.85) (.72) (.72) .48**
13. CS sessions facilitate reflective practice 4.2 (0.82) (.67) (.67) .15
MCSS total 138.7 (16.8) .91 .89
* p< .05, ** p< .01
1) Score reversed

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