Journal of Genetic Counseling - 2016 - MacFarlane - Effects of Anxiety On Novice Genetic Counseling Students Experience of

J Genet Counsel (2016) 25:742–766
DOI 10.1007/s10897-016-9953-x
ORIGINAL RESEARCH
Effects of Anxiety on Novice Genetic Counseling Students’

Experience of Supervised Clinical Rotations
Ian M. MacFarlane 1 & Pat McCarthy Veach 2 & Janelle E. Grier 3 & Derek J. Meister 4 &
Bonnie S. LeRoy 5
Received: 29 July 2015 / Accepted: 23 March 2016 / Published online: 21 April 2016
# National Society of Genetic Counselors, Inc. 2016
Abstract Supervised clinical experiences with patients com- on their performance in general and in supervision. Common
prise a critical component of genetic counseling student educa- themes included supervisors’ balancing support and guidance,
tion. Previous research has found genetic counseling students the importance of feedback, ego-centric responses, and supervi-
tend to be more anxiety prone than the general population, and sors as focal points. The results of the present study are largely
anxiety related to supervision has been found in genetic consistent with current literature. Further research findings and
counseling and related fields. The present study investigated research, practice, and training recommendations are provided.
how anxiety affects the experience of supervision for genetic
counseling students. Second year genetic counseling students Keywords Supervision . Anxiety . Professional
were invited to participate through email invitations distributed development . Training . Consensual qualitative research
via training directors of the 33 programs accredited at the time of (CQR) . Genetic counseling student
the study by the American Board of Genetic Counseling. An
initial online survey contained the trait scale of the State-Trait
Anxiety Inventory to estimate anxiety proneness in this popula- Clinical supervision is a critical component of genetic counsel-
tion and an invitation to participate in a 45-minute semi-struc- ing preparation (McCarthy Veach and LeRoy 2009). Bernard
tured phone interview focusing on students’ experiences of and Goodyear (2009) define supervision as an evaluative rela-
supervision during their clinical rotations. High and low trait tionship that is typically between a more experienced member of
anxiety groups were created using STAI scores, and the groups’ a profession and trainees or novices in that same profession. The
interview responses were compared using consensual qualitative purposes of the supervisory relationship, according to Bernard
research methodology (CQR; Hill 2012). The high anxiety group and Goodyear, are ensuring a standard of client care, promoting
was more likely to describe problematic supervisory relation- supervisee skill development, socializing supervisees into the
ships, appreciate the supervisor’s ability to help them when they profession, and Bgatekeeping^ so only qualified individuals are
get stuck in sessions, and feel their anxiety had a negative effect able to enter the profession. Supervised clinical training is a
required component of genetic counseling programs so students
can develop clinical skills in an environment which protects the
* Ian M. MacFarlane students as well as patients. The intention is to gradually increase
imacfarlane@austincollege.edu
students’ independence in preparation for professional status
(Wherley et al. 2015).
1
Having an experienced professional to turn to for support
Department of Psychology, Austin College, 900 N Grand Ave, Suite
61557, Sherman, TX 75092, USA
and guidance as they begin to navigate the challenging world
2
of genetic counseling can be a wonderful professional devel-
University of Minnesota, Minneapolis, MN, USA
opment experience for beginners. Arguably, however, the gate-
3
International School Manila, Manila, Philippines keeping aspects of supervision rarely go unnoticed by
4
Ketchikan Gateway Borough School District, Ketchikan, AK, USA supervisees. Students in particular may feel tension in the su-
5
Department of Genetics, Cell Biology, and Development, University pervisory relationship; they want to perform as well as possible
of Minnesota, Minneapolis, MN, USA to secure positive evaluations, but they also need to share their
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Anxiety and Supervision 743
challenging moments and mistakes in order to grow as genetic did not address factors related to clinical rotations specifically,
counselors in training. These often conflicting imperatives as many in their sample were 1st year students without rotation
would seem to be anxiety-provoking, as the stakes are high, experience, which leaves unanswered the question of how anx-
evaluation is fairly subjective, and students are just beginning iety manifests in the clinic and in supervision.
to develop the skills necessary for the profession. It also seems A study of anxiety in a sample of professional genetic
intuitive that having a supervisor directly observe one’s work counselors (Lee et al. 2015). yielded somewhat contradictory
would be more anxiety-provoking than supervision based on findings to those of Jungbluth et al. (2011). The genetic coun-
supervisee self-report, as there is no opportunity for the selors had lower levels of trait anxiety (M = 37.6, SD = 8.55)
supervisee to frame issues in a more positive light. Live su- that were much closer to the adult female mean (34.8,
pervision is the most common supervision modality in genetic Spielberger et al. 1983), suggesting the graduate school setting
counseling training programs, followed by review of student may be more stressful than professional life, the younger gener-
self-reported descriptions of the session (Lindh et al. 2003; ation of would-be genetic counselors may be more anxiety prone
Masunga et al. 2014). These are the dominant methods of than those established in the field (see Venne and Coleman 2010
supervision in genetic counseling, as less than 10 % of one sample for a discussion of supervising of millennial learners), or those
of supervisors reported using audio or visual recording or remote with high levels of anxiety may leave the field (Lee et al. 2015).
supervision (Masunga et al. 2014), though peer supervision has
been explored in the U.S. (Zahm et al. 2008), Canada (Goldsmith
et al. 2011), and Australia (Sexton et al. 2013). Given the added Anxiety Among Psychologists and Trainees
pressure of having a supervisor present on top of already being
evaluated, the present study sought to investigate potential differ- While relationships between anxiety and performance have
ences in the way supervisees perceive supervision across different been found in mental health fields (e.g., Barbee et al. 2003;
levels of anxiety. Birk and Mahalik 1996; Friedlander et al. 1986; Hiebert et al.
1998) similar studies with genetic counselors are lacking.
Thus, the mental health literature may offer some insights.
Anxiety Among Genetic Counseling Students Empirical literature spanning over 50 years (e.g., Bandura
and Counselors 1956) consistently demonstrates counselor anxiety leads to
diminished performance. Anxiety has been shown to be neg-
Anxiety related to supervision has been called Ba given…which atively correlated with performance on case conceptualization
must be taken into consideration by supervisors^ (Borders et al. and session planning activities (Friedlander et al. 1986) and
2006, p. 212) and described as normative in genetic counseling counseling self-efficacy (Barbee et al. 2003). Self-efficacy has
(e.g., McCarthy Veach et al. 2003; Wherley et al. 2015) as well as been linked to levels of counselor development in a number of
in related fields such as medicine (e.g., Hajek et al. 2000; Jiang studies (e.g., Leach et al. 1997; Melchert et al. 1996), suggest-
et al. 2003; Sarikaya et al. 2006) and mental health (e.g., Bernard ing anxiety may delay or prevent students from reaching more
and Goodyear 2009; Skovholt and Ronnestad 2003; Stoltenberg sophisticated ways of interacting with clients. There is also
and Delworth 1987). Anxiety has been shown to affect genetic evidence these effects may be practically significant, such as
counseling supervision from both the supervisors’ perspective El-Ghoroury and colleagues’ (2012) finding that 60.7 % of a
(Lindh et al. 2003) and the students’ perspective (Hendrickson sample of psychology graduate students reported their anxiety
et al. 2002); it has been linked to Bgames^ played in supervision was significant enough to impair their functioning in their
by supervisees and supervisors (McIntosh et al. 2006); and it program.
may increase when counseling in a second language (Vanneste Anxiety has also been shown to be positively correlated with
et al. 2013). As literature on supervision continues to grow and a tendency to focus on oneself during sessions (Williams 2003;
become more empirically-based (cf. supervision competencies Williams 2008); as well as disruption of the flow of speech,
published by Eubanks Higgins et al. 2013), it is critical to gather reduced accuracy in perceptions of one’s client, reduced ability
data about how anxiety affects the training of students and their to remember the words and emotions expressed by the client in
delivery of clinical services. session, and argumentative behavior (Schauer et al. 1985). The
The only published study on genetic counseling student anx- tendency to focus on the self instead of the client during session
iety to date is Jungbluth et al. (2011), who administered the may be particularly important, as this has been linked to lower
State-Trait Anxiety Inventory (STAI; Spielberger et al. 1983) ratings of helpfulness both by the therapists-in-training them-
to a sample of genetic counseling students. They found an selves (Nutt-Williams and Hill 1996) and clients (e.g., Hiebert
average trait anxiety score of 44.6 (SD = 4.10, Range: 31–57) et al. 1998). These results are complicated, however, by other
which corresponds to the 85th percentile for adult female norms research where counselors rated their self-awareness during
(Spielberger et al. 1983) and is higher than levels reported in a sessions as generally helpful (Fauth and Williams 2005;
medical student sample (Jiang et al. 2003). These researchers Williams and Fauth 2005). Self-awareness was also positively
744 MacFarlane et al.
correlated with therapists’ impressions of positive interpersonal compared to those of high anxiety students to investigate prelim-
experiences with clients and client ratings of therapists’ helpful- inary connections between anxiety and students’ experiences of
ness in these two studies. A likely, though untested, explanation supervision. The four major areas of focus during the interviews
is self-awareness is important in counseling settings (both mental were students’: (1) satisfaction with supervision and clinical ro-
health and genetic counseling), as it allows the counselor access tations in general, (2) perceptions of the structure and logistics of
to her or his own countertransference reactions and intuition. If supervision, (3) perceptions of supervision processes, and (4)
the self-focus centers on anxiety or comes at the expense of self-assessment of how anxiety personally affects them.
paying close attention to the client/patient, however it becomes
counterproductive.
Anxiety has been shown to affect the supervisory relation- Method
ship as well. Taylor (1991) found that, regardless of experience
level, students reported a preference for more directive super- Participants
vision as their anxiety increased. Birk and Mahalik (1996)
found supervisors perceived anxious supervisees to be working After receiving approval from the University of Minnesota
at higher developmental levels than the students’ themselves Institutional Review Board, an email invitation was sent to
perceived. This might lead to supervisor expectations being the program director of each of the genetic counseling pro-
higher than supervisees think is appropriate and create even grams in the U.S. and Canada accredited at that time by the
more anxiety for the supervisees. Failure to recognize and pro- American Board of Genetic Counseling (ABGC) except the
cess these dynamics could lead to frustration by both student researchers’ institution (n = 32). At the time of the study, an
and supervisor, as well as potentially cause alliance ruptures. As estimated 400 students were enrolled across these programs,
supervisory working alliance has been linked to client working with approximately half being in their 2nd year. This email
alliance (e.g., Alper 1991; Friedlander et al. 1989; Patton and asked program directors to forward an email invitation to the
Kivlighan 1997), this is a dynamic that needs to be monitored. 2nd year students currently enrolled in their programs, invit-
The effects of supervisee anxiety on supervision itself are ing them to participate in a study of anxiety and supervision in
most commonly discussed in literature on supervisee resistance. genetic counseling students. The invitation included a link to
Numerous scholars have labeled anxiety as the primary cause participate in the online survey portion of the study. The last
of supervisee resistance and linked anxiety to decreased ability page of the online survey included an invitation to participate
to focus, learn, and improve, as well as a tendency to distort in the interview portion of the study.
reality, engage in power struggles, and conceal problems (e.g., Following Hill’s (2012) recommendation that 12–15 par-
Bradley and Gould 1994; Dodge 1982; Liddle 1986). Some ticipants are sufficient to obtain data saturation (redundancy),
empirical support for these theorized relationships has been and the plan to compare high, moderate, and low trait anxiety
demonstrated in recent years (e.g., Enyedy et al. 2003). In students, the original target was 36-45 interviews. Determination
particular, several studies have linked anxiety to students of anxiety groups was made by using the 33rd and 66th percen-
withholding information from supervisors (e.g., Hess et al. tiles of trait anxiety scores in the overall survey sample. The
2008; Ladany et al. 1996; Mehr et al. 2010). While this may participants in each group who gave permission to be contacted
be less problematic in genetic counseling supervision due to for the interview phase of the study were randomly ordered and
the much greater rates of live supervision practices, a tendency the first 15 people were sent email invitations to be interviewed.
to be less forthcoming with supervisors could still potentially If no response was received within 7 days, the next person on the
damage the supervision process. list was sent an invitation. The final sample included 15 partici-
pants from the high anxiety group, 12 from the moderate anxiety
group, and 13 from the low anxiety group. Upon preliminary
Purpose of the Present Study analysis, however, participants in the moderate anxiety group
seemed to be comprised of some who responded like high anx-
Given the significant negative effects of anxiety on counselor iety participants and some who responded like low anxiety par-
performance and supervision in mental health settings, it is ticipants, rather than a distinct group of their own and were thus
critical to examine the extent to which anxiety affects genetic removed from the analysis. The remaining high and low anxi-
counseling students in these same domains. Informed by work ety groups therefore represent an extreme groups comparison
from related fields, the present study was designed to create an approach to best characterize the most consistent similarities
understanding unique to genetic counseling students. and differences. Randomly generated five-digit identification
Qualitative interviews were conducted to explore a variety of numbers were assigned to each participant to reduce the likeli-
issues related to clinical practice and supervision using a sample hood the interviewer, who is the first author, would recall which
of genetic counseling students who varied in their anxiety anxiety group participants belonged to during interviews and
levels. The interview responses of low anxiety students were data analysis.
Instrumentation Procedure
Online Survey The online survey contained 35 items distrib- Recruitment Students selected to participate in the interview
uted among three sections. The first section consisted of 10 phase of the study were contacted by the first author via email
items. Two of these items confirmed eligibility for the study to schedule their semi-structured, audio-recorded, phone inter-
[i.e., BWill this coming academic year (2011–2012) be your views. Those who did not respond within 7 days were sent the
second year in your program?^ and BWill you have started email invitation again. If they still did not respond, no further
clinical rotations by September 15th, 2011?^]. A third item contact attempts were made. Students who scheduled an in-
asked if the participant had received formal clinical supervision terview were sent a confirmation email the day before the
in a health services field other than genetic counseling. The next interview reminding them of the appointment and providing
seven items assessed demographic information. The second a definition of supervision (from Bernard and Goodyear
section consisted of the trait subscale of the STAI (Spielberger 2009). The first author conducted all interviews between
et al. 1983), a self-report measure of anxiety-proneness. The August and early October of 2011.
authors characterize anxiety as Bsubjective feelings [emphasis
added] of tension, apprehension and worry, and by activation or At the beginning of each interview, the interview reviewed
arousal of the autonomic nervous system^ (p. 4); they distin- informed consent, secured participant consent to record the
guish state anxiety (the felt experience of anxiety in the current interview, and then read the following definition of clinical
moment), and trait anxiety (how often and how intensely one supervision:
tends to experience state anxiety). The 20-items on the trait
subscale assess how a respondent typically feels (e.g., I lack Supervision is an intervention provided by a more senior
self-confidence); they are scored on a 4-point rating scale member of a profession to a more junior member or
(1 = Never; 2 = Somewhat; 3 = Moderately so, 4 = Almost members of that same profession. This relationship is
always). Possible scores range from 20 to 80, with a larger score evaluative and hierarchical, extends over time, and has
indicating higher anxiety. The STAI has been well validated the simultaneous purposes of enhancing the professional
and used in over 2000 studies (Spielberger et al. 1983). functioning of the more junior person(s); monitoring the
Spielberger et al. (1983) report empirical evidence of strong quality of professional services offered to the clients that
internal consistency, high test-retest reliability for the trait sub- she, he, or they see; and serving as a gatekeeper for those
scale, and construct validity. The final section of the survey who are to enter the particular profession. (Bernard and
contained an invitation to participate in a 30-45 minute tele- Goodyear 2009, p. 7)
phone interview.
The interviewer used a semi-structured interview protocol
The online survey was piloted with four doctoral students in to ensure participants received the questions in the same order
counseling psychology to test for delivery and implementation while also allowing for follow-up questions/prompts to clarify
issues as well as clarity of content. The online survey was also or explain responses (Patton 2002). Before beginning the inter-
piloted with four recent genetic counseling graduates to test views, the interviewer bracketed his biases by writing what he
for clarity and relevance of content. Minor revisions were expected to hear in response to the questions. Interviews were
made to survey items and the format of the survey to clarify recorded and later transcribed by a professional transcriptionist.
content and improve readability.
Analysis Team Preparation The primary analysis team

Interview Questions The research team, comprised of grad- consisted of the first author and two graduate student research
uate students in counseling psychology, licensed psycholo- assistants who used a procedure based on Consensual
gists, and a genetic counseling program training director, de- Qualitative Research (CQR; Hill 2012; Hill et al. 2005; Hill
veloped 8 questions derived from a review of literature and the et al. 1997) methods. The auditor (second author) had served
team’s clinical and research experience. An additional five as a data auditor for several previously published CQR stud-
questions pertaining to three other research questions were ies. She participated in the development of the research ques-
also developed, but will not be reported here. The inter- tions but did not participate in the development of domains
view protocol was piloted on one doctoral student in psy- and categories according to Hill’s (2012) recommendations
chology who previously worked as a genetic counselor, to for using only one (external) auditor. Before beginning work
gauge participant reactions to questions and fatigue dur- on the project, the research assistants were given a copy of the
ing the interview. Minor revisions were made to interview interview questions, received training in CQR methods, and
questions to improve clarity based on feedback from the received information about the structure of genetic counseling
pilot participant. training and the format of clinical rotations.
Data Analysis likelihood of differences between groups, as long as there is

more than a two participant difference between them. For do-
The research team used CQR procedures to inductively clas- mains or categories in which one of the groups has no partici-
sify the content from the interview questions. The analysis pants, this will also be considered a moderate likelihood of
results in specific categories of responses housed within larger differences. Finally, groups which have the same frequency
conceptual domains. These results were then labeled to denote label or are only one or two participant difference are consid-
the relative frequency of responses according to Hill’s (2012) ered to indicate a low likelihood of differences between groups.
criteria: general, all or nearly all participants are represented; The current study, however, deviated significantly from the
typical, more than half the participants are represented; CQR method in two ways. The first deviation is the interviews
variant, less than half but a sizeable amount of participants were analyzed by question instead of holistically. Proceeding
are represented; rare, only a small number of participants are in this fashion has several risks, including redundancy of find-
represented. ings between questions and artificial deflation of frequencies
The analysis team met after each member independently for domains and categories (e.g., Participant 3 and 4 both
went through the first transcript to compare what they identi- mentioned enjoying having a supportive supervisor, but one
fied as significant sections of text (i.e., the initial domains), did so in response to Question 5 and one did so in response to
using discussion to reach consensus as to what was important Question 6, so the frequencies appear lower). We decided to
in each response. They repeated this process for the next 15 pursue this method despite the risks because of the exploratory
transcripts. All analysis team members were blind to which nature of the study. We hoped to shed light on areas for further
anxiety group the transcripts belonged until the final domains investigation as well as allow for nuanced identification of
and categories were set. After 16 transcripts had been coded at differences over time via a planned follow-up study. Having
the domain level, each team member independently construct- more specific information about the context in which percep-
ed core ideas (i.e., the essence of what the participant said) and tions arose will hopefully assist in designing future studies and
gathered them together to form categories. The team then met building hypotheses.
to discuss classifications and preliminary names and defini- The second deviation involves the application of the fre-
tions for each domain and category. Discussion ensued until quency labels typically reserved for categories to the domains.
consensus was obtained. This deviation follows from the first. Domains in CQR typical-
These preliminary domains and categories were used for the ly represent a sizeable portion of the participants. In our study,
remaining 24 transcripts. The first author and either the third or however, a number of domains were fairly small due to the
fourth author independently reviewed each of these transcripts. deflation described above. We considered it important to apply
One transcript from each group was also randomly selected to be the frequency labels to the domains so the representativeness of
reviewed by the third team member (i.e., internal auditing) to the domains and categories could be better interpreted.
ensure that moving from three reviewers to two did not negative-
ly impact coding. The first author reviewed the contents of each
domain and category to determine if the preliminary definition Results
was still representative of the responses and adjusted the defini-
tion if appropriate. Following cross-analysis, the final coding was Participants
reviewed by the data auditor (the second author) and discussed
with the research team until a consensus was reached. Eighty-six genetic counseling students began the online sur-
Next, an additional round of cross-analysis was conducted to vey, and 83 completed the entire survey. Given an estimated
determine if differences between anxiety groups were present. 200 second year genetic counseling students, approximate
Hill (Hill 2012; Hill et al. 2005) recommends a discrepancy of conservative response rate was 41.5 %. Three surveys were
at least two frequency labels in order to call groups different removed because the respondents’ training programs were not
(e.g., rare vs. typical, general vs. variant). The original CQR located in the U.S. or Canada, leaving a final sample of 80
protocol (Hill et al. 1997) called for a single label discrepancy participants (useable response rate = 40 %). Demographics for
(e.g., typical vs. variant), but this was adjusted because of con- the survey sample are presented in Table 1. The sample was
cerns that a one-person difference could be seen as meaningful. largely European American (90 %) and female (97.5 %),
While the concerns over the original protocol are valid, the which is consistent with previous estimates of the population
revised recommendation appears overly stringent. Thus, in the of genetic counseling students (Yashar 2010). Overall, 68 stu-
present study, especially given the relatively large sample for a dents (85 %) who filled out the survey consented to participate
qualitative investigation, domains and categories that differ by in interviews.
at least two frequency labels are considered to indicate a high Anxiety groups were determined by separating the sam-
likelihood of differences between groups. Those which are one ple according to percentiles. The low anxiety group includ-
frequency label apart are considered to indicate a moderate ed those at or below the 33rd percentile, which in this
Table 1 Demographic
characteristics of survey Variable Survey samplea Interview sampleb
respondents and interviewees by
trait anxiety group Total Low High Total Low High
n % n % n % n % n % n %
Trait anxiety score

M 37.5 – 29.0 – 47.5 – 38.1 – 27.1 – 47.7 –
SD 8.98 – 2.52 – 6.19 – 2.14 – 2.02 – 6.80 –
Supervision in another setting
No 66 82.5 27 87.1 23 82.1 24 85.7 11 84.6 13 86.7
Yes 14 17.5 4 12.9 5 17.9 4 14.3 2 15.4 2 13.3
Gender
Female 78 97.5 31 100 27 96.4 27 96.4 13 100 14 93.3
Male 2 2.5 0 0.0 1 3.6 1 3.6 0 0.0 1 6.7
Racial identity
Euro. Am. 72 90.0 29 93.5 24 85.7 24 85.7 11 84.6 13 86.7
Asian Am. 4 5.0 0 0.0 2 7.1 1 3.6 0 0.0 1 6.7
Other 4 5.0 2 6.4 2 7.2 3 10.8 2 14.4 1 6.7
Age
M 25.3 – 25.2 – 26.0 – 25.9 – 26.6 – 25.3 –
SD 4.61 – 5.33 – 5.26 – 2.49 – 7.95 – 4.70 –
Relationship status
Committed 37 46.3 11 35.5 15 53.6 12 42.8 3 23.1 9 60.0
relation-
ship
Single 24 30.0 13 41.9 5 17.9 9 32.1 6 46.2 3 20.0
Married 14 17.5 3 9.7 7 25.0 4 14.2 1 7.7 3 20.0
Divorced 3 3.8 3 9.7 0 0.0 3 10.8 3 23.1 0 0.0
Other 1 1.3 0 0.0 1 3.6 0 0.0 0 0.0 0 0.0
Highest degree completed
Bachelor’s 72 90.0 29 93.5 23 82.1 25 89.2 12 92.3 13 86.7
Master’s 7 8.8 2 6.5 4 14.3 3 10.8 1 7.7 2 13.3
Doctoral 1 1.3 0 0.0 1 3.6 0 0.0 0 0.0 0 0.0
Size of cohort
7 or more 52 65.0 22 71.0 16 57.1 15 53.6 8 61.5 7 46.7
6 or less 27 35.0 9 29.0 12 42.9 13 46.4 5 38.5 8 53.3
Location of program
USA 76 95.0 30 96.8 26 92.9 27 96.4 13 100 14 93.3
Canada 4 5.0 1 3.2 2 7.1 1 3.6 0 0.0 1 6.7
consent to participate in interview
Yes 68 85.0 27 87.1 26 92.9 – – – – – –
No 12 15.0 4 12.9 2 7.1 – – – – – –
Note. a N = 80; b n = 28
sample corresponded to trait anxiety scores of ≤ 32 (n = 31). classification appears to have largely aligned with self-
The high anxiety group included those above the 67th identification.
percentile, which corresponded to trait anxiety scores > 41 Demographic characteristics were similar across anxiety groups
(n = 28). When asked in the interview if they consider and generally comparable to the overall sample (see Table 1), as
themselves an anxious person, 11 of 15 students in the was willingness to participate in the interview portion of the study.
high anxiety group said yes, while only 3 of 13 students Participants who completed the interview phase of the study had
in the low anxiety group said yes. Thus empirical similar demographics to the overall sample (see Table 1).
Thematic Analyses responses focused on either practical or emotional benefits

gained by students. There are four domains.
A total of 71 domains and 68 categories were extracted from
the interviews. They are listed in Tables 2, 3, 4 and 5, along Domain 1: Supervision (Total n = 15; LA = 8; HA = 7)
with frequency labels. As responses were often complex, they Participants in this domain noted particular aspects of super-
were classified in multiple domains/categories when appropri- vision which enhanced their experience of their rotations.
ate. Descriptions of domains classified as general, typical, or Most commented on the feedback they have received from
variant are described next and include descriptions of the most supervisors as being particularly helpful. Another frequently
frequent subordinate categories. Illustrative quotations are mentioned aspect was supervisor efforts, characteristics, or
provided in the Appendix. qualities that make them feel supported or comfortable, both
On average, participants appeared to be fairly open and inside and outside of patient sessions.
honest. Interviews averaged 32.43 minutes in length
(SD = 7.94, Mdn = 31.5, range = 19–52), with the high anx- Domain 2: Practical Experience & Skill Development
iety group, on average, having lengthier interviews
(Total n = 14; LA = 5; HA = 9) Participants in this domain,
[M = 36.65 vs. 29.86, t(26) = 2.19, p = .04]. Participants
which was more commonly endorsed by the high anxiety
typically provided rich answers without the need for much group, commented on their improvement in clinical knowl-
prompting or clarification from the interviewer. The partic-
edge or skills through interactions with patients. Many noted
ipants tended to be engaged and pleasant to converse with,
the transfer of information from the classroom to the clinic.
but generally took a fairly intellectual approach to answer-
ing questions. A few spoke with significant emotion during
Domain 3: Variety of Clinical Experiences (Total n = 11;
the interviews, but the emotions expressed tended to be
LA = 4; HA = 7). Many participants spoke to the diversity of
admiration, frustration, embarrassment, and satisfaction.
settings, patients, and supervisors they have encountered in
Interestingly, the participants used both BI^ and Bwe^
their rotations. They found this diversity valuable because it
throughout the interviews. Some questions may have
pulled for responses that were either general observations gave them more experiences to draw upon in future counsel-
ing sessions and opportunities to see different aspects of the
or specific to participants, but there may be other factors at
field.
play, including assumptions that personal experiences or
perspectives are normative, a feeling of safety or anonym-
ity from using general language, or aspects of their training Domain 4: Confidence & Comfort (Total n = 6; LA = 3;
(i.e., some research indicates the use of Bwe^ is common in HA = 3) Students in this domain commented on their in-
genetic counselors’ responses to patients, such as Kao creased confidence in their clinical skills and greater comfort
2010). Technical difficulties (i.e., dropped calls) briefly working with patients as a result of their clinical rotation ex-
disrupted four interviews, but no interviews were signifi- periences. A number referenced having to get used to simply
cantly affected. Bbeing^ with patients in this new role.
What Have Been the Most Challenging Things

About Your Clinical Rotations?
Satisfaction with Clinical Rotations and Supervision
in General Responses to this question tended to focus on relationships
with others or managing internal reactions to rotations, though
The frequencies and frequency labels for domains and categories a few other factors were also mentioned. Three domains were
pertinent to this area are presented in Table 2. Communication extracted from responses to this question.
and emotion management were recurrent themes. Both anxiety
groups had fairly similar responses to the specific interview ques-
Domain 1: Relational Factors (Total n = 18; LA = 9;
tions in this area. Three domains and two categories, however,
HA = 9) Many students focused on interpersonal aspects, es-
met criteria for moderate likelihood of differences between
pecially those with patients and supervisors, which made their
groups and are noted in the following descriptions.
experiences challenging. Situations with supervisors were
challenging for a number of different reasons, including diffi-
What Have Been the Most Positive Things about Your culty communicating with supervisors, adapting to different
Clinical Rotations? supervision styles, lack of role clarity, difficulty reading su-
pervisors, receiving corrective feedback, being observed, and/
Responses to this question frequently included supervision or logistical issues. Challenging patient interactions tended to
even though it was not referenced in the question. Other reflect areas where students were unsure of how to proceed,
Table 2 Domain and category

frequencies for satisfaction with Domain/Category Total Low High
rotations and supervision in
general n Type n Type n Type
What have been the most positive things about your clinical rotations?
Supervision 15 Typical 8 Typical 7 Variant
Feedback 13 Variant 7 Typical 5 Variant
Support 8 Variant 4 Variant 4 Variant
Practical experience & skill development* 14 Variant 5 Variant 9 Typical
Variety of clinical experiences 11 Variant 4 Variant 7 Variant
Confidence & comfort 6 Variant 3 Variant 3 Variant
What have been the most challenging things about your clinical rotations?
Relational factors 18 Typical 9 Typical 9 Typical
Challenging supervisor interactions 8 Variant 3 Variant 5 Variant
Challenging patient interactions 8 Variant 5 Variant 3 Variant
Personal factors 16 Typical 7 Typical 9 Typical
Managing anxiety* 9 Variant 2 Rare 7 Variant
External factors 4 Variant 1 Rare 3 Variant
What have been the most positive things about clinical supervision?
Supervisor guidance and support 25 Typical 11 General 14 General
A source of comfort/ support 15 Variant 7 Typical 8 Typical
Advice/feedback 14 Typical 7 Typical 7 Variant
A source of confidence/trust 7 Variant 3 Variant 4 Variant
Supervisee growth 9 Variant 5 Variant 4 Variant
Professional growth 9 Variant 5 Variant 4 Variant
Supervisor characteristics 4 Variant 1 Rare 3 Variant
What have been the most challenging things about clinical supervision?
Communication with supervisor* 14 Variant 5 Variant 9 Typical
Unclear expectations 6 Variant 2 Rare 4 Variant
Lack of feedback 6 Variant 2 Rare 4 Variant
Affective experiences* 12 Variant 4 Variant 8 Typical
Stress/anxiety 10 Variant 4 Variant 6 Variant
Lack of control 10 Variant 5 Variant 5 Variant
Student status 5 Variant 2 Rare 3 Variant
Working with multiple supervisors 7 Variant 3 Variant 4 Variant
Managing multiple styles and expectations 6 Variant 3 Variant 3 Variant
Perceived supervisor credibility/feedback validity* 3 Variant 0 – 3 Variant
Note. General = All or all but 1–2; Typical = More than half; Variant = Less than half; Rare = Very few; *moderate
likelihood of differences between anxiety groups
such as sessions which did not follow their original agenda, Domain 3: External Factors (Total n = 4; LA = 1; HA = 3) A
verbose patients, or emotional patients. few students referenced factors related to transitioning be-
tween rotations, managing the workload of rotations, and
Domain 2: Personal Factors (Total n = 16; LA = 7; HA = 9) dealing with clinic-level problems.
Interviewees in this domain commented on intrapersonal issues
which made their clinical rotation experience challenging. The What Have Been the Most Positive Things About Clinical
predominant issue was managing anxiety, nervousness, and Supervision?
stress they encountered during their rotations. About half of
these students specifically referenced the supervisor’s presence Participants focused primarily on supervisor behaviors in their
in sessions as anxiety-provoking. Managing anxiety was more responses, rather than personal characteristics. Positive communi-
commonly discussed by those in the high anxiety group. cation appeared to be an overarching theme across three domains.

frequency labels for structure and Domain/Category Total Low High
logistics of supervision questions
n Type n Type n Type
What are the advantages of having your supervisor sit in on sessions with you?
Safety net 24 Typical 13 General 11 Typical
Information* 18 Typical 11 Typical 7 Variant
Guidance* 7 Variant 2 Rare 5 Variant
Confidence/comfort 6 Variant 3 Variant 3 Variant
Improves training* 15 Typical 6 Variant 9 Typical
First-hand feedback & evaluations 11 Variant 5 Variant 6 Variant
Notice student blind spots* 6 Variant 1 Rare 5 Variant
Quality assurance for patients* 7 Variant 5 Variant 2 Rare
What have been the disadvantages of having your supervisor sit in on sessions with you?
Internal reactions 22 Typical 10 Typical 12 Typical
Stress/anxiety of being watched 19 Typical 8 Typical 11 Typical
Lack of independence 5 Variant 3 Variant 2 Rare
Session dynamics 18 Typical 10 Typical 8 Typical
Difficulty establishing rapport 10 Variant 5 Variant 5 Typical
Counsel for supervisor, not patient 6 Variant 3 Variant 3 Variant
Interruptions/taken over 4 Variant 3 Variant 1 Rare
Overly dependent on supervisor* 3 Variant 3 Variant 0 –
What have been the advantages of having multiple supervisors per rotation?
See multiple styles 24 Typical 12 General 12 Typical
Develop your own style 18 Typical 9 Typical 9 Typical
Counseling techniques* 15 Typical 9 Typical 6 Variant
Feedback from different perspectives 9 Variant 5 Variant 4 Variant
Improved training 6 Variant 3 Variant 3 Variant
Strengths & specialties 6 Variant 3 Variant 3 Variant
What have been the disadvantages of having multiple supervisors per rotation?
Supervisor expectations 19 Typical 10 Typical 9 Typical
Supervisor pleasing 17 Typical 8 Typical 9 Typical
Modifying one’s approach 17 Typical 8 Typical 9 Typical
Impedes growth of own style 7 Variant 4 Variant 3 Variant
Limits accurate evaluation 5 Variant 2 Rare 3 Variant
Note. General = All or all but 1-2; Typical = More than half; Variant = Less than half; Rare = Very few; *moderate
likelihood of differences between anxiety groups
Domain 1: Supervisors Provide… (Total n = 25; LA = 11; Domain 2: Supervisees Gain… (Total n = 9; LA = 5;
HA = 14) This domain refers to an action or service provided HA = 4) A number of participants commented on how they
by one’s supervisors. Many students mentioned ways they felt have benefitted from being supervised, particularly in terms of a
supported by their supervisor in performing their work. For greater sense of confidence, professional growth, and self-aware-
instance, they felt comforted by having an experienced prac- ness. They emphasized the effects of supervision on their overall
titioner in the counseling sessions in case they made a mistake, professional development, specifically citing increased responsi-
by receiving praise, and by having someone with whom to bilities, improved clinical skills, and beginning to determine their
process difficult cases. A similar number described the bene- personal counseling style.
fits of receiving timely suggestions from supervisors to help
them get past stumbling blocks and develop skills to become Domain 3: Supervisors Are… (Total n = 4; LA = 1; HA = 3)
an independent practitioner. A few described situations in A few interviewees referenced specific characteristics of super-
which they felt their supervisors showed confidence in them visors related to good supervision (e.g., broad clinical experience,
or trusted them to accomplish a difficult task. enthusiasm, empathy, and patience).

frequency labels for perceptions Domain Total Low High
of supervision processes
n Type n Type n Type
On average, across all supervisors, what would be the ideal balance between your own reactions or impressions of
sessions versus talking about clinical or patient-focused issues?
Moderately skewed to patient 10 Variant 6 Variant 4 Variant
50-50 9 Variant 5 Variant 4 Variant
Moderately skewed to personal* 5 Variant 1 Rare 4 Variant
On average, across all supervisors, what would be the ideal balance of how much of the content of supervision is
decided by you versus decided by your supervisor?
50-50* 15 Typical 6 Variant 9 Typical
Moderately skewed to supervisor 10 Variant 4 Variant 6 Variant
On average, across all supervisors, how much have you talked with your supervisor about the relationship
between the two of you?
Rarely** 11 Variant 2 Rare 9 Typical
Never* 6 Variant 5 Variant 1 Rare
Frequently 6 Variant 2 Rare 4 Variant
likelihood of differences between anxiety groups; **high likelihood of differences between anxiety groups
What Have Been the Most Challenging Things concrete or procedural issues than emotional support. Responses
About Clinical Supervision? to this question yielded four domains.
Communication was once again frequently referenced in response Domain 1: Communication with Supervisor (Total n = 14;
to this question, though these responses tended to focus on more LA = 5; HA = 9) Many students, primarily those in the high

frequency labels for self-assessed Domain/Category Total Low High
effects of anxiety
n % n % n %
How has your level of anxiety improved your performance as a genetic counselor?
Behavioral effects 16 Typical 7 Typical 9 Typical
Increased case preparation 10 Variant 3 Variant 7 Variant
Rolling with the punches* 5 Variant 4 Variant 1 Rare
Staying calm 10 Variant 6 Variant 4 Variant
Patient benefits* 7 Variant 6 Variant 1 Rare
Motivation to improve 5 Variant 2 Rare 3 Variant
How has your level of anxiety gotten in the way of your performance as a genetic counselor?
Too much anxiety* 17 Typical 5 Variant 12 Typical
Feeling overwhelmed* 6 Variant 1 Rare 5 Variant
Self-consciousness* 6 Variant 1 Rare 5 Variant
Too little anxiety 6 Variant 4 Variant 2 Rare
It doesn’t* 5 Variant 4 Variant 1 Rare
How has your level of anxiety affected you during supervision?
Little to no impact* 13 Variant 8 Typical 5 Variant
Detrimental to supervision* 12 Variant 3 Variant 9 Typical
Worry about perceptions of the supervisor or evaluation 9 Variant 3 Variant 6 Variant
Getting tongue-tied/ not speaking up* 3 Variant 0 – 3 Variant
Depends on the supervisor* 4 Variant 0 – 4 Variant
likelihood of differences between anxiety groups; ** high likelihood of differences between anxiety groups
anxiety group, described challenges related to communicating rotations. Responses to these questions centered primarily on
with their supervisors, especially surrounding issues of feed- their emotional reactions and effects on the development of
back and expectations. Some mentioned not knowing what rapport with the patient. Most responses were fairly similar
was expected of them at given times and discussed how they between anxiety groups, but two domains and six categories
thought lack of clarity made it more difficult for them to prog- met criteria for moderate likelihood of differences between
ress as genetic counselors. Others spoke about not receiving groups. Generally, the high anxiety group was more likely to
enough feedback from their supervisors to accurately gauge discuss how these aspects affected their own experience, while
how well they were progressing or being surprised by sum- the low anxiety group was more likely to discuss how they
mative evaluations. affect the genetic counseling sessions overall.
Domain 2: Affective Experiences (Total n = 12; LA = 4; What Have Been the Advantages of Having Your
HA = 8) Emotional reactions to supervision comprised the Supervisor Sit in on Sessions with You?
most difficult aspects of clinical supervision for a number of
participants. Comments focused on negative emotions and/or Many students likened the presence of the supervisor to a
struggles to reconcile their intellectual understanding of the safety net, though the reasons for wanting that safety did vary.
value of supervision with their affective experiences. The pri- The other major theme was improved quality control, but the
mary emotion discussed was anxiety, while many students focus was split between services to the patient and training
explicitly related these feelings to evaluations or being judged provided to the student. This question revealed a number of
by supervisors. Some mentioned the live supervision aspect of potential group differences across the three domains.
clinical supervision as heightening their stress. One person,
however, commented that stress and anxiety varied by supervi- Domain 1: Safety Net (Total n = 24; LA = 13; HA = 11) A
sor, and two acknowledged evaluation is part of a supervisor’s large majority of students commented that the supervisor’s
role. High anxiety participants more often discussed affective presence provides several forms of back up and support.
experiences. Many focused on informational aspects, such as times when
they had either not known or been unsure about the answer to
Domain 3: Lack of Control (Total n = 10; LA = 5; HA = 5) a patient’s question. Information was more common among
Many interviewees described situations where they were unable low anxiety participants. A number of participants mentioned
to exert the control and independence they desired, most com- guidance, typically in the form of the supervisor helping them
monly wanting more responsibilities than they were allowed. when they did not know what to do or were uncertain during a
They attributed their limited control and independence to their session. Guidance was more commonly referenced by high
status as students, perceptions of their supervisors as controlling, anxiety participants. Several students noted feeling more cer-
or logistical issues. tain patients would leave with all the necessary information,
more confident what they said had been correct, and more
Domain 4: Working with Multiple Supervisors (Total comfortable interacting with the patient, due to a supervisor’s
n = 7; LA = 3; HA = 4) Participants in this domain mentioned presence.
logistical issues and concerns related to having multiple super-
visors. Several considered it challenging to integrate feedback Domain 2: Improves Training (Total n = 15; LA = 6;
from multiple sources which were sometimes contradictory, HA = 9) Participants in this domain expressed that the supervi-
keep straight the expectations of their various supervisors, or sor’s presence increased the quality of their training. High anx-
discern what feedback was due to stylistic differences versus iety students were more strongly represented in this domain.
core skills. Three individuals expressed concerns that some of Many highlighted the fact that supervisors have first-hand
their supervisors may not be good sources of information be- knowledge of their skills and the full context of situations that
cause of the supervisor’s lack of clinical experience or a lack of arose in sessions, which in turn leads to better feedback and
interactions between the student and supervisor. Only high anx- assessment of their training needs. A few spoke about supervi-
iety participants expressed these last concerns. sors’ ability to notice things outside the awareness of the
supervisee; high anxiety students were more likely to comment
on this aspect.
Perceptions of the Structure or Logistics
of Supervision Domain 3: Quality Assurance for Patients (Total n = 7;
LA = 5; HA = 2) Some students commented on the benefits
The frequencies and frequency labels for this area are presented to the patient of having the supervisor in the room, including
in Table 3. Participants presented a fairly balanced picture of the stronger feelings of safety, confidence that the information pro-
advantages and disadvantages of the structure of supervision in vided is correct due to the supervisor’s expertise, and satisfaction
with the quality of care. This domain was more common among not a single Bright^ way to be a genetic counselor. This was
low anxiety individuals. typically discussed either in terms of developing their own
style or seeing specific techniques that varied from counselor
What Have Been the Disadvantages of Having Your to counselor. The low anxiety participants were more likely to
Supervisor Sit in on Sessions with You? mention techniques specifically.
Responses to this question were balanced almost equally be- Domain 2: Feedback from Different Perspectives (Total
tween self- and session-focused issues. There was considerable n = 9; LA = 5; HA = 4) Students in this domain mentioned mul-
consensus between anxiety groups, with only one category tiple supervisors enhance the feedback they receive. Specifically,
showing evidence of differences across the two domains. having multiple sources to compare and contrast feedback
allowed for more nuanced understanding of their progress.
Domain 1: Internal Reactions (Total n = 22; LA = 10;
HA = 12) A large majority of students focused on their personal Domain 3: Improved Training (Total n = 6; LA = 3;
cognitive and affective experiences during sessions in describ- HA = 3) A few students commented on the ways having mul-
ing disadvantages of having their supervisor present. A great tiple supervisors created a more well-rounded educational ex-
number reported feeling additional stress, anxiety, nervousness, perience for them. They mentioned varied strengths and spe-
pressure, and self-consciousness during sessions. A few stu- cialties of their supervisors and the sense of getting to put
dents expressed frustration with their inability to direct sessions together the best pieces of their supervisors as they moved
because the supervisor Bstep-ins,^ patients want to interact with through their training.
the supervisor, or having the supervisor put students in more of
an Bobserving^ role. What Have Been the Disadvantages of Having Multiple
Supervisors Per Rotation?
Domain 2: Session Dynamics (Total n = 18; LA = 10;
HA = 8) Many students commented on how the session was There were no differences between anxiety groups across the
affected by the supervisor’s presence. A number mentioned that three domains for responses to this question. The most com-
patients would sometimes address the supervisor instead of the mon responses focused on either managing multiple sets of
supervisee, patients would have less faith in the supervisee be- expectations or keeping multiple supervisors happy.
cause she or he needed a supervisor present, or the small talk at
the beginning of sessions was more difficult, all of which affected Domain 1: Supervisor Expectations (Total n = 19; LA = 10;
the ability to build rapport with the patient. Some interviewees HA = 9) Many students noted challenges associated with hav-
thought they had to concentrate on doing things to satisfy the ing to manage the expectations of their supervisors, especially
supervisor rather than what they felt was natural to them or what when these expectations were not consistent, or even directly
they thought was best for the patient. A few students commented contradictory, within or across rotations. This domain was
on supervisors who would interject either too frequently or too often tied to the previous question as the Bbad side^ of getting
early in sessions, and a few others described sometimes using the feedback from a variety of perspectives.
supervisor too frequently to help them work through difficult
situations or explanations. Only low anxiety participants brought Domain 2: Supervisor Pleasing (Total n = 17; LA = 8;
up the latter issue. HA = 9) A large majority of participants noted feeling pressure
to please their supervisors and having to do things just because
What Have Been the Advantages of Having Multiple their supervisor wanted them to do so. Many students de-
Supervisors Per Rotation? scribed their perceptions of having to Bcater^ their counseling
to their supervisors’ preferences and finding it challenging to
Responses to this question again reflected significant consensus keep track of each supervisor’s requirements. Some went a
across anxiety groups, with only one category showing evidence step further and said it was more difficult to develop their
of differences. The opportunity to see different counselors work own style because supervisors required them to do things a
with clients was by far the most common response, with more certain way.
specific benefits of this arrangement brought up by some partic-
ipants. This question produced three domains. Domain 3: Limits Accurate Evaluation (Total n = 5;
LA = 2; HA = 3) A few students expressed that having multi-
Domain 1: Exposure to Multiple Styles (Total n = 24; ple supervisors may result in not having worked with them
LA = 12; HA = 12) Many students focused on how different enough to form an accurate basis for evaluation. In particular,
supervisors showed them varied methods and styles of genetic growth over the course of a rotation may not be appreciated if
counseling, often saying this helped them understand there is a supervisor has limited experience with the student.
Perceptions of Supervision Processes benefits to themselves and their patients. There are four
domains.
Participants’ responses to questions in this area of investiga-
tion were often brief and concrete, thereby creating simple Domain 1: Behavioral Effects (Total n = 16; LA = 7;
domains which are more effectively reported in narrative by HA = 9) Many students focused on the effects of their level
question rather than by specific domains. The frequencies and of anxiety on their behavior. Most commonly, anxiety led
frequency labels for this area are presented in Table 4. them to spend more time preparing for cases because of fear
Responses to questions in this area produced a relatively large of making mistakes or earning poor evaluations. A few par-
number of differences between groups, with three domains ticipants, primarily low anxiety, noted the absence of anxiety
meeting criteria for moderate likelihood of differences be- allowed them to remain flexible in sessions and handle diffi-
tween groups and one domain meeting criteria for high likeli- cult situations as they arise.
hood of differences. Participants generally valued balance
across several situations described below. Domain 2: Staying Calm (Total n = 10; LA = 6; HA = 4)
When describing the ideal balance between discussing Several students mentioned they can enter new situations or
personal reactions to sessions versus patient-focused issues challenges while maintaining a sense of comfort and confi-
during supervision, most students described an even split dence. This was variously attributed to the effects of extra
or a slight skew toward patient issues. A few participants, preparation or having low baseline anxiety.
primarily from the high anxiety group, preferred a slight
skew toward personal reactions. When asked about the Domain 3: Patient Benefits (Total n = 7; LA = 6; HA = 1)
ideal balance between supervisor or supervisee determina- Participants in this domain noted that patients may feel more
tion of the content for supervision conversations, many comfortable and they are better able to focus on, understand,
described a 50-50 distribution, with high anxiety partici- or attend to the needs of the patient. This domain was predom-
pants endorsing this situation more frequently. A sizeable inantly described by low anxiety participants.
number of participants also described a moderate skew
toward supervisor control. Domain 4: Motivation to Improve (Total n = 5; LA = 2;
Most students reported little explicit discussion of the HA = 3) These participants spoke about using their anxiety
supervisory relationship with their supervisor. High anxi- as a driving force to continue working on their skills and
ety participants were more likely to characterize it as rarely knowledge. This was often referenced in terms of fear of re-
happening, which was the only difference in the study to peating the same mistakes or needing to make up for less than
reach the high likelihood criteria. Low anxiety participants ideal first impressions with a new set of supervisors.
were more likely to report never having a discussion about
the relationship. Only a few participants from each group How has Your Level of Anxiety Gotten in the Way of Your
characterized these discussions as happening frequently. Performance as a Genetic Counselor?
Responses to this question primarily focused on the distractions

Student Self-Assessment of How Anxiety Affects caused by increased anxiety, though some participants also
Them commented on disadvantages of having insufficient anxiety
regarding their performance. Three domains were extracted
The frequencies and frequency labels for this area are presented from responses.
in Table 5. This area produced the most differences between
groups, with six domains and four categories in this area meet- Domain 1: Too Much Anxiety (Total n = 17; LA = 5;
ing criteria for a moderate likelihood level. Generally, the low HA = 12) Participants in this domain, primarily from the high
anxiety group did not perceive their anxiety as problematic, anxiety group, indicated their anxiety can rise to an unhelpful
while the high anxiety group did. Of note, these interview ques- level in a number of ways. Several described feeling anxiety to
tions were framed in terms of each participant’s typical level of the extent that it became too much to handle constructively or led
anxiety, so some responses reflect effects of low anxiety while them to shut down in sessions. Others expressed that they be-
others reflect effects of high anxiety. come distracted by wondering how their supervisors or patients
are viewing the session or the students’ performance. Both these
How Has Your Level of Anxiety Improved Your aspects were more strongly endorsed by high anxiety
Performance as a Genetic Counselor? participants.
Participants most frequently discussed their behaviors in re- Domain 2: Too Little Anxiety (Total n = 6; LA = 4; HA = 2)
sponse to this question, but framed responses both in terms of Several participants shared that being overly confident may be
a detriment in that they may not prepare as extensively as their Survey Results
colleagues, or they may allow sessions to get off topic. They
speculated that more anxiety would likely cause more atten- The principal finding from an initial screening survey was the
tion to details and concern about time constraints. low level of trait anxiety (M = 37.5, SD = 8.98) relative to that
found by Jungbluth et al. (2011; M = 44.5, SD = 4.1). The average
trait anxiety score in the present study is nearly a full standard
Domain 3: Anxiety Does Not Get in the Way (Total n = 5;
deviation difference according to instrument norms, for working
LA = 4; HA = 1) Several students, primarily from the low anx-
adult women (SD = 9.22) and female college students
iety group, said their anxiety level does not impede their per-
(SD = 10.15), respectively (Spielberger et al. 1983). This may
formance. Some seemed perplexed by the question, as if having
low anxiety could not possibly have a negative effect. simply represent sampling error, especially considering
Jungbluth et al. had a better response rate (68 % vs. 40 %) and
nearly 3 times as many participants, but there may be other
How Does Your Level of Anxiety Affect You
During Supervision? explanations.
The difference in findings might be the result of cohort effects,
such that those students in training during the Jungbluth et al.
The sample was split approximately equally between
reporting anxiety does not make a significant impact on them (2011) study were simply more anxious than those in training at
the time of the present study. Another possible explanation is the
during supervision and anxiety has negatively influenced su-
current sample includes only 2nd year students, though
pervision. There are three domains.
Jungbluth and colleagues found no significant differences be-
tween 1st and 2nd year students in terms of trait anxiety; so this
Domain 1: Little to no Impact (Total n = 13; LA = 8; appears unlikely. The timing of the study may be another impor-
HA = 5) Many students said their anxiety has not meaningful- tant factor. The present survey was conducted in the summer
ly affected them during supervision. This was more common months, when students are presumably less stressed than during
among the low anxiety group. the academic year, whereas Jungbluth et al. surveyed students in
December and January, a time of noteworthy stressors (e.g., final
Domain 2: Detrimental to Supervision (Total n = 12; exams, holiday travel, family gatherings). While trait anxiety is a
LA = 3; HA = 9) Participants in this domain, most of which relatively stable construct (test-retest reliability for 104 days = .77;
were in the high anxiety group, emphasized ways their anxiety Spielberger et al. 1983), taking the instrument during times of
prevented them from functioning the way they would like during high distress might lead participants to over-estimate how anx-
interactions with their supervisors. A number highlighted feeling ious they typically feel, just as taking it at times of low distress
more concerned with how their supervisor views them or will could lead to under-estimation.
evaluate them than with gaining competence with the counseling
or getting the most from their rotations. Others described feeling Interview Broad Themes
hesitant or freezing during supervision sessions, overthinking the
words they use in a supervision session, or not clarifying misun- Participant Consensus The domains and categories extracted
derstandings with supervisors. This tendency was only reported from the interviews resulted in few general classifications
by high anxiety participants. according to CQR criteria (i.e., all or all but one or two
participants supplying a response; Hill 2012; Hill et al.
2005). No domains or categories reached the level of general
Domain 3: Depends on the Supervisor (Total n = 4; LA = 0; when considering the interview sample as a whole. This is not
HA = 4) A few students, all of whom were high anxiety, noted overly surprising given the decision to analyze results by
their anxiety affected them differently depending on the su- question rather than holistically. These findings may also
pervisor, typically indicating more positive relationships with suggest heterogeneous subgroups within the sample (Hill
supervisors mitigated some of their anxiety. 2012), which supports the decision to split the sample into
anxiety-based groups. Only one domain was classified as
general across both anxiety groups: Supervision Support
Discussion and Guidance (most positive aspects of supervision). Only
two other domains reached general in either of the groups
This qualitative study investigated the role of trait anxiety in (Safety Net and See Multiple Styles, both in the low anxiety
the experience of 28, 2nd year genetic counseling students. group). The lack of general labels within the anxiety-based
Major findings are presented and compared with the literature, groups could signal the decision to use percentile splits was
followed by study limitations, training implications, and re- not the best way to capture subgroups, or may be an artifact of
search recommendations. analyzing smaller sections of text independently. Participant
responses tended to be more similar when asked about Supervisor as Focal Point One of the fundamental aspects of
positive aspects or benefits than challenges or disadvantages, forming relationships with patients is the ability to be present
which is consistent with previous supervision research (e.g., and focused on them. The centrality of the relationship to ge-
Hendrickson et al. 2002). Participants tended to mention more netic counseling has been demonstrated in prior research (e.g.,
general situations when talking about positive situations and Lobb et al. 2005; McCarthy Veach et al. 1999; Roter et al. 2006;
more specifics when discussing difficult aspects, which could Skirton 2001), and it is a core component of the Reciprocal-
explain the increased diversity of responses. Engagement Model of Genetic Counseling Practice (McCarthy
Veach et al. 2007). Yet in several instances throughout these
Lack of High Likelihood of Differences Of all the compar- interviews, it appears the students’ attention during genetic
isons between the high and low anxiety groups, only one met counseling sessions was more focused on the supervisor than
criteria for high likelihood of differences based on CQR rec- the patients, and they may value their supervisors’ evaluations
ommendations (i.e., the classification labels differ by two or more than the patients’. Prior research has found some genetic
more levels, such as general and variant; Hill 2012; Hill et al. counseling students counsel Bfor their supervisors^ rather than
2005). The low anxiety group was less likely to say they rarely for the patients (Hendrickson et al. 2002). Adjusting one’s
(as opposed to never) discuss the supervisory relationship counseling because of supervisor feedback is an important part
with their supervisors. The remaining differences met the of development, but many of the participants characterized the
moderate likelihood of differences criteria adapted from the supervisors’ requests as arbitrary or made because of the super-
original CQR recommendations (Hill et al. 1997). Thus, the visor’s lack of flexibility. Some even said the changes went
present results point to few large differences but highlight against their own instincts of what would most benefit the pa-
numerous areas worthy of additional exploration. This may tient, though the accuracy of these instincts could not be
again suggest percentile splits were not ideal, that differences established in the current study. A sizeable number of partici-
between groups are more subtle than obvious, or trait anxiety pants also considered their amount of concern about supervisor
is not the ideal operational definition for high vs. low anxiety perceptions or evaluations to be detrimental to their experience
students. It may also be that participant recall focused on only of supervision, indicating this issue is non-trivial in these stu-
the most memorable or extreme experiences, which obscured dents’ perceptions.
tendencies across the overall experience of supervision. An important counterpoint, however, is the importance of a
strong supervisory relationship to trainee development. While
Ego-Centric Responses Participant responses focused over- this has not been demonstrated empirically in genetic counsel-
whelmingly on themselves. This seems logical given their devel- ing, in related fields the supervisory relationship has been
opmental level and that most interview questions focused on their linked to decreased stress (Gnilka et al. 2012; Sterner 2009),
impressions and experiences. Only a few students referenced role conflict, and role ambiguity (Ladany and Friedlander
other parties, especially patients (e.g., only two participants men- 1995), as well as increased coping (Gnilka et al. 2012) and
tioned their impact on patients as one of the most positive aspects work satisfaction (Ladany et al. 1999; Sterner 2009). Ladany
of their rotations). Also, the idea of live supervision providing (2014) even lists Bdenigrating the supervisory relationship^
quality assurance for patients was the least frequently endorsed first in his BIngredients for Supervisor Failure.^ Thus the
domain of advantages. When the relationship with the patient did amount of attention being paid to supervisors may be devel-
come up, it was typically related to challenges with establishing opmentally appropriate to some extent, given the novice status
rapport. For example, when discussing disadvantages of live of trainees at the time of the study. Investigations of students
supervision, Difficulty Establishing Rapport was the most closer to graduation could shed light on whether this balance
common category in the Session Dynamics domain, with of attention between patient and supervisor shifts as students
participants describing the supervisor’s presence as either gain experience.
distracting for the patient or undermining the student’s perceived
competency.Psychotherapy research has identified clinician self- Satisfaction with Supervision or Clinical Rotations
awareness during sessions as a component of skilled therapy
(e.g., Jennings and Skovholt 1999). Specific to trainees, however, When asked about the most positive aspects of rotations, super-
the results are more mixed. Both trainees (e.g., Nutt-Williams vision was the most prevalent domain, suggesting a strong role
and Hill 1996) and volunteer clients (e.g., Williams 2003) linked in overall satisfaction. Responses related to positive aspects of
adverse effects to trainee self-awareness, particularly if that supervision focused much more on what the supervisor was
awareness included negative self-talk. Fauth and Williams doing (e.g., providing feedback) or students’ reactions to super-
(2005), however, found self-awareness to be generally beneficial. visor actions (e.g., feeling supported or trusted) rather than their
The role of self-awareness was not explicitly explored in the own development. Fewer still involved descriptions of supervi-
present study, but several students commented on being sor characteristics. Personality characteristics have been theo-
distracted by their anxiety. rized to affect the style and efficacy of supervision in genetic
counseling (Eubanks Higgins et al. 2013; Wherley et al. 2015), The dominant response to the advantages of multiple su-
but empirical studies have yet to be conducted. While the re- pervisors was the opportunity to see how different genetic
sults of the current study seem to suggest personality type is less counselors approach their work. Being able to see the different
important than the behaviors exhibited by supervisors, these are styles manifested in actual genetic counseling sessions was by
likely related. When discussing the positive aspects of their far the most prevalent domain, regardless of anxiety group. As
rotations, the high anxiety group was more likely to focus on for the disadvantages of multiple supervisors, having to man-
personal skill development. Perhaps these students had more age multiple sets of expectations was the most commonly
self-doubt or insecurities related to their skills. Alternatively, described challenge. Many students said they had to adjust
they may have been more likely to focus on concrete aspects their counseling for each supervisor in order to receive posi-
or areas in which they received direct feedback from supervi- tive evaluations, which leads to the next most common do-
sors via evaluations. main of working to please the supervisor rather than focusing
on their growth or their patients’ needs. As this is the students’
perspective, it is unclear whether conforming to supervisors’
Perceptions of the Structure or Logistics of Supervision desires is appropriate in every situation.
Regarding live supervision, the most common response was Perceptions of Supervision Processes
the presence of the supervisor provides students with a safety
net during sessions. This finding is consistent with previous The most preferred option for both the focus of supervision
research on live supervision in genetic counseling (supervisee or patient) and determination of content (supervisee
(Hendrickson et al. 2002). Improved training and feedback or supervisor), regardless of anxiety group, was an even balance.
were also highlighted in the present study and Hendrickson The high anxiety group was more likely to prefer a moderate
et al.’s study. Perceived limitations of live supervision also skew toward themselves as a focus of supervision, perhaps be-
align closely to Hendrickson et al.’s findings. Students in both cause they feel a greater need to discuss their experiences, receive
studies reported experiencing anxiety when the supervisor validation, or get corrective feedback. No one reported a prefer-
was present. Interestingly, the tendency to report increased ence for having supervision focus heavily on themselves. The
stress or anxiety did not differ across anxiety groups in the high anxiety group was more likely to prefer an equal split on
present study, suggesting the experience of anxiety in this content determination, which may reflect a hesitation to feel in
context is fairly universal and/or the effects of the experiential control or a fear of missing out on valuable supervisor feedback.
component of genetic counseling training operates similarly They may also trust their own impressions less and desire the
regardless of how anxiety-prone one is. The themes of chang- supervisor’s assessment of how well they perform during
ing their behavior to fit the supervisor’s desires rather than sessions.
patient needs, deferring too easily or relying too much upon The majority of participants said the supervisory relation-
the supervisor, and thinking some supervisors were overly ship was discussed either rarely or not at all. The low anxiety
involved in the students’ sessions were also consistent across group was less likely to say they rarely discussed the super-
studies. visory relationship but more likely to report never discussing
The low anxiety group was more likely to describe the it. Perhaps the high anxiety participants tended to bring up the
supervisor’s ability to provide answers to questions when they relationship because they wanted more reassurance or support
did not know the answer as advantageous. Perhaps the high from their supervisors. Or maybe their supervisors initiated
anxiety group was more embarrassed to seek the supervisor’s such conversations because the high anxiety students were
help in session because they thought it would reflect poorly on less likely to open up during supervision.
them. The low anxiety group was also less likely than the high
anxiety group to mention a supervisor being able to provide Self-Assessment of Anxiety’s Effects
guidance when the student does not know what to do next in
session. It could be that low anxiety participants are less likely Unsurprisingly, the high anxiety group reported more negative
to experience these situations and/or less likely to turn to their effects of anxiety on their performance with patients and in
supervisors for help when they feel unsure of how to proceed. supervision while the low anxiety group was more likely to
In the latter case, they may be more comfortable forging ahead endorse increased ability to adapt to unexpected situations.
despite their uncertainty because the supervisor is there to The low anxiety group generally saw few negative effects
adjust the course of the session if necessary. Low anxiety due to anxiety, though some mentioned not preparing for ses-
students may also be more likely to see supervisors more as sions as well as their colleagues. The tendency to feel
consultants available to them in sessions, while high anxiety overwhelmed and freeze in supervision reported by high anx-
students perceive themselves as Bborrowing^ the authority of iety participants may be part of a vicious cycle, where anxiety
the supervisor. prevents them from getting the most out of supervision, which
in turn leads to poorer performance, which in turn increases how these results should be viewed. Additional qualitative
anxiety. It is encouraging, however, to see supervisors can and quantitative studies are needed to make more solid
make a difference in this dynamic for some of these partici- conclusions.
pants. Perhaps the high anxiety students’ greater focus on the Finally, only students were interviewed, the perspective
supervisory relationship is due to an increased need for a pos- of supervisors and others involved in student training were
itive relationship in order to perform well. not captured by the present study. Triangulation should be
sought through future research investigating perspectives
Study Limitations of supervisors and others involved in student training.
Regardless of the congruence between student and super-
Several factors must be taken into account when con- visor impressions of the experience of supervision, the
sidering the results of the present study. The initial sur- present study provides valuable insights into how the ex-
vey sample had a useable response rate of 40 %; thus perience is perceived by one half of the supervision dyad.
the anxiety thresholds used to classify interviewees may
not be reflective of the population as a whole. The Practice/Training Recommendations
decision to use percentile splits to create groups was a
rational choice, but does not guarantee qualitatively dif- The present results suggest several contexts where inter-
ferent groups. Average trait anxiety levels were quite vention could enhance the experience of student
d i ffe r e n t a c r o s s g r o u p s an d p a r t i c i p a n t s’ s e l f - supervisees. The quality of the supervisory relationship
classifications largely agreed with the empirical classifi- seems to underlie numerous aspects of students’ experi-
cations, but alternative group formations (e.g., high/low ences in supervision. Ideally, ongoing assessment and
median split, self-classification) may have yielded differ- discussion of the relationship could help prevent some
ent results. of the challenging issues reported in this study. Thus an
Although the average trait anxiety score did not differ be- important supervisor intervention, particularly with anx-
tween survey and interview samples for the high anxiety ious students, may be spending extra time and energy
group, several survey respondents with the highest trait anxi- building rapport and strengthening the supervisory rela-
ety levels did not respond to interview requests. Their partic- tionship. Such efforts might allow students to participate
ipation may have added to the analysis. Also, none of the optimally in supervision. Given the prevalence of anxi-
interviewees reported overall dissatisfaction with their rota- ety during supervision, rapport building may include
tions or their supervision. While the population of those who normalization of anxiety, which is consistent with pre-
are dissatisfied with these aspects of their training is hopefully vious recommendations (e.g., Borders et al. 2006;
small, a lack of their perspectives in this study limits the ap- Eubanks Higgins et al. 2013; Wherley et al. 2015).
plicability of the results. Supervisors should initiate conversations about the
The current study also only includes those with rela- relationship early, as the power differential may be
tively little supervision experience; participants had ~7– too much for supervisees to feel comfortable doing
9 months of supervised experience remaining before so. They should occasionally revisit the topic, as re-
graduation. Perceptions of supervision likely will shift lationships are dynamic and students may be unwill-
over time, so it would be valuable to compare these ing to voluntarily express their concerns. In addition
results to data collected at or near the end of students’ to benefitting the supervisory relationship, such con-
supervised experiences. Another related issue is the versations could provide numerous opportunities for
present sample had varying amounts of experience with discussion of parallel processes with patients, such
supervision as training programs begin rotations at dif- as building rapport, non-verbal communication, and
ferent stages of training. Given the relatively small sam- assumptions.
ple, differences could not be factored into the analysis. Given the impact of feedback on students’ percep-
The deviations from standard CQR protocol, primar- tions of training broadly and supervision specifically,
ily the decision to analyze results by question rather feedback should be a focal point for both supervisors
than holistically, must also be taken into account when and supervisees. Supervisors can strive to maintain a
interpreting the findings. The frequencies associated balance between reinforcing strengths and providing
with domains and categories may be under- or over- corrective feedback. Students can be encouraged to
inflated. As described in the Method section, we shape some feedback they receive by framing questions
deemed this a risk worth taking, but a holistic approach to their supervisors to promote discussion (e.g., BI see
would likely have produced more accurate estimations of the what you consider the cons to how I handled that situ-
prominence of the themes present in the interviews. We ation, but were there any pros to that approach?^).
sought to identify issues for further exploration, and that is Supervisors could also verbalize their thought processes
behind their evaluations, similar to the Thinking Aloud students at multiple times during their training program.
approach advocated by Borders et al. (2006). If framed Such research would allow for better understanding of
properly, Socratic questioning could potentially be used the ebb and flow of anxiety and provide more stable esti-
as an exercise to model self-supervision skills (Wherley mates of anxiety prevalence in the population.
et al. 2015). Given participants’ reported importance of supervisor
Students may also need additional discussions about super- feedback and evidence from psychotherapy training re-
visor expectations and their rationale. This may require addi- search that feedback affects anxiety and self-efficacy
tional time at the outset of rotations, but would likely prevent (Daniels and Larson 2001), further exploration of the con-
misunderstandings later. Perhaps some of the common issues tent and processes of feedback is needed. Students who
could be incorporated into a supervisory disclosure statement desire feedback to feel challenged, for example, may seek
(e.g., McCarthy Veach and LeRoy 2009). Articulating expec- or receive feedback from supervisors very differently than
tations in writing would likely help anxious supervisees nav- those who desire reassurance. Supervisors and supervisees
igate entering new rotations as they would have to discover would benefit from further understanding of the dynamics
fewer Bunwritten^ rules. at play in this critical process.
While proposed supervision competencies (Eubanks Studies of supervisors’ perceptions as well as others
Higgins et al. 2013) call for supervisors to BSeek to lessen involved in student training (e.g., program directors)
students’ anxieties and help students find productive ways would help to triangulate the findings. As many of the
to manage anxiety^ (p. 46), they do not provide specific present students reported anxiety related to being a
direction for doing so. Supervisors may benefit from work- supervisee, arguably, becoming a supervisor would trigger
shops or seminars in methods for helping their supervisees some of the same issues once students enter the profession-
reduce anxiety (Wherley et al. 2015). Relatedly, students al ranks. Thus investigation of supervisors’ own anxiety in
could be encouraged to use more proactive approaches to addition to their perceptions of students’ anxiety would
learning to manage their own anxiety. Successful interven- yield valuable insights. Studies of actual supervision dyads
tions have been demonstrated among therapists in training would be particularly valuable.
(e.g., Abel et al. 2012; Shapiro et al. 2007) using programs The supervisory methods used by supervisors tend to
focusing on mindfulness to cope with the stress of training shift as supervisees become more experienced (Masunga
and professional practice. Training could focus on self-care et al. 2014). Effects of different methods on students’
strategies, teaching students life-long skills and be poten- perceptions before beginning their clinical rotations
tially useful with patients in highly anxious states. should be assessed. Studies of this type will deepen
Discussions of the benefits of psychotherapy may also be understanding of the impact of student anxiety on their
helpful for genetic counseling students. None of the pres- experience of clinical rotations and supervision. The
ent participants mentioned receiving therapy as a method resulting data will contribute to knowledge about genet-
for managing anxiety, while this was the sixth most com- ic counseling student professional development.
mon coping strategy in a recent survey of psychology
trainees (El-Ghoroury et al. 2012).
Acknowledgments This study was completed in partial fulfillment
of the requirements for the first author’s Doctor of Philosophy degree
Research Recommendations from the University of Minnesota. We would like to thank Salina
Renninger for her assistance developing the interview protocol and
Cami Takkunen for transcribing the interviews. We thank the partic-
Additional investigations of the effects of anxiety on the
ipants who shared their insights, successes, and failures to contribute
experience of genetic counseling students in supervision to our understanding of supervision.
are warranted. The present sample consisted of only one
male and four students of color, and while this is fairly
Compliance with Ethical Standards
representative of the population of genetic counseling stu-
dents, these students may have different experiences. Conflict of Interest Ian M. MacFarlane, Patricia McCarthy Veach,
Future qualitative studies could target these populations Janelle E. Meier, Derek J. Meister, and Bonnie LeRoy declare they have
no conflict of interest.
more specifically. Future studies could also target more
specific components of the supervisory relationship, spe-
Ethical Treatment of Subjects All procedures followed were in ac-
cific events in supervision, and interventions to improve cordance with the ethical standards of the responsible committee on
student training. The differences between the current sam- human experimentation (institutional and national) and with the
ple and Jungbluth and colleagues’ (2011) in terms of trait Helsinki Declaration of 1975, as revised in 2000. This study was
approved by the University of Minnesota IRB. Informed consent
anxiety levels demonstrates the need for further investiga-
was obtained from all individual participants included in the study.
tion of anxiety trends among genetic counseling students. This article does not contain any studies with animals performed by
Surveys could be conducted with several cohorts of any of the authors.
Appendix
Table 6 Illustrative interviewee quotations for general, typical, and variant domains and categories
Domain/Category Illustrative quotation for domain/category
What have been the most positive things about your clinical rotations?
Supervision
Feedback …getting really constructive feedback is really helpful for me and I think my supervisors have all been
great at giving me tangible things that I can work on for the future. (HA)
Support I think that it’s, I guess the word is, comforting, to know that someone is there who has more experience
than you and who can step in just in case you slip up, or if you need extra help explaining a concept to a
patient, or something like that. (LA)
Practical experience & skill …having that knowledge base is nice, but also having the practical knowledge is even better… (HA)
development*
Variety of clinical experiences I’ve had the opportunity to work with a lot of different individuals with a lot of, that each have their own
styles of counseling which, I love the opportunity to try out different things and also I’ve had the
opportunity to see a lot of different clinical indications. (HA)
Confidence & comfort [In] the beginning of the year it was pretty terrifying being the one talking to patients about their condition
or their child’s condition and now through encouragement and through practice I’ve been able to be a lot
more confident in the session… (LA)
What have been the most challenging things about your clinical rotations?
Relational factors
Challenging supervisor interactions …if my internal experience is that I’m freaking out and that’s not obvious, then the supervisor chooses to
focus on different aspects of my performance than they would if they were aware of how my anxiety and
lack of confidence is kind of driving what I’m doing. That’s a hard thing to bring up to say, BOh, and by
the way, you didn’t mention anything about the fact that I’m kind of terrified of this but can we talk about
that?^ (HA)
Challenging patient interactions With genetics some things come up that are very rare that maybe you’ve never heard of or some social
circumstances with the patient that are very extreme come up that you weren’t expecting. So kind of
dealing with things off the cuff, that’s challenging. (HA)
Personal factors
Managing anxiety* I would say it would be the stress of always being evaluated. The anxiety that brings on every time I do a
counseling session. Knowing that there’s somebody who will be there to evaluate and ultimately criticize
what I have done. (HA)
External factors Just kind of how temporary [clinical rotations] are. Once you get into the vibe of a certain rotation your two
months is up and you’re on to the next one. It’s hard to establish a relationship with the people you’re
working with… [You want to] feel like you have a role in their little team instead of just being something
they have to accommodate…it’s hard in the timeframe to feel useful. (HA)
What have been the most positive things about clinical supervision?
Supervisor guidance and support
A source of comfort/ support I think hearing supervisors say that everyone struggles with certain aspects of learning and genetic
counseling in general makes me feel better about any feelings of inadequacy, so it makes me feel more
confident in myself and my abilities by them supporting and normalizing it for me. (HA)
Advice/feedback I think the supervisors who really make a point of telling me the positive things I have done and pointing
out where I’ve made improvements or where I’ve grown, while at the same time giving me more
information and more feedback on where to go from here. (LA)
A source of confidence/trust There have been a couple of times when I needed to take a minute to think about what I was about to say to
a patient. Sometimes they jump in during those couple seconds of quietness. When they let me take that
time and let me speak, those were the better sessions for me. (HA)
Supervisee growth
Professional growth It was really great to be able to start off at zero, really from scratch, and observe a supervisor doing sessions,
but then have this transformation throughout the summer to where by the end she was the one observing
me. It was really great to be able to do that in a stepwise fashion, gradually getting there. (LA)
Supervisor characteristics I guess having someone who’s been there before and knows what you’re going through and that it’s not
always easy. That you’re still learning things, and most of the time a situation that you encounter, your
supervisor has already been in, whether it’s been last year, last month, or 10 years ago. (LA)
What have been the most challenging things about clinical supervision?
Communication with supervisor*
Table 6 (continued)
Unclear expectations I think supervisors who don’t communicate well and who don’t tell you what their expectations are and
then give you feedback that you’re not following their expectations when they haven’t actually been
clear on what they were to begin with… (LA)
Lack of feedback I think when they don’t give us any feedback after watching what we’re doing. Especially during my
prenatal rotation, I felt like I didn’t really hear a whole lot back during the semester. Then at the end of the
semester evaluation I didn’t get very high marks, and I was a little bit blindsided because…nobody had
been talking to me along the way about these things… (HA)
Affective experiences*
Stress/anxiety I think it can also be challenging when you’re in the session and you know that your supervisor is there,
sitting, watching you, listening to every word you say. I think it’s much more stressful than if you’re in a
session by yourself… (LA)
Lack of control
Student status But when you go to a new location, the supervisors there have their specific ideas about what they want you
to do and what they want you to say. So in a way, sometimes supervisors can actually kind of dampen
your independence because they’re enforcing the ways that they want to do things even though you’ve
been developing your own way, and that has been a difficulty. (HA)
Working with multiple supervisors
Managing multiple styles and A lot of [supervisors] want different things from you. Some people like a very thorough counseling outline
expectations and want to know word for word what you’re going to say before you go in, whereas other counselors
might kind of say BJust give me bullet points, that’s fine.^ Just having to know what supervisor you have
and kind of what they like to see from you before you go in; their styles are different…while I think it’s a
good thing also, it is hard because you do have to keep in mind who your supervisor is at the time, how
they do their supervision, and what they like to see from their students. (LA)
Perceived supervisor credibility/ …sometimes [receiving feedback is] a bit of a difficult pill to swallow from a genetic counselor who is not
feedback validity* much older than me. (HA)
What are the advantages of having your supervisor sit in on sessions with you?
Safety net
Information* Knowing that I have the expert in the room for when I get asked a question I don’t know the answer to.
(HA)
Guidance* I know that they’re there in case something comes up that I’m not sure how to handle. (LA)
Confidence/comfort Physically in the session I get the confidence that everything that I say in a session kind of has that seal of
approval, and I’m not doubting my information, and I’m not doubting the way that I’m portraying that
information. I know that there is another set of ears acting as a backup for me… (HA)
Improves training*
First-hand feedback & evaluations They can directly observe what I’m doing instead of me having to like tell them afterwards…They can also
feel a shift of emotions in the room and get their own sense of what’s going on, because during a
counseling session it’s not just like what’s being said, it’s also body language and emotions. So I thought
the patient was being distant, but maybe my supervisor thought the patient was just having an emotional
moment. We can have different takes on stuff, so it’s nice for them to be there and see what’s going on,
and then we can compare notes afterwards. (HA)
Notice student blind spots* …a lot of times there are things that I don’t even realize that I’ve done, like words that I’ve thrown in, or
that I talk really fast. Things I hadn’t even recognized that I was doing that she can point out. (HA)
Quality assurance for patients* I think it can make a patient more comfortable, especially because I feel like I do look like a student and I do
introduce myself as a student, and so the patient might feel like, BOkay, it’s fine if a student’s here, but
it’d be nice to have someone who’s also…well-trained and a professional to be in the room just in case I
do have a difficult question,^ or something like that. (LA)
What have been the disadvantages of having your supervisor sit in on sessions with you?
Internal reactions
Stress/anxiety of being watched Well, the obvious one would be you feel like someone is breathing down your back all the time…Just that
feeling of always being watched…. (HA)
Lack of independence … some supervisors tend to jump in a lot more than we need…They’ll answer questions instead of you
answering questions for the patient. I’ve also noticed that sometimes the patients will look directly to the
supervisor as opposed to looking at you, possibly because they know you are a student and they kind of
want to make sure that you are saying the right things, and that can be frustrating because it’s supposed to
be my session. And sometimes when they’re directly looking at the supervisor, the supervisor tends to
take over a little bit, and I don’t have as much independence or control over the session. (LA)
Table 6 (continued)
Session dynamics
Difficulty establishing rapport I think that it changes the rapport. Some patients might look at the counselor even though you’re explaining
something to them, whereas if you’re the only person in the room, all their attention would be on you.
Sometimes if you’re with a supervisor, the patient has less trust in the student…a general theme is that it
might take away rapport from the student while there’s a counselor in the room. (HA)
Counsel for supervisor, not patient I think that when my supervisor is in the room I’m more focused on what words I’m choosing, I’m more
focusing on genetic counseling in a textbook way rather than responding to the patients because I know
I’m…getting marked on what a genetic counselor would do and what a genetic counselor would say
instead of going with my gut feeling. (HA)
Interruptions/taken over …if [the supervisor] thought I had completed my thoughts, then they start talking and kind of take over.
That’s kind of frustrating because a lot of the time I was going to say that, just in a different point in the
conversation. (HA)
Overly dependent on supervisor* Say for instance there’s a carrier frequency or a recurrence risk or maybe a chance that it goes along with a
syndrome that you’re pretty sure you have, but because that supervisor is sitting in the room you might
defer to them and ask them anyway, when, for me at least, I need to just be more comfortable with the
information that I know and just use it, not relying on them for support. (LA)
What have been the advantages of having multiple supervisors per rotation?
See multiple styles
Develop your own style …I’m trying to build my own style, so the more different people I can observe and the more different input
that I get just helps me to figure out exactly what kind of counselor I want to be and what I want my style
to be… (LA)
Counseling techniques* The advantages of multiple supervisors are certainly that you can see different ways of doing the same
things still accomplishing the same goal… (LA)
Feedback from different perspectives If you have just one supervisor at one clinical site then I think [the supervisor] really [gets] to know you and
your counseling style but with different supervisors it’s sometimes helpful to have that different
perspective of either being reaffirmed in what you’ve already heard before or hearing new feedback
about other points of your counseling that can be improved upon. (HA)
Improved training
Strengths & specialties And I also think that certain people are better at certain skills, and they might be able to identify…the things
that you need to work on that another counselor might not notice or focus on, so I think you get a more
well-rounded feedback because it’s not just one person. (LA)
What have been the disadvantages of having multiple supervisors per rotation?
Supervisor expectations I try to tailor what I do to what I have been evaluated on in a previous session with a supervisor, and so I
start doing something a little differently because this is the way I’ve been sort of evaluated and
encouraged to do something. The new supervisor will say, BWhy did you do that? I would’ve done it this
way.^ Sometimes the differences are enough that it changes the way that the evaluation goes. I might get
something pointed out as something I should do differently when it was, in fact, something I changed for
the supervisor that I just had yesterday. (LA)
Supervisor pleasing
Modifying one’s approach I think just that every supervisor expects different things and prefers different things. It’s kind of hard for a
student to stay on their toes and remember, okay, I’m counseling with so and so, this is what they like but
now I’m counseling with another counselor and this is what they like. So I think that’s probably the
biggest challenge of it, keeping in mind who you’re working with and how you need to adjust your
counseling for their supervising. (LA)
Impedes growth of own style …you’d have to remember, BOkay, who am I with now? How did they like this done?^ and so it becomes
not about…finding your own style, but about BWhat can I do here so that this person isn’t going to
criticize this little point yet again?^ (HA)
Limits accurate evaluation …as I progress through a rotation, if somebody hasn’t been with me the whole time, and there’s been other
people with me the whole time, then they don’t really necessarily see how I’ve progressed and don’t
really know how to judge me at the point that they’re coming in and doing a session with me, because
they haven’t seen that I’ve gotten better from previous sessions… (HA)
On average, across all supervisors, what would be the ideal balance between your own reactions or impressions of sessions versus talking
about clinical or patient-focused issues?
Moderately Skewed to Patient I would say 70 % clinical, 30 % what I felt about it. (LA)
50-50 I’d probably say it would be better to be half and half because, particularly in our field you need to learn to
take care of yourself and understand why you react certain ways to certain situations so that you can
Table 6 (continued)
better control that in the future, but that doesn’t seem to be necessarily the way it happens. But, I would
say half and half because it’s important to know how the patient reacts with what you’re saying and how
to use that with other patients, but also to be able to take care of yourself and know what you need to do
better or think about later next time. (LA)
Moderately Skewed to Personal* Maybe like 60/40. I would keep the focus on me just because this is the place where I’m supposed to be
learning, and if we don’t talk about what I did and my skills and how to work on it, I won’t be able to
learn how to be a counselor as much. But I think it is also important to talk about how the patient reacted
and how the patient felt, and bring that into it. So, a little more focus on the patient, but definitely keeping
it on my learning. (HA)
On average, across all supervisors, what would be the ideal balance of how much of the content of supervision is decided by you versus
decided by your supervisor?
50-50* I’d put it close to 50/50. The place I’m at now is closer to that, whereas this summer anytime I wanted to
talk about stuff regarding clinic, I had to bring it up. I was never really sure if I was doing enough, if I was
doing too much, if I was asking the right questions. That was a little nerve-wracking for me. (HA)
Moderately skewed to supervisor I think from a student’s point you don’t necessarily always even know what you want to talk about with the
supervisors (HA)
On average, across all supervisors, how much have you talked with your supervisor about the relationship between the two of you?
Rarely** Oh, hardly at all I would think. I think we talk about expectations but not so much about expectations for
our relationship. More of expectations for deadlines for preparation, deadlines for writing letters, and,
what’s expected of me in clinic, but not so much about how we’re going to interact together. I think that’s
a very rare conversation. (LA)
Never* I’m not sure I’ve ever really talked to them directly about my relationship with them (LA)
Frequently With my first supervisor we were very open in talking about it and very open to talking about, you know,
the relationship of the supervisor with the student and how that impacted both of us. (HA)
How has your level of anxiety improved your performance as a genetic counselor?
Behavioral effects
Increased case preparation I think it always pushes me to do well. You know, I’m too anxious to ever under prep for a patient or to sort
of slack off I guess in creating my outlines and preparing myself. (HA)
Rolling with the punches* I think it helps me in being able to go with the flow of the patients during counseling sessions and not get
flustered or off track when the patient takes you to a place that you didn’t necessarily have in an outline
or had discussed with a supervisor. (LA)
Staying calm …it allows me to not get very anxious during a session and if something gets very difficult or very
complicated or very heated, it allows me to kind of stay calm and still continue with the session and try to
keep it all on track. (HA)
Patient benefits* I just think people can read anxiety on someone very easily. It would be very difficult if I was a patient and
the person talking to me was obviously anxious or nervous. I would feel uncomfortable that they were
new or didn’t really know what they were doing. So I think having a confident presence in a counseling
room is really, really essential for having a patient feel comfortable and trust you as a care provider. (LA)
Motivation to improve I don’t think it’s a bad thing necessarily. It definitely makes me more self-aware and I think quicker to want
to do things the right way just because I’m worried about making mistakes. So it’s definitely improved
my work ethic. (HA)
How has your level of anxiety gotten in the way of your performance as a genetic counselor?
Too much anxiety*
Feeling overwhelmed* I actually think it hurts my performance because when I get anxious I become like a deer in the headlights,
and you miss things that are said, and you’re so busy panicking that you can’t think properly… (HA)
Self-consciousness* I think in the session being anxious or nervous reduces my comfort level and my ability to really just focus
on the patient instead of my own worry about what my supervisor is thinking as I’m going through the
case or the session. (HA)
Too little anxiety Sometimes I don’t prepare as much as I probably should have, and so if I’m seeing somebody tomorrow
and there’s something that I’ve explained 2 weeks ago, I would say, BOh yeah, I know how to do it,^ and
tomorrow comes and I make a mistake in giving that simple explanation because I didn’t practice or I
wasn’t anxious enough to practice that. (HA)
It doesn’t* I don’t see how it would, no. (LA)
How has your level of anxiety affected you during supervision?
Little to no impact*
Table 6 (continued)
I don’t stress out about my relationship with my supervisors and are they going to approve of this, or am I
doing the right thing, or what are they going to think. I’m not very externally oriented. I think I’m more
internally oriented. Like, I want to be doing the best possible job and how can my supervisor help me get
there, but I’m not worried about the evaluation or anxious because they’re sitting in the room or anything
like that. (LA)
Detrimental to supervision*
Worry about perceptions of the I think that’s probably the most difficult aspect of supervision is the anxiety of knowing somebody is
supervisor or evaluation evaluating you constantly. (HA)
Getting tongue-tied/ not speaking up* …sometimes it makes me hesitant to ask questions if I’m afraid that they are stupid questions just because I
don’t like to sound like I am not completely prepared, or I’m not completely sure about what I’m doing. I
don’t like to come across like that, so I’ll avoid asking [the supervisor] questions that would help me…
(HA)
Depends on the supervisor* It really depends on whether I have a supervisor with whom I feel like I can discuss the anxiety. (HA)
Note. **high likelihood of differences between groups; *moderate likelihood of differences between groups, LA low anxiety participant, HA high anxiety
participant
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J Genet Counsel (2016) 25:742–766

Effects of Anxiety on Novice Genetic Counseling Students’

Analysis Team Preparation The primary analysis team

Data Analysis likelihood of differences between groups, as long as there is

Trait anxiety score

Thematic Analyses responses focused on either practical or emotional benefits

What Have Been the Most Challenging Things

Table 2 Domain and category

Table 3 Domain and category

Table 4 Domain and category

Table 5 Domain and category

Responses to this question primarily focused on the distractions

Domain/Category Illustrative quotation for domain/category

Domain/Category Illustrative quotation for domain/category

Domain/Category Illustrative quotation for domain/category

Domain/Category Illustrative quotation for domain/category

Domain/Category Illustrative quotation for domain/category

References Fauth, J., & Williams, E. N. (2005). The in-session self-awareness of

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