Clinical Supervision for Healthcare Professionals

Clinical Supervision for Healthcare Professionals An Evaluation May 2017

Contents 1. Acknowledgements... 2 2. Executive Summary... 3 3. Background... 4 4. Methods... 7 5. Results... 9 6. Focus Groups... 11 7. Limitations of Data... 15 8. References... 16 9. Appendix... 17 1

1. Acknowledgements 1.1 A huge thank you must go to Phil Harris who played a huge role in assisting with this project by analysing literature, interview transcripts and for casting an eye over data collection tools. Most importantly, a big thank you must go the staff members of the health boards who took part in the supervisions and agreed to provide feedback as part of the evaluation. Their information and thoughts were vital to ensure that future clinical supervision is as useful and productive as possible. 2

2. Executive Summary 2.1 This report is an evaluation of a clinical supervision service undertaken by Tenovus Cancer Care for two groups of staff in the ABMU health board. The purpose of the evaluation was to measure trends that indicated the effectiveness of the supervisions for staff, ascertaining the acceptability and value of the service according to staff and compiling recommendations, according to the participants, as to what encourages the sessions to be as useful and productive as possible. 2.2 Whilst largely superficial at this stage, the evidence suggests that, overall, the supervisions are effective at promoting a positive change in two of the three supervision domains measured (Compassion Satisfaction and Burnout). It was less effective at promoting change in the domain Secondary Traumatic Stress. 2.3 Overall, the supervisions were welcomed by the staff that took part. They felt the sessions added significant value, assisted in both their professional and personal lives, would recommend the service and wanted the service to continue. 2.4.1 A tool kit was devised consisting of thoughts by the participants as to what would make a successful service. Suggestions included getting information in advance, the importance of having an appropriate supervisor present, the correct composition of the group and the emphasis in being open and honest. 3

3. Background 3.1 Working in palliative care and oncology settings is both rewarding and challenging for health care professionals and has been shown to increase the risk of distress, burnout and compassion fatigue leading to job dissatisfaction (Najjar et al 2009, Peters et al 2012, Ruotsalainen et al 2008, Terakado et al 2015). Burnout in nursing practice has been described as an impaired or compromised ability to cope, characterized by a depletion of energy and perceived lack of support in the work situation (Pereira et al 2012). In the absence of effective coping strategies, nurses and care workers in oncology and palliative care are at risk of stress and burnout although there is evidence that the intrinsic rewards of this type of work may provide some protection from emotional distress (Pereira et al 2012, Goodrich et al 2015). 3.2 It is thought that compassion fatigue can occur when health care workers closely identify with the patient s suffering and pain, specific signs and symptoms may include re-experiencing traumatic events, having intrusive thoughts, sleep disturbance, and loss of empathy and motivation. Compassion fatigue has been linked to decreased productivity, more sick days, and higher turnover among nurses (Najjar et al 2009). 3.3 The risk factors associated with stress, burnout, and compassion fatigue included both personal attributes, for example ineffective coping styles, and organizational stressors particularly high workload (Najjar et al 2009, Peters et al 2012, Ruotsalainen et al 2008). There is some evidence that organizational factors are more important considerations than professional issues or emotional factors in the causation and alleviation of occupational stress in healthcare (Peters et al 2012, Ruotsalainen et al 2008). 3.4 Although there is clearly evidence of the stress associated with caring for people who are terminally ill, there are few examples of interventions to alleviate and manage the stressors and fewer evaluations of these interventions (Aycock & Boyle 2009,Goodrich et al 2015). Ruotsalainen et al (2008) conducted a systematic review of studies evaluating the effectiveness of interventions for reducing occupational stress and burnout among health care workers. Fourteen randomized controlled trials met the inclusion criteria, and only two of these trials were rated as high quality. The interventions were characterized in one of three ways: i) person-directed, aimed at 4

changing the personal characteristics of the care workers, ii) person-work interface to improve the fit between the person and the organization, and iii) organizational interventions that set out to change the organization or social environment. Despite the lack of available studies, the report was able to conclude that, overall, there was limited evidence of small but probably relevant reductions in stress levels from all three types of interventions. The evidence was sufficient to suggest that stress management can lead to positive health benefits for healthcare personnel but more, and better quality trials are needed. 3.5 A more recent review of the research literature was conducted by Goodrich et al (2015) with the intention of identifying strategies that hospices could adopt to support their workforce and enable them to continue to provide high quality care. The majority of the studies included in the review were of nursing staff. The subsequent report identified two main sources of stress in healthcare settings: i) stress associated with caring for people who are ill, suffering, and may be dying, and ii) stress linked to organizational life resulting in care staff feeling disengaged or unsupported. The report stated that staff and volunteers are unlikely to provide high quality care if they are under persistent stress. The review found that the available evidence of the usefulness of strategies and interventions to reduce stress was not strong enough to recommend to hospices that they adopt one type of practice over another. However, the report concluded that the quality of the work environment significantly impacted on stress levels, and that many factors causing stress among the hospice workforce could be alleviated by effective leadership, a participatory culture, and good linemanagement of staff and volunteers. 3.6 Effective supervision of staff incorporates many aspects of good leadership and management. In essence, effective clinical supervision is about maintaining and developing professionalism; it enables staff to reflect on and, where necessary, change or modify their practice, and identify any training and continuing development needs. The Care Quality Commission (2013) maintains that an effective system of clinical supervision helps set the values and behaviours expected of health care staff, ensures high quality care for people who use services, and is associated with increased job satisfaction, improved retention, and reduced turnover. There is, however, a dearth of research evaluating the use of clinical supervision in practice. 5

3.7 The current research aims to evaluate the perceived usefulness of group supervision for nurses and care workers in palliative care using quantitative and qualitative measures. 6

4. Methods 4.1 Evaluation of clinical supervision came in two forms: Survey design and focus groups. 4.2 Surveys: Using a validated survey measure, Professional Quality of Life Scale (PROQOL), participants were asked to complete a survey during each counselling session. This measure consisted of 30 questions, each being scored on a Likert scaling system of 1 to 5. Each of the 30 questions relate to 1 of 3 separate domains (Compassion Satisfaction, Burnout and Secondary Traumatic Stress). Stamm (2012) explains each domain as follows: 4.3 Compassion Satisfaction Compassion satisfaction is about the pleasure you derive from being able to do your work well. For example, you may feel like it is a pleasure to help others through your work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society. Higher scores on this scale represent a greater satisfaction related to your ability to be an effective caregiver in your job. The average score is 50 (SD 10; alpha scale reliability.88). About 25% of people score higher than 57 and about 25% of people score below 43. If you are in the higher range, you probably derive a good deal of professional satisfaction from your position. If your scores are below 40, you may either find problems with your job, or there may be some other reason for example, you might derive your satisfaction from activities other than your job. 4.4 Burnout Most people have an intuitive idea of what burnout is. From the research perspective, burnout is one of the elements of Compassion Fatigue (CF). It is associated with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that your efforts make no difference, or they can be associated with a very high workload or a non-supportive work environment. Higher scores on this scale mean that you are at higher risk for burnout. The average score on the burnout scale is 50 (SD 10; alpha scale reliability.75). About 25% of people score above 57 and about 25% of people score below 43. If your score is below 43, this probably reflects positive feelings about your ability to be effective in your work. If you score above 57 you may wish to think about what at work makes you feel like you are not effective in your position. Your score may reflect your mood; perhaps you were having a bad day or are in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern. 4.5 Secondary Traumatic Stress 7

The second component of Compassion Fatigue (CF) is secondary traumatic stress (STS). It is about your work related, secondary exposure to extremely or traumatically stressful events. Developing problems due to exposure to other s trauma is somewhat rare but does happen to many people who care for those who have experienced extremely or traumatically stressful events. For example, you may repeatedly hear stories about the traumatic things that happen to other people, commonly called Vicarious Traumatization. If your work puts you directly in the path of danger, for example, field work in a war or area of civil violence, this is not secondary exposure; your exposure is primary. However, if you are exposed to others traumatic events as a result of your work, for example, as a therapist or an emergency worker, this is secondary exposure. The symptoms of STS are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind you of the event. The average score on this scale is 50 (SD 10; alpha scale reliability.81). About 25% of people score below 43 and about 25% of people score above 57. If your score is above 57, you may want to take some time to think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You may wish to discuss this with your supervisor, a colleague, or a health care professional. These scores were then found as prescribed by the measure and then averaged per group and per session in order to show the trend of average score per group as the sessions progressed. 4.6 Focus Groups: Following the completion of the clinical supervision sessions, the research manager at Tenovus Cancer Care then undertook a focus group with each of the groups that participated. This took place at the time and place of the group s supervision session in the month after the supervision ended. The focus groups were semi-structured in design to allow for an exploration of topics that could be compared whilst also allowing for further areas to be discussed that were felt to be of importance and interest. The first group lasted 1 hour 15 minutes taking place with three participants. The second supervision was 45 minutes with 4 participants. Each interview was recorded using a Dictaphone and transcribed using specialist software. The transcripts were thematically analysed and triangulated using two analysts. 8

5. Results 5.1 Survey Data: Validated Scores 120.0 100.0 80.0 60.0 40.0 20.0 0.0 Compassion Satisfaction Scale 34.5 36.1 35.7 36.3 35.9 37.5 38.8 38.5 41.1 39.3 31.5 33.4 32.8 31.5 32.5 1 2 3 4 5 Group 1 Group 2 Average 5.2 The scale above shows the average score for compassion satisfaction per group as well as the average of the two groups. Unfortunately, though six sessions took place at each site, group 1 only completed the first five surveys. Therefore, only five surveys can be used for comparison. For this scale, the higher the score, the higher personal satisfaction the individual has in the work they do. The average compassion satisfaction score between the two groups rose from 34.5 to 35.9. Group 1 saw an average rise of 1 with group 2 seeing a rise of 1.8. 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Burnout Scale 27.0 24.7 24.2 24.4 25.7 25.0 23.8 21.0 20.2 21.8 29.0 25.6 27.3 28.5 29.6 1 2 3 4 5 Group 1 Group 2 Average 9

5.3 For this scale, the lower the score, the lower the risk the individual is experiencing burnout. Here, the average score between the two groups saw a decrease of 1.3. This is largely accounted for by group 2 seeing a significant decrease of 3.2 as group 1 saw a slight rise of 0.6. 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Secondary Traumatic Stress Scale 27.4 28.3 24.9 24.1 28.8 26.6 24.3 22.5 26.0 25.4 25.8 30.0 1 2 3 4 5 Group 1 Group 2 Average 25.5 24.5 26.5 5.4 In this scale, a lower score is conducive to a reduction in stress. However, the population average is 50 with a score of 57+ indicating that additional help may be sought. As can be seen from the above scores, the starting score for each group was well below this. However, similarly to the burnout scale, the average score saw a reduction of 1.9. Group 1 saw a rise of 0.5 though group 2 saw a decrease of 4.3. 10

6. Focus Groups 6.1 Two focus groups were undertaken, one with each group. The groups will be reported on together with any differences being highlighted. The following themes emerged: 6.2 Make-up of the group As discussed, Group 1 had three members in the focus group whilst group 2 had four members. In both cases, the make-up of the supervisions consisted of more than this on average but the participants in the focus groups were those who had also attended the most sessions even though all participants were encouraged to attend all sessions. This level of commitment is important to note because the corresponding views expressed are from those participants who were motivated to attend as many sessions as possible, thus benefitting the most. 1 Group 1 was made up of staff members from different disciplines e.g. Ward sister, OT Technician and Physiotherapist whilst group 2 were all clinical nurse specialists. Another difference was that the participants in group 1 were unfamiliar with each other prior to the sessions where group 2 staff had worked closely with each other for a number of years. Both groups felt there were benefits of the makeup of the groups being multidisciplinary (even though only group 1 were made up this way) as it was able to show how staff, no matter what grade, experienced difficulties and stress and participants felt this was important for others to be aware of. Comforting I found it you realize you are not on your own then don t you. (Liz). Group 2, however, felt that knowing each other allowed them to open up quicker. Group 1 stated that it took them longer to achieve this due to the need to build up trust in advance. It was agreed that the fact that the sessions were group based rather than individual were beneficial. 6.3 Value of the service All participants valued the supervision sessions and found them beneficial. All felt they would recommend the service to others. There were differences in the way that the groups were utilised and this was perhaps an indication of the makeup of the group and the coping resources on offer prior to the sessions. Group 1 described experiencing strong emotions during the sessions which they felt were both 1 This potential bias in reporting is somewhat alleviated as the groups felt able to express some views they felt were pertinent from absent participants. Whilst these views were secondary, they were felt to be largely reliable as they were often corroborated by other members of the group. 11

unexpected and difficult to manage after the sessions ended. One participant (Dawn) described the following: You know the sessions were raw and then to jump in my car and go back to work once we d opened this rawness was difficult but at the same time I found it extremely useful. Group 2 highlighted that the themes discussed were more often regarding organisational issues which adds to their stress rather than patient care. 6.4 Impact/Difference made Both groups felt the service had made a positive difference to the levels of stress and improved quality of life of the participants. The sessions got them thinking about the impact their work role has on them and reminded them that they need to look after themselves. So it really made us think about how we work and what we do to ourselves and how we don't look after ourselves and gave us little tips as to how we could put things in place and think yes I did do all right. (Meg). Both groups experienced a change of supervisor which came with it a change of approach. The first promoted self-reflection on important non-clinical aspects of the role. Whilst the sessions did provide emotional support and an opportunity to air issues, both groups highlighted that of particular benefit to them was being offered, practical tools to cope. Before this service was on offer, neither group felt there was somewhere suitable they could go for this type of support. Group 1 highlighted the well-being service though participants said they knew no one who had used the service claiming it to be too generic for their needs. Group 2 felt that the only other opportunities they had to talk was with each other but felt aware that this was difficult and felt uncomfortable doing so as they felt it encroached on time that would otherwise be spent with the patient. Both groups felt that being officially given the time off the ward to access these supervisions meant they felt legitimised in doing so. Neither group felt that there was anything suitably in place to replace the supervision sessions now that the sessions had ended though both groups expressed a desire for something to continue. Whilst group 2 felt they would try and increase informal contact with each other e.g. lunch breaks together etc. they recognise that without it being a formal session with a trained supervisor, the impact of this would be limited. In addition, this is something they have tried to put in place for some time with limited success. Group 1, given that they are from different hospital sites, felt it was highly unlikely that they would be able to maintain anything similar. This is something of real regret, and some concern, for them as they felt not only were supervisions of huge benefit but was something that was only just starting bear fruit. 6.5 Important components of the service 12

The following themes emerged in the interviews as important components or learning points if this programme was to be expanded or replicated elsewhere: 6.6 Information It was felt more information prior to the sessions would have been useful. Not only would this have made it clear as to the purpose for the sessions, but for those who agreed to take part, it would have prepared them better for the potential for the emotional components of the sessions. 6.7 Supervisor The participants reported the supervisor s experience and skill was a vital factor. This was important as it added structure, expertise and also legitimacy to the sessions. It was also important that the supervisor acts as a facilitator, ensuring the group has ground rules. Supervisor presence also encouraged the meetings to take place rather than other activities taking such priority that they are cancelled. It was also felt to be important that the supervisor was independent from the working practices of the group as it meant they could be non-judgemental. There was felt to be a fine line between providing a service that was too generic whilst also not being too closely tied to the service. Both groups felt that it was preferable to have continuity of the same supervisor for all of the sessions. This allowed trust and familiarity that had been built to flourish as well as consistency of expectations. 6.8 Composition of the group Trust was very important, particularly in group 1. Having ground rules, especially if the group did not previously know each other, is vital to encourage participants to be open and honest. Both groups felt that it was advantageous for participants to attend regularly. It was felt that it was necessary to attend as many sessions as possible to properly benefit as they did not work in isolation. For those who did attend regularly, they also reported it being difficult when others only went sporadically as it disrupted flow as well as meaning trust had to be re-established. Interestingly, both groups felt that the nature of the supervisee group was very important. It was vital that the participants felt comfortable and familiar with each other in order to be more open and honest. As discussed, the groups had a different relationship with each other prior to the sessions as well as the makeup of disciplines within the group being different, yet both groups felt that the way their group was constructed was the ideal template moving forward. Both groups saw the benefit of having supervision as a group. This allowed participants to reflect within the group, prompt each other and share experiences, creating a context for sharing and support. However, group 1 recognised that one to 13

one sessions, perhaps in addition, would also have been beneficial, particularly for one member of staff, not present, who had significant problems. Having an element of closure was felt to be important. Group 1 in particular felt that, with the sessions being a set of six, it was important to ensure that members were sufficiently prepared for when the sessions ended. 14

7. Limitations of Data 7.1 The data for the quantifiable data were small so the trends are only able to show superficial results. For example, the n number for group 1 session 1 was only 2. In addition, the data sets were also incomplete for one of the groups, so we were only able to fully analyse data for five of the six sessions. Whilst this means that data can only be used to suggest possible trends, provided that this is recognised with the results interpreted as such, this is more acceptable. 7.2 The surveys that were completed may not all have been completed in the manner in which they were designed. For example, in the focus group, one participant commented she filled in the survey to reflect her attitudes for the previous week only. The surveys request the participant to consider the whole of the previous month. This may have led to data not being truly reflective of what was intended. 7.3 The focus groups were made up of those who had attended practically all the sessions and therefore, it could be assumed, were those who had the most positive experience. Perhaps more importantly, there is no data from those who stopped attending the supervisions and it would have been very useful to gauge their feelings towards the service for a more rounded account. 15

8. References 8.1 Aycock, N. and Boyle, D. (2009). Interventions to Manage Compassion Fatigue in Oncology Nursing.Clinical Journal of Oncology Nursing 13:2, 183-191. 8.2 B. Hudnall Stamm, 2009-2012. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). 8.3 Care Quality Commission (2013). Supporting information and guidance: Supporting effective clinical supervision. https://www.cqc.org.uk/sites/default/files/documents/20130625_800734_v1_00_supp orting_information-effective_clinical_supervision_for_publication.pdf. [Accessed 25.07.17] 8.4 Goodrich J, Harrison T, Cornwell J (2015). Supporting hospice staff to flourish in stressful times. Hospice UK. 8.5 Najjar N, Davies LW, K Beck Coon, CC Doebbeling CC (2009). Compassion fatigue a review of the research to date and relevance to cancer-care providers. Journal of Health Psychology 14:2, 267-277. 8.6 Pereira SM, Fonsecca AM, Carvalho AS (2012). Burnout in nurses working in Portuguese palliative care teams: a mixed methods study. International Journal of Palliative care Nursing 12:8, 373-381. 8.7 Peters L, Cant R, Sellick K, O Connor M, Lee S, Burney S Karimi (2012). Is work stress in palliative care nurses a cause for concern? a literature review. International Journal of Palliative Nursing 18:11, 561-7. 8.8 Ruotsalainen J, Serra C, Marine A, Verbeek J (2008). Systematic review of interventions for reducing occupational stress in healthcare workers. Scandinavian Journal of Work and Environmental Health, 34 3, 169-79. 8.9 Terakado A, Matsushima E (2015). Work stress among nurses engaged in palliative care on general wards. Psycho-Oncology 25:1, 63-69. 8.10 Visser-Meily A, van Heugten C, Post M, Schepers V, Lindeman E (2005). Intervention studies for caregivers of stroke survivors: a critical review. Patient Education and Counseling 56:3, 257-267. 16

9. Appendix 9.1 PROFESSIONAL QUALITY OF LIFE SCALE (PROQOL) 91.COMPASSION SATISFACTION AND COMPASSION FATIGUE (PROQOL) VERSION 5 (2009) When you [help] people you have direct contact with their lives. As you may have found, your compassion for those you [help] can affect you in positive and negative ways. Below are some questions about your experiences, both positive and negative, as a [helper]. Consider each of the following questions about you and your current work situation. Select the number that honestly reflects how frequently you experienced these things in the last 30 days. 1=Never 2=Rarely 3=Sometimes 4=Often 5=Very Often 1. I am happy. 2. I am preoccupied with more than one person I [help]. 3. I get satisfaction from being able to [help] people. 4. I feel connected to others. 5. I jump or am startled by unexpected sounds. 6. I feel invigorated after working with those I [help]. 7. I find it difficult to separate my personal life from my life as a [helper]. 8. I am not as productive at work because I am losing sleep over traumatic experiences of a person I [help]. 9. I think that I might have been affected by the traumatic stress of those I [help]. 10. I feel trapped by my job as a [helper]. 11. Because of my [helping], I have felt "on edge" about various things. 12. I like my work as a [helper]. 13. I feel depressed because of the traumatic experiences of the people I [help]. 14. I feel as though I am experiencing the trauma of someone I have [helped]. 15. I have beliefs that sustain me. 16. I am pleased with how I am able to keep up with [helping] techniques and protocols. 17. I am the person I always wanted to be. 18. My work makes me feel satisfied. 19. I feel worn out because of my work as a [helper]. 20. I have happy thoughts and feelings about those I [help] and how I could help them. 21. I feel overwhelmed because my case [work] load seems endless. 22. I believe I can make a difference through my work. 23. I avoid certain activities or situations because they remind me of frightening experiences of the people I [help]. 24. I am proud of what I can do to [help]. 25. As a result of my [helping], I have intrusive, frightening thoughts. 26. I feel "bogged down" by the system. 27. I have thoughts that I am a "success" as a [helper]. 28. I can't recall important parts of my work with trauma victims. 29. I am a very caring person. 30. I am happy that I chose to do this work. 17