Level 2 clinical supervision for community practitioners working with palliative and end-of-life care patients

Caring for those who have palliative and end-of-life conditions has become a common aspect of community care (Public Health England, 2018; The King's Fund, 2022). More patients are requesting treatment at home, even into the active dying phases (Hunter, 2018). In an ideally staffed NHS, this would include access to a range of specialist palliative care services, including clinical health psychology (Hussain et al, 2016).

However, in reality, limited funding has resulted in large gaps in service provision, with a significant proportion of daily care, including psychological input, falling on non-specialist, general services, such as those provided by community and district nurses (Hussain et al, 2016; Hunter, 2018). District nurses, for example, are now seen as the most frequent and regular providers of hands-on palliative care and will visit patients with increasing frequency towards the end of life (Independent Cancer Taskforce, 2015).

Little can be found in the wider literature on psychological training and supervision for non-specialist community staff, such as community and district nurses, who frequently work with patients with palliative and end-of-life conditions (Kingsley et al, 2015; Hussain et al, 2016).

While mental health is covered in nurses’ training programmes, this is often at a foundation level, and many community nurses note they lack confidence in their psychosocial treatment skills (Coxon, 2012). Similarly, the impact of working with palliative and end-of-life caseloads on the wellbeing and mental health of practitioners working in the community deserves greater attention (Hospice UK, 2015; Copeland, 2019).

Staff turnover in community health is high. The number of nurses and health visitors working in these settings has continued its long-term decline: more nurses are now leaving the professional register than are joining it (Hospice UK, 2015; Copeland, 2019; The King's Fund, 2022). Work-related stress, burnout and compassion fatigue have been said to be significant factors related to these resignations (Copeland, 2019; National Workforce Skills Development Unit, 2019). Such emotionally exhausting environments take their toll on staff even if they are performing well (Hospice UK, 2015; West, 2019).

The emotional labour of providing care has been researched for many years, particularly in palliative and end-of-life care (EOLC) settings (Wakefield, 2000; Rokach, 2005; Hospice UK, 2015). Research conducted by Kamau et al (2014) found, for example, that up to 50% of palliative care staff may be at risk of poor psychological outcomes. Redshaw et al (2013) noted that this stress could be even higher in community palliative services, because of factors such as the high level of engagement between community nurses, patients and families. For some, this may be increased by traditional professional role expectations such as stoicism (Rafferty, 2000).

It is imperative that community practitioners are provided with psychological support when helping patients with high levels of pain and distress. It was with this in mind that the idea of providing psychological clinical discussion groups for community palliative care staff was considered (Kingsley et al, 2015).

Level 2 supervision group model

National Institute for Health and Care Excellence (NICE) (2004) guidance describes a four-tier model for the assessment and management of mental health difficulties in patients with cancer.

To be working at level 2, professionals have to complete both advanced communication skills training and a one-day course run by level 3 or 4 mental health specialists, as well as attending monthly level 2 supervision groups (Transforming Cancer Services Team for London (TCSTL), 2018).

In line with the TCSTL (2018) framework, each level 2 group is developed to consider:

• Support for level 2 clinical nurse specialists on detecting and managing patients’ psychological distress
• In-depth discussions on how to support staff to manage their own emotional wellbeing.

North East London Foundation Trust (NELFT) obtained permission from the TCSTL to develop an adapted level 2 group (AL2G) model of care specifically for community palliative care settings as an extension of existing level 2 groups but expanded to include non-malignant palliative conditions and a broader scope of staff, going beyond cancer nurse specialists.

The adapted model was also focused on specific aspects of community EOLC, such as working with bereavement, support for families in a home context and the complexities of care across a variety of acute, community and hospice settings. Group facilitators were qualified at level 4 of mental health awareness — ie they were senior clinical psychologists.

Research aims

The aim of this study was to investigate the outcome of the monthly AL2Gs. These clinical supervision groups, adapted from the level 2 four-tier model for cancer supervision to support a wider group of health professionals, were piloted in the three palliative care teams in community settings.

The groups have now been running over the past 7 years, and there was interest from NELFT as an organisation to support the concept's further expansion in general palliative care community settings.

The objective was to gain insight into whether participants who obtained specialist psychological supervision (through the pilot) differed in their responses from those who had not yet attended such specialist supervision groups.

The hypothesis posed was that regular attendance would enhance attendees’ confidence to detect and manage the psychological presentations of their patients, as well as improve their ability to manage the impact of their clinical work on their own emotional wellbeing.

Participants and procedure

The study was conducted at an NHS trust where the participants worked in community palliative care settings. The NELFT communications team initially sent out the surveys to the identified staff groups via email, and their confidentiality was guaranteed since responses were kept anonymous, with no identifiable demographics required.

All participants received written information about the aims of the research and gave their informed consent for the findings of the audit to be shared. Participation was voluntary; there were no adverse consequences of declining or withdrawing from participation. Participants received no incentive for their involvement.

The target population for this study included nurses, allied health professionals, such as occupational therapists, dietitians, speech and language therapists and social workers, who met the following inclusion criteria:

• They were employed by NELFT community teams during the study (for at least 1 month)
• They had no access to the original (not adapted) level 2 groups in acute hospital settings at the time of the study
• They interacted directly with patients and their families in the community on a regular basis.

Method

The lead author worked closely with the trust's director of nursing to develop the survey questionnaires. The research and development team at NELFT confirmed that an NHS research ethics committee review was not required, and the study was registered as an audit.

Construct validity was established through a review process by an expert panel including a director of nursing (n=1), senior psychologists (n=3) and a trainee clinical psychologist (n=1). Reliability was established by piloting a similar survey on a sample of nurses (n=270) in 2019.

The survey contained questions to measure two key constructs: increasing confidence in detecting psychological distress in patients; and raising practitioners’ awareness of the impact of their clinical work on their own emotional wellbeing. It was run on the Survey Monkey platform,

Content validity was improved by taking into account the community context of the supervision groups and the broader staff group, which included nurses and allied health professionals.

A questionnaire was developed for participants who attended community AL2Gs. The questions concerned:

• Benefits of the groups: whether the groups had improved participants’ confidence and capability in working with patients in palliative care/EOLC settings, and their ability to managing their own emotional wellbeing
• Explorations of recommendations of AL2Gs to their colleagues
• The nature of their caseloads and additional support obtained.

Another questionnaire was designed for participants who did not attend the groups. This had a similar structure and content to that for attendees but also asked non-attendees whether they would participate in a AL2G should one become available.

A mixture of fixed responses and open-ended questions was used throughout the surveys; spaces for comments was included after all questions, asking for opinions to encourage respondents to expand on their answers. This was to prevent a key limitation of closed-ended questionnaires, which is that participants may not have an opportunity to provide subjective feedback (Sincero, 2012).

Statistical analysis

The two groups of participants (attendees and non-attendees) received differing questionnaires, with one section—regarding the nature of their caseloads and support they received—the same for both groups.

Given that all variables were categorical, a chi-square test was used to compare proportional differences in answers between attendees and non-attendees.

All analyses were carried out using Stata v14.

Results

Response rate

In total, 11 participants completed the questionnaire for attendees; all had previously attended or were currently attending a level 2 community supervision group. Twenty-seven participants completed the questionnaire for non-attendees, none of whom had ever attended any form of level 2 supervision.

Those who attended AL2Gs reported significant benefits. Not only did 82% (n=9) of the attendees report that the groups improved their capability in managing their own emotional wellbeing inside and outside work, but more than 90% (n=10) found they had boosted their confidence in working with patients experiencing emotional distress. The same 10 participants said that they would recommend the group to colleagues who also worked in palliative care/EOLC settings, and all of them preferred group over individual supervision (Table 1).

Regarding the non-attendees, the majority were not aware of the concept of level 2 supervision at all (88.89%; n=24) until they read the definition in the questionnaire. However, almost half said they would attend such a group if they were invited.

Of those who showed an interest in attending these groups, the majority (80%; n=16) cited a wish to become more capable of managing their patients’ emotional distress and to understand mental health presentations better. Sixty per cent (n=12) of these respondents also cited managing their own emotional wellbeing as a reason for attending the group.

The majority of non-attendees (72%; 14 out of the 19 individuals who answered) also preferred the idea of group to individual supervision. The main reasons respondents cited for not attending a group were they invited were busy work schedules and high caseloads, although a few gave more personal reasons. These included not having sufficient information to commit to an AL2G, as well as discomfort with the idea of sharing information in a group supervision format. For detailed results, see Table 2.

For the questions that were answered by both attendees and non-attendees, significant between-group differences were found in their answers (all P<0.001). Attendees were more likely to report that their own emotional wellbeing at work was affected by their palliative/EOLC caseload as well as by not having sufficient formal support.

A difference was also found regarding the nature of caseloads; attendees had more patients presenting with psychological complexity (Table 3).

Five AL2G attendees (almost 50%) made additional comments, whereas non-attendees provided no additional comments (Table 4).

These comments showed some common themes emerged as to the benefits of AL2Gs:

• Facilitators provided a safe and confidential environment, which enabled responders to talk freely and to discuss their difficulties and concerns with their patients or those related to work/their organisation
• The groups themselves provided a sense of containment, especially for complex and distressing material that could otherwise feel overwhelming to participants
• The provision of a supportive peer environment: group attendees reported they were able to learn from other members’ experiences, and that the emotional support and suggestions they received from others helped them plan their patient care
• Attendees experienced a sense of sharing related experiences. They were able to recognise similar rewards, difficulties and challenges evoked by the palliative/end-of-life work context, and their impact on their emotional wellbeing. This seemed especially important in terms of complex cases, in which mental health concerns were as much of or more of a concern than physical symptoms
• Attendees reported feeling less isolated by being able to share their concerns with the group; the uniqueness of their job role was noted, as was how this could lead to difficulties at times, with friends and family not fully understanding their work experiences
• The group discussions provided a therapeutic space in which attendees felt truly listened to and that their feelings and thoughts were validated by the facilitator and group members
• The groups improved participants’ confidence, especially regarding working with mental health presentations, compared to when they first started in the group.

Discussion

The results of this study confirm the wider literature in that there is a significant variation in how much clinical supervision is available for community palliative care/EOLC clinicians to support both staff and patients in addressing mental health issues (Kingsley et al, 2015; Hussain et al, 2016).

Only a small number of clinicians surveyed in the non-attendee group had any formal individual or group supervision structures in place, and none of those were focused on mental health.

Furthermore, the current study found that palliative care clinicians in the community were often left without specialist support to manage growing and complex caseloads, which included significant comorbid mental health difficulties and psychological distress in patients and their families. This is of concern, as it is well established that a vital component of working with emotional distress is the availability of regular reflective spaces, such as supervision by specialists in mental health training (level 3 or 4 practitioners) (National Council for Palliative Care, 2015; TCSTL, 2018).

A finding from this study was that more than half of non-attendees lacked any regular or formal clinical case support but obtained this from peers on an ad-hoc basis instead. This confirms the limited wider research, which has found informal peer discussions were the main source of support for community practitioners (Adams et al, 2013).

The ad-hoc basis of the support reported in this study may reflect the lone working patterns of community staff, especially district nurses, who spend a lot of their time in patients’ homes and travelling between sites. This may leave them with little time available to meet and, even informally, find a release in sharing their experiences. This is of concern as that, without such social support at work, there may be an increased risk of isolation and a lack of opportunity for reflective feedback on complex cases (Hospice UK, 2015; The King's Fund, 2022).

Attendees were less likely to report that they required any additional peer support with cases beyond those of the monthly AL2Gs (<0.001). These results possibly indicate that attendees felt contained and supported enough by their monthly level 2 groups as a space to reflect with peers and a facilitator on any difficult presentations.

Attendees found the level 2 groups of great benefit, especially in terms of improving their confidence in detecting and managing psychological distress, as well as in managing their own emotional wellbeing. There is evidence in the literature to support this, as training and supervision have been found to be essential to promote feelings of competence and confidence among health professionals working in difficult situations, such as with dying patients (Rokach, 2005; Shipman et al, 2012; Hospice UK, 2015).

Almost 86% of the non-attendees disclosed that their own emotional wellbeing at work was adversely affected by the nature of their caseload, and many reported they received no formal support with complex patients or their own emotional responses to such cases. The majority of non-attendees noted that a key reason for joining an AL2G was to gain support in managing work-related stress and their own emotional wellbeing.

When non-attendees were asked about the reasons why they would not join an AL2G if invited (multiple choices; 24 non-attendees answered), the most common reasons given (over 70%) were busy work schedules and high work caseloads. This is in line with wider research, which notes that, with a continuing reduction in nurses and an increasing number of patients in the community, staff are increasingly stretching themselves thin to provide this care, which may result in sacrificing their own need for support and supervision (Hospice UK, 2015; Copeland, 2019).

The qualitative feedback from those who attended the AL2Gs added a dimension to the study results. It showed that the groups’ cohesion and supportive functions were deemed to be greatly beneficial by group members. This is in line with evidence from the literature, such as that by Brunetto et al (2013), which found that group supervision provided clinicians such as palliative care nurses with cohesive experiences including sharing resources and mutual support. Similarly, Rothwell et al (2019) noted that group supervision provided an opportunity for individuals to receive affirmation from colleagues in the group, which builds their sense of confidence. This demonstrates how vital social support from peers can be for work engagement and effective team wellbeing (Hospice UK, 2015; Rothwell et al, 2019).

Another important dimension from the qualitative feedback was that it pointed to the containing functions of the AL2Gs (Casement, 1985). It became apparent that attendees were able to find a sense of relief in freely bringing often painful and sometimes unbearable material to the group, and to find that this could not only be tolerated but also made more manageable.

A trusting relationship with the group facilitator was said to be vital, particularly so practitioners would feel free to bring confidential material and reflections to the group without concern that the facilitator would share this with the broader service. This confirms the findings of wider research, which shows a trusting relationship between supervisees and supervisors is of paramount importance for the success of supervision (Rafferty, 2000; Rothwell et al, 2019).

Limitations

The authors were aware of the limitations of comprehensive feedback in group settings. This is down to a number of variables including that participants may feel vulnerable when providing feedback in a group setting or in front of others, or where a facilitator is deemed to be in a position of power (Conley, 2018). The survey was therefore devised with confidentiality in mind to try to counterbalance some of these difficulties. The anonymity of the questionnaires ensured respondents could provide feedback without the risk of being recognised by their demographic information. However, even with these safeguards in place, respondents’ feelings and concerns around expressing the full range of their opinions in a questionnaire need to be considered (Sincero, 2012).

Second, a breakdown by health profession in the results of both attendees and non-attendees may have proved helpful in that it may have picked up any variation between professional groups working in palliative/end-of-life community settings. For example, it would have been useful to detect whether district nurses per se may be more at risk of isolation because of their frequent lone working.

Third, the study did not include questions related to specific forms of work-related stress, such as compassion fatigue and burnout, which have been documented in the wider literature as higher risks to palliative care clinicians (Doka, 2014; Duarte and Pinto-Gouveia, 2017). Including these may have helped to analyse whether particular types of work-related stress were occurring and, if so, whether there were any differences between attendees and non-attendees of AL2Gs.

Lastly, as this study did not provide questionnaires before and after groups to the attendees, overall changes in terms of emotional wellbeing could not be measured over time to correlate an improvement with attendance.

On a similar note, although a chi-square test was used to detect between-group proportional differences in the questions answered by both attendees and non-attendees, the significant differences have limited implications. It cannot be determined if attending AL2Gs resulted in these differences or whether these between-group differences existed before group attendance.

Conclusion

The experiences of attendees and non-attendees of AL2Gs were found to be significantly different. Not only did the attendees report increased confidence in addressing the psychological distress and mental health presentation of their patients, but they also noted improved abilities in self-caring and managing their own emotional wellbeing since joining the AL2Gs. Qualitative feedback from the attendees expanded on these themes by emphasising the cohesive and mutually supportive qualities of the group, as well as the containing functions of the group facilitators.

It is recommended that all community palliative care/EOLC clinicians are provided with the opportunity to join formal supervision structures to discuss complex cases, especially those with an underlying mental health presentation.

Several supervision forums are available for community staff, such as AL2Gs, based on groups that have been successfully implemented in acute oncology hospital settings in the NHS.

Key points

• There is little guidance on the provision of psychological level 2 supervision for healthcare staff beyond those working in acute services
• A more specific model is required to contextualise the work environment of practitioners providing palliative and end-of-life care in the community and related patient needs
• An adapted level 2 group for community care teams has been shown to support confidence, improve wellbeing and provide a sense of for staff when managing patient psychological presentations

CPD reflective questions

• What psychological issues do your patients face?
• What skills do you have to address these?
• How can you use an adapted level 2 group to address challenging cases that impact not only your patients but also your professional experiences of working in palliative care?