This article explores the challenges for nurses in attending and engaging in level 2 psychological supervision and offers recommendations to address these issues
The National Institute for Health and Care Excellence recommends that nursing staff attend level 2 psychological supervision to facilitate the management of psychological distress in patients. However, challenges to the professional role often mean that accessing this support is difficult or impossible. Nurse managers can take a role in facilitating attendance and enable support staff to gain the benefits of taking part in supervision, both for their patients and for themselves.
Citation: Hussain F (2023) Level 2 psychological supervision: barriers to attendance. Nursing Times [online]; 119: 12.
Author: Feryad Hussain is consultant clinical psychologist, North East London NHS Foundation Trust.
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The past decade has seen the introduction and implementation of principles of compassionate management in the NHS (West, 2019). The Francis (2013) inquiry on care failings at Mid Staffordshire NHS Foundation Trust concluded that patient experience of receiving care was closely linked to staff experience of giving care as part of their professional roles. The Francis report, coupled with the growing impact of managing the effect of staff and patient psychological distress on staff sickness and retention, resulted in a welcome and increased focus on staff wellbeing (Hussain et al, 2023; The King’s Fund, 2022; NHS England, 2022).
A decade before the Francis inquiry, the level 2 psychological supervision (L2PS) model had been developed, in part as a response to such issues for acute nursing staff in oncology and palliative care services; it took the form of a four-tier model for managing patient psychological distress (National Institute for Health and Care Excellence (NICE), 2004). It was recommended that nursing teams work in conjunction with specialist psychology services to offer a time-protected space in which nurses could discuss clinical cases to better identify and address patient psychological distress, and consider the role of referral to specialist psychology services (London Cancer Alliance, 2015).
Research around the benefits of supervision in general is specific to clinically relevant professional requirements. Existing literature reviews show benefits, such as improved wellbeing and development of clinical skills and knowledge through sharing (Dilworth et al, 2013; Koivu et al, 2012), as well as its effects on mitigating the risk of burnout, positively affecting staff retention and improving the work environment (Iosim et al, 2021; Wallbank and Hatton, 2011). Benefits were further affected by the quality and model of supervision (Martin et al, 2021; Nordbøe and Enmarker, 2017).
Specific benefits for staff in attending L2PS groups have been shown to include:
- Increased confidence in detecting and managing psychological distress in patients;
- Reducing the risk of burnout and increasing emotional capacity in themselves (Kingsley et al, 2023; Hussain, 2021).
Over time, L2PS groups in the UK have been adapted to include staff self-care and general psychological wellbeing as inherent to this process, and supervision sessions have been extended to include nurses working in the community and, more recently, taken beyond nursing to be adapted for medical colleagues in palliative care and oncology (Hussain et al, 2023; Hussain, 2022).
In spite of good intentions, the implementation and existence of L2PS groups remains scarce and, where groups are offered, there are notable problems in uptake, resulting in erratic or poor attendance and engagement. With competing priorities of self versus patient care, staff face a constant battle between maintaining their professional role and personal work-related stress, resulting in the forced acceptance of a harsh reality.
Invitations to L2PS groups are regularly experienced as an additional pressure, leaving staff feeling that the support is strategic. It is experienced less as an offering of support on how to successfully ‘spin plates’ and more as an offering of ‘glue’ to ensure multiple tasks continue with minimal disruption, with no apparent acknowledgement of the very real need for extra hands. This ultimately leaves staff feeling ambivalent about attendance and then unable to access any benefit – with little change in the overall picture of support.
This article aims to highlight some barriers to attendance at L2PS and reflect on issues of engagement in the hope that the overall implementation process may be reviewed to accommodate concerns at a practical level, allowing staff to fully engage and gain benefit from available support. The author is an experienced level 2 group facilitator, offering a range of groups to nursing and medical colleagues across acute, community, NHS and private sectors in different clinical specialisms beyond cancer and palliative care.
The L2PS four-tier model
NICE’s (2004) guidance on the provision of supportive and palliative care to adults with cancer and their families proposed a four-tier model of psychological assessment and intervention. It involved offering specialist psychological support and supervision to a range of professionals who might offer varying levels of psychological support to patients and their carers across the diagnostic and treatment pathway. The tiers/levels were aimed at all health professionals in disciplines other than psychiatry, psychology or counselling.
It was recommended that psychological supervision should be offered also to:
- Professionals with some training in assessment of, and specialist interventions in, psychological problems who are not mental health or psychological support professionals (levels 1 and 2);
- Trained mental health or psychological support professionals (levels 3 and 4) (NICE, 2004).
All staff who offer L2PS attend the relevant training and are usually working at levels 3 and 4. Box 1 provides an overview of the model as it is used today.
Box 1. The four-tier model of psychological assessment and intervention
Level 1: Staff involved in any degree of psychological screening, intervention and support that is deliverable by any qualified health/social care professional, without any further psychological training other than that provided by the basic training in their discipline. This level requires basic compassionate communication and information giving
Level 2: Staff involved in a degree of psychological screening, intervention and support that requires delivery by a practitioner who is a health/social care professional and who has received further psychological training in addition to that provided by the basic training in their own discipline. This includes the National Advanced Communications Skills Training course, attendance at a nationally approved programme or a network-based training programme relevant to cancer patients and their carers
Level 3: Staff more directly involved in psychological screening, intervention and support that requires a practitioner, such as a counsellor, an NHS psychotherapist, a registered mental health nurse with a diploma in counselling, or a social worker with an additional university-accredited clinical diploma in counselling or psychotherapy. Other accredited health/social care professionals are also considered able to practice at this level
Level 4: Staff directly involved in and/or overseeing professionals who are involved in psychological screening, intervention and support that requires a consultant psychiatrist, consultant liaison psychiatrist, or clinical/counselling psychologist
Sources: Johnson et al (2015); London Cancer Alliance (2015); Reilly (2014); National Institute for Health and Care Excellence (2004)
The aim of L2PS
The core aim of L2PS is to support staff to identify and facilitate psychological management of patient psychological distress. The group setting offers an opportunity for staff to reflect and build on existing clinical skills, and develop new strategies. This in no way suggests that nursing staff are not familiar with, or capable of, addressing psychological concerns in their patients – rather, the aim is to reduce the related burden on time and the skillset expansion associated with patient and carer psychological needs.
The model also allows for the impact of work on staff psychological wellbeing and self-care to be considered. It offers relevant strategies, as well as signposting, to staff-specific mental health services. As L2PS models have been adapted, it is common for psychological services to offer one-to-one sessions for those issues nurses feel cannot be raised in a group. This excludes personal therapy, but may include assessment for signposting, as needed.
Benefits of L2PS
Research highlighting the benefits of L2PS is rare, and studies that are specific to L2PS are rarer still. This may be explained by the fact that the actual implementation of L2PS is a recent recommendation and not yet mandatory. With the obvious emphasis on building a greater evidence base, we may look to generic supervision studies to highlight benefits of supervision in general, as well as to available studies on L2PS.
Clinical supervision has been shown to have extensive benefits, including:
- Positive effects on listening and supportive management of patients and colleagues (Jenkins et al, 2010);
- Improved association between effective care and patient experience (Snowdon et al, 2017; Bégat et al, 2005);
- Reduced work stress, anxiety and burnout (Iosim et al, 2021);
- Improved wellbeing and mental health (Kingsley et al, 2023; Dilworth et al, 2013);
- Improved perceptions of mastery of challenging behaviour;
- Facilitated access to specialist support for staff (Hussain et al, 2023; Chenoweth et al, 2010; Buus and Gonge, 2009).
Specific to level 2, Jenkins et al (2010) carried out a study to identify the benefits of staff attending L2PS. Facilitators included a clinical psychologist, counsellor, social worker and assistant psychologist, all of whom were involved in supporting staff to screen and offer patient psychoeducational skills. Evaluation involved the use of a pre- and post-intervention self-reported confidence questionnaire, with a follow-up at six months. The results suggested that staff attending showed a statistically significant improvement in all areas, which was maintained at follow-up.
A more recent study by Kingsley et al (2023) found that a level 2 model adapted to community nurses showed self-reported improvements in confidence and identification of patient psychological distress, as well as increased confidence in offering strategies and improved recognition of complex cases suited for referrals to specialist services. This study also highlighted positive changes in staff attitudes and action on personal care and wellbeing.
From this limited source, we see the tangible benefits of psychological clinical supervision, not only on clinical practice and patient care, but also on staff’s confidence and capacity to manage their own and patient distress, in line with the intentions of the original four-tier model.
L2PS: challenges for staff
In light of the scarcity of literature, we refer to our own clinical practice-based evidence as facilitators of L2PS on challenges to attendance and engagement for nurses. This information, sourced from records of attendance and a result of direct exploration with attendees as to why they have been unable to join or have declined invitations, falls into two categories:
- Practical attendance challenges;
- Engagement challenges.
Practical attendance challenges
In spite of protected time to attend, there are practical challenges that can prevent staff from attending, either completely or in part. These include:
- Patient priorities, often due to unexpected changes in clinic lists. This often results in repeated invites, either being sent by leads and facilitators as a reminder or requested by staff to avoid delay by going through emails on the day;
- Administration priorities;
- Staff shortages due to sickness, recruitment issues and unfilled vacancies;
- Changes in rotas and shift patterns;
- Time pressures – especially when district nurses are driving between patients and have no chance to attend between visits;
- Feeling under duress to attend as part of mandatory continuing professional development and this being recorded by managers;
- An underlying ambivalence about their future career as a nurse, due to ongoing dissatisfaction around role expectations.
Challenges with engagement are not all problematic in themselves and may improve with ongoing attendance. However, they often represent greater concerns and misunderstandings around the intention behind L2PS. Box 2 offers an overview of the issues with engagement that we encountered.
Box 2. Engagement challenges
- Intentionally not turning on cameras – this can create a barrier between connecting with the facilitator and other participants, and means it is unclear who is present and engaged in the activity
- Answering emails during conversations
- Eating lunch – this may be the only opportunity to do this during the day
- Repeatedly muting discussions mid-conversation to respond to colleagues or telephone calls in their clinical environment
- A belief – either spoken or implied – that there is no sincerity in the offer beyond it being a tick-box exercise
- A (mistaken) belief that the training implies that staff are not competent to deal with psychological issues related to themselves or their patients
- A (realistic) concern that attendance at the group will result in having to work overtime at the end of the day to make up for the hour ‘missed’
- A fear of expressing vulnerability in the presence of other colleagues and being seen as less competent
- A fear of being seen as emotionally weak in a work culture in which nurses are expected to absorb distress on a daily basis
- A (realistic) belief that the group cannot help them change issues with their employment situation (for example, changes in shift patterns or resources) in a practical sense. Although understandable, this results in an increasing sense of frustration across sessions and an absence of engagement with facilitator and/or other attendees
- A belief that local managers and leads are helpless to change situations, resulting in increased feelings of hopelessness
Challenges for facilitators
A literature review by Rothwell et al (2021) identified the related consequences of some of the above barriers, and included:
- A lack of consistency;
- Disruption in group dynamics due to ever-changing group members;
- Difficulty in developing relationships between the group and the facilitator;
- A sense of pressure to provide each session as a ‘one off’.
It is notable that, by and large, it is practicalities, rather than individual attitudes, that create barriers to attending a group intended to improve work-related stress, and a cycle of dysfunction is created. Further, we see that the consequences of not actively addressing these barriers means that we run a risk of undermining the whole process, suggesting little can be done until the practical and engagement challenges have been addressed.
Staff attending L2PS groups report that engagement issues originate in wider policy decisions about clinical workloads and resources. They have argued that, without changes to the wider system, little can be offered to staff other than flexibility in access and availability of sessions.
Research highlighting specific steps taken to improve engagement and remove barriers to supervision in general are scarce. Where this exists, it tends to focus on professional supervision, rather than L2PS, and on models themselves, rather than issues of practical access and attendance. However, Rothwell et al (2021) explored enablers and barriers of engagement to clinical supervision, and highlighted that the following were needed:
- Supervision based on mutual trust;
- A positive relationship and a cultural understanding between supervisor and supervisee;
- A shared understanding of the purpose of supervision, based on individual needs;
- A focus on enhancing knowledge and skills;
- Training and feedback provided for supervisors.
As with our clinical practice in delivering L2PS, Rothwell et al (2021) highlighted a lack of ongoing support and engagement from leadership and organisations in terms of issues, such as:
- Staffing and its practical management;
- Staff training needs.
These issues are in a context of profession-specific models of nursing supervision, but the conclusions drawn are still relevant to the implementation of L2PS.
Actions that can be taken
While acknowledging that local service managers may be restricted by overarching local and national policies, actions can be taken to facilitate the implementation of L2PS. These include:
- Allowing protected time for staff and direct verbal encouragement to attend;
- Clearly introducing the aims and remit of L2PS offered to all staff;
- Ensuring a shared link is available to all staff, at the outset, for staff-specific mental health services;
- Allowing for individual and group sessions (keeping within the remit);
- Creating a forum where practical/role-related concerns raised in the group can be addressed;
- Reviewing and reformulating sessions with attendees on an ongoing basis.
All these ideas are inherent in identifying and managing both staff and patient psychological care and wellbeing. The above steps may go some way towards giving a clear message that the principles of compassionate management go beyond theory and are not simply limited to within sessions or restricted to specialist psychology services. These processes also validate the association between emotional distress and professional roles experienced by staff, but challenge the beliefs of helplessness and hopelessness.
The measures themselves may appear to cause some disruption to service delivery at the coalface, but ignoring the issues will likely only result in greater disruption through staff sickness and resignations, in favour of less-demanding roles or careers.
While L2PS is intended to facilitate both staff and patient psychological wellbeing, professional roles themselves appear to create barriers to use. Feedback from L2PS attendees suggests that, unless greater practical action is taken to address concerns raised in sessions – including those that affect subjective psychological distress – the effects of attending become prohibitive.
It is only with a message from the wider system that is consistent with the aims of L2PS and values of compassionate management that successful attendance, and subsequent benefits, may be obtained for both staff and patients alike. Service managers have a key role in nurturing these processes, acting as mediators between staff teams and local policy makers.
- National Institute for Health and Care Excellence guidelines recommend that level 2 psychological supervision be offered to nurses
- The model has been adapted for nurses across all settings
- The model’s core aim is to support staff to identify and facilitate psychological management of patient distress
- The conflict between policy and practice can lead to issues with attendance and engagement
- Nurse managers can play a role in breaking down these barriers
- Acknowledgement – All nursing colleagues and team leads organising and attending level 2 groups across all specialities and settings, and Dr Marc Kingsley, consultant clinical psychologist – lead for clinical health psychology services, for their discussions around these issues, North East London NHS Foundation Trust
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