A pilot for a support service for groups of ward-based staff in medium and low secure units in the south west. The rationale was that group supervision would offer an opportunity for staff to contemplate their work together within a safe and secure environment, and a place where the staff are a resource of ideas and experience for each other. It was anticipated that group supervision might reverse the isolation that staff may experience in a forensic mental health hospital. Group supervision was initiated to promote open communication and encourage individuals to contribute to the group discussion and to clinical practice. The pilot was established as a small-scale, short-term trial that would that would offer learning for the Secure LDU and MUS on how a large-scale group supervision support service might work in practice.
Aims and objectives
The rationale was that group supervision would offer an opportunity for staff to contemplate their work together within a safe, protected and allocated time within their working day. To offer a place where the staff are a resource of ideas and experience for each other. It was anticipated that group supervision might reverse the isolation that staff may experience in a forensic mental health hospital and promote open communication and encouraging individuals to contribute to the group discussion and to clinical practice.
This relates to NICE guideline: Safe staffing for nursing in adult inpatient wards in acute hospitals
Safe staffing guideline [SG1] Published date: July 2014
1.2 Principles for determining nursing staff requirements
These recommendations are for registered nurses in charge of individual wards or shifts who should be responsible for assessing the various factors used to determine nursing staff requirements.
Nursing staff factors:
- Nursing activities and responsibilities, other than direct patient care. These include:
- professional supervision and mentoring of nursing staff. Student nurses are considered supernumerary
- communicating with and providing nursing clinical support to all healthcare staff involved with the care of patients on the ward
- Support from non-nursing staff such as the medical team, allied health professionals and administrative staff.
1.6 Psychological interventions - Delivering psychological interventions for mental health problems
1.6.1 Refer to relevant NICE guidance for the psychological treatment of mental health problems for adults in contact with the criminal justice system, taking into account the need:
- to modify the delivery of psychological interventions in the criminal justice system
- for staff to be trained and competent in the interventions they are delivering
- for supervision
1.9.4 Give all staff involved in direct care, training (as part of induction training and continuing professional development) and supervision to support them.
It was a pilot support service, for ward-based staff nursing, healthcare assistants, occupational therapists and occupational technicians.
The group supervision aimed to provide a place for learning, reflection and support.
Reasons for implementing your project
The Quality Network for Forensic Mental Health Standards QNFMHS states in its Standards for Forensic Mental Health Services: Low and Medium Secure Care (2017) that ‘all clinical staff members receive clinical supervision at least monthly, or as otherwise specified by their professional body’. (Standard 130, p.19). And that ‘all staff members have access to monthly formal reflective practice sessions. Guidance: This forum provides staff members with the opportunity to reflect on their own actions and the actions of others. This forum can also be used to discuss concerns and issues of relational security’. (Standard 133, p.19)
Reflective practice was previously offered in the unit and co-ordinated by a psychotherapist. When the psychotherapist left this provision did not continue. The reflective practice was difficult to maintain, the experience of reflective practice space was not considered valuable by staff and was evident in lack of attendance. Given the requirement by the QNFMHS it was necessary to provide this service to staff. A small pilot was developed on one of the wards, with distinct aims and functions of learning, reflection and support. Working in Forensic psychiatric environments can be both challenging and rewarding for staff. In terms of staff satisfaction we aimed to develop staff capacity to be reflective about their work. This, we hoped would enable proactive reflection and competency in applying to theory to professional practice, which would support them in their work with service users. Over time this aimed to build and grow staff confidence and autonomy in their professional work, encouraging vitality and curiosity in their working practice population demographics
How did you implement the project
Prior to the pilot we invited existing senior members of staff to register their interest in becoming a supervisor for the Group Supervision Pilot. With this in mind, there was no additional cost for staff other than the Supervisor’s time during the working day.
The criteria for being a Supervisor were: committing to completing the pilot duration of ten months, band 6 or above and committing to attend monthly supervision-for-supervisors meeting.
Ten multi-disciplinary supervisors were recruited to cover ten wards. There was a brief training for Supervisors focusing on the group supervision framework - the Supervisors’ understanding of the theory of the unconscious and the parallel process, their understanding of the structure of supervision as a discipline separate from therapy, their understanding of learning in supervision and confirming their commitment to engage in honest questioning of personal beliefs and prejudices.
Each Supervisor met with the ward manager and the staff of the ward they were supervising to arrange the day of the group supervision. They negotiated with the ward manager for cover on the ward during group supervision so that the staff would be able to attend.
The problems encountered prior to and during the pilot was reflected in the feedback from Supervisees and Supervisors in the post-intervention questionnaire. In general, there was feedback about the lack of support from ward managers and senior MDT and management to prioritise the group supervision sessions, which had been a problem in the previous provision of reflective practice. Having this previous knowledge, we attempted to safeguard against it with several strategies. We met with a member of the senior management team monthly, which bridged communication about the pilot to staff who were not ward-based and teams with whom we had less contact. In addition: we set up a system where the unit Nurse in charge would arrange the provision of extra staff to cover the ward while Group Supervision was happening; we ensured that Group Supervision sessions were evenly spaced throughout the week to enable staff from other wards to support the ward while staff were in the Group Supervision session; we agreed a set time of handover 2.00 – 3.00pm, to enable more staff to attend and allow cover.
We set up an evaluation of the pilot by creating a short questionnaire for both Supervisors and Supervisees. From a small sample of 22 returned questionnaires (from approximately 200 staff):
18 staff members agreed that their needs had been met
15 felt the group had supported them emotionally
20said that it offered opportunity to discuss work with colleagues in a protected space
15agreed that group supervision supported them with managing the emotional intensity of working on the ward
In the qualitative feedback from the supervisees some of the comments were:
- ‘[Group Supervision] is a brilliant way to talk about problems and situations [in the clinical work]’
- ‘Very helpful during difficult times on the ward’
- ‘A valuable resource’
- ‘Helpful to discuss things as a team’
- ‘[Group Supervision] is vital to feel better and empathise with others’
- ‘Promotes team work and decision making’
- ‘Empowers everyone’
We have aimed that this Group Supervision intervention for staff would maintain and improve interest and curiosity with their working practice, and in turn enables them to provide a thoughtful and empathic service to the service users. This was raised in the NHS Workforce Health and Wellbeing Framework published in 2018. Within the Mental health: prevention and self-management Section they recommend: ‘Reflective practice is encouraged where time is made to reflect on experiences that occur in the job and to learn from them, for example using Schwartz Rounds, peer support or providing quiet space to ‘decompress’. And in this section it is noted that ‘Investments and wellbeing programmes should improve both the local work culture and the wider organisation’s performance…’ (taken from Understanding staff wellbeing, its impact on patient experience and healthcare quality, Picker Institute, 2015)
Supervisors in their feedback noticed the development of the staff during the pilot:
- ‘Regular attendance deepened understanding of the role of the supervisor - understanding [that] the supervisor facilitates an open and safe space to explore and process thoughts and feelings around the impact of their work’
- ‘Staff grasped the notion of it being a serious forum to discuss work, outside of informal conversation with colleagues’
Key learning points
The group supervision aimed to support and promote continued professional learning and personal development, which we achieved.
The key learning from the pilot is the effectiveness of the group supervision provision, and that it is beneficial to staff on many levels. Equally the other aspect of this is an understanding of the complexities of providing a ‘thinking space’ as opposed to ‘doing’ within the forensic psychiatric environment. To support staff to be able to reflect on their responses and develop reflective capacity as opposed to reactive. And to educate staff in the value of reflection and thinking as well as the task orientated aspects of their clinical profession.
There were some areas of difficulty that we encountered which have been described elsewhere in this submission. The nature of these difficulties however, were mostly symptomatic of the disconnected lines of communication between professions within the unit, so ultimately, this enabled to build communication and open new lines of dialogue.