VOL: 99, ISSUE: 33, PAGE NO: 32
Peter Thomas, MSc, SRN, NDN, PWT, is part-time counselling supervisor, London NHS Mental Health Trust, and part-time counsellor in primary care and part-time counselling consultant, Southwark Primary Care Trust, LondonThere is a consensus that maintaining staff morale, well-being and motivation is essential for the commitment to high standards of practice (Borrill et al, 1996). It is also recognised that psychotherapeutically trained staff can provide supervision, training and support to 'front-line' mental health workers by providing models of understanding and managing mental distress (Parry, 1996).
There is a consensus that maintaining staff morale, well-being and motivation is essential for the commitment to high standards of practice (Borrill et al, 1996). It is also recognised that psychotherapeutically trained staff can provide supervision, training and support to 'front-line' mental health workers by providing models of understanding and managing mental distress (Parry, 1996).
The facilitator role
The staff support group led by a suitably trained facilitator has traditionally been a way of meeting the needs of front-line staff. This legacy of the therapeutic community movement has been a mixed blessing (Bolton and Roberts, 1994) because it can be viewed by staff as a magical solution to the inherent difficulty of their work or it can be used defensively to prevent conflict resolution and change.
This article will only explore one part of the model, the role of the facilitator and how the boundaries are maintained. The Tripartite Model is a developmental model of intervention with staff groups that attempts to foster conditions for constructive group work and to limit the regressive pull into the security of primitive institutionalised defences and rituals (Hirschhorn, 1988). For a full description of this model see Thomas et al (2001).
Over the past 10 years in my work with health care workers in a variety of settings, I have developed the role of the facilitator model, with supervisory help from Rance (1998). In the early days I worked with single-grading groups at the request of the groups themselves (Thomas, 1995). However, during the last seven years I have moved towards developing professional development groups (PDGs) because I firmly believe that these are the way forward.
Aims of the professional development group
The three main aims of the PDGs are:
- To develop effective multidisciplinary communication structures that contribute to the effectiveness of team communication and lead to a greater understanding of and respect for the role of others. It was assumed that better communication would lead to improved patient care;
- To give staff an opportunity to develop reflective practice and encourage them to explore the effect of the work setting on their personal, physical and psychological health. All staff receive clinical supervision in their own discipline. Supervisory issues may enter the group but the group explores them from the angle that they impact on the team not the presenting issues of the client;
- To develop an awareness of how group culture can reflect the culture of the work environment, which, in turn, can reflect the culture of the organisation. By using the group as a diagnostic tool, rather than a traditional supportive structure, the intention is that, with a correct diagnosis or at least a reasonable hypothesis, the members of the group are empowered to take steps to resolve issues outside of the group in the daily life of the ward.
These aims are not hidden and are made clear to all new members of the group. When a new member joins, the facilitator meets with the new staff member and talks to him or her about the purpose of the staff groups, the boundaries and his or her previous experiences of being a member of a group.
The value of meeting with prospective members cannot be overstated. It gives both parties a chance for a discussion before joining the group. Any concerns about membership can be explored and the rationale for the groups is explained.
It also seems to have the effect of denying staff members immediate access to the group while they wait for a meeting with the facilitator. This means that initially they are left out as their colleagues all disappear to the meeting, which seems to create an urgency to join the group to find out what goes on.
Main tenets of the model
A basic tenet of this work is that a PDG can encourage staff to explore and modify the anxieties experienced in the work setting by allowing these anxieties to be felt and expressed in a safe, contained environment. The role of the facilitator is to maintain a boundary between inside and outside, in oneself and in others.
The facilitator also keeps an attendance register and goes through the list at the beginning of each group. This has developed into quite an important ritual because it cements the membership of the group and allows the facilitator, and also the staff members present, to know whether staff absences are due to days off, illness, study leave or other duties. It also enables the facilitator to establish patterns of behaviour among group members.
If a group member is frequently absent the facilitator offers to meet him or her individually to discuss the lapsed membership. This has happened more often with the medical and administrative staff who suffer less peer pressure than the nurses. The effect of these individual meetings has frequently been positive and they can be viewed in a caring way rather than as punitive.
After five years both groups are now fully established with nurses, doctors, managers, art therapists and administrators attending the meetings. Only a few nurses have opted to stay out of the group and agency nurses are on duty on the ward during group time, which has become sacred for all staff members.
Sometimes nurses have to leave the group suddenly to answer alarm calls. It has been speculated that patients may resent staff disappearing from the ward and express their disapproval by 'acting out'. Confidentiality has been maintained within the group and the communication structures outside the group are improving.
It was decided to have the PDGs evaluated by their members. A detailed questionnaire was posted to all 30 current group members on two acute mental health wards (15 on each ward). A stamped addressed envelope was enclosed to make it easy for the participants to return the form and everyone was assured that all replies would remain confidential.
The response rate for both wards was 80 per cent. This compared with 67 per cent in the previous study (Thomas, 1995). The results of the two wards have been combined because they were almost identical. Results for questions 1-13 are shown in Figs 1-3. Responses to question 14 showed that 50 per cent worked on ward A and 50 per cent on ward B. Question 15 indicated that 67 per cent of respondents were grade A to F.
Questions one to six demonstrate a strong argument for the model with very high scores:
- 84 per cent found the group very helpful or helpful, with only one member finding it unhelpful, and 75 per cent felt the group was very helpful or helpful as a means of encouraging communication between staff;
- 67 per cent found the group helpful or very helpful as a space for personal reflection on their work roles;
- 80 per cent felt the group was very helpful or helpful as a place for debriefing. Because the group meets each week the incidents remain fresh in people's minds.
Several of the comments received back this up:
- 'It helps to resolve the difficult dynamics in the staff team';
- 'We seem to discuss difficulties at the interface, stressful working, occasional positive feedback and support, information sharing and planning';
- 'It meets my needs to address issues that affect me on the ward and to gain support and ideas'.
In addition, 80 per cent of participants felt that the group was very helpful or helpful as a diagnostic tool for highlighting issues on the ward, which, I believe, demonstrates the ability of staff to use the group format in a helpful rather than a destructive way. One respondent commented that: 'Each group on the ward throws up issues that never get resolved. I would like a group that resolves the difficult dynamics in the staff team.'
This comment highlights the fact that the groups do serve the purpose of diagnosing problems but there is not always an arena for resolving them because this often lies outside the scope of a group that only meets for one hour a week.
Interestingly, 67 per cent found the group helpful or very helpful for the discussion of difficult patients and the impact they have on the staff. One staff member stated: 'It is an avenue for sharing experience and exploring potential solutions to problems.'
Because of the staff mix the groups often have a role in disseminating information about wider organisational contexts, 'finding out what is going on in the trust', 'finding out what is happening on the ward, who is talking to who and how people are coping'.
The results also showed that 58 per cent believed having a long-term group helped them cope with work stresses and understanding each other's roles. One member commented that the group helped to 'support staff, develop staff and self-awareness'.
The outside facilitator was felt to be very helpful or helpful by 83 per cent of respondents, while only one respondent found the facilitator to be unhelpful. No one found that the group had been unhelpful in their understanding of each other's roles.
I was also interested to know whether the groups had become stale after five years. Hence, could the time be used in a different way, such as a clinical supervision group or a teaching group. One participant commented: 'I'd prefer the group to be more focused on the here and now and would like more people to talk and that issues get followed through more effectively.'
Of those who answered this question (Fig 2), 54 per cent did not want the group format to change. This indicated that having an ongoing group retains some positive elements. Another respondent stated: 'I think the group meets the individual's needs at the time of the meeting'. In addition, 25 per cent felt that a teaching group would be useful and 21 per cent wanted a clinical supervision group. One respondent commented: 'A chance to talk and sometimes be with one another in a relaxed environment rather than a stressful one. More understanding of how individuals work, and therefore how the team functions or doesn't.'
One member felt that the group would benefit from better attendance and another stated: 'I think it is unfortunate that some team members feel strongly that the group is unhelpful and refuse to attend'. Unfortunately, it would appear that the people with this viewpoint did not return their questionnaires so I am not in a position to explore their views.
One person felt: 'It would be nice if the service manager stops attending so that staff can feel free to discuss issues without the fear of recrimination'. However, I believe the strength of the groups lies in the fact that they are multidisciplinary and that this reduces rather than increases negative transferences.
I suspect that because there is a fairly high turnover of staff the constantly changing group membership prevents the groups from becoming stale. The results showed that 46 per cent of members had been on the wards for less than two years, while only 17 per cent had been in the group for more than three years and this group was mainly made up of nursing staff and the consultant psychiatrists.
The results indicate the model could be developed within other areas of the health service to good effect. I believe that PDGs have an advantage over staff support groups in that they reflect the positive elements of staff groups rather than the idea that groups are a place where individuals are given support. This is reflected in the positive results of the questionnaires.