Introduction
The evidence base demonstrating the effectiveness of psychological assessment, formulation and treatment has grown significantly in the last 20 years (e.g. Layard, 2006; Layard & Clark 2014). In Scotland, HEAT targets are contributing to the Scottish Government national outcomes and National Health Service in Scotland's (NHS Scotland) Quality Ambitions (HEAT: Health improvements, Efficiency and Governance Improvements, Access to services, Treatment appropriate to individuals) (Scottish Government, 2012). An ambitious 18-week access to psychological therapies target has brought considerable focus to supporting and expanding the psychological therapies workforce (NHS Scotland Information Services Division, 2014). This has necessitated the provision of effective, evidence-based supervision of staff delivering psychological therapies in order to ensure appropriate standards and the delivery of efficacious and effective treatments are met [NHS Education for Scotland (NES), 2011].
In 2008 a UK-wide commissioned project was funded to produce a set of supervisory competences for psychological therapies. Roth and Pilling, together with an Expert Reference Group, produced a detailed framework for competences (Roth & Pilling, 2008) which has been subdivided into:
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(1) Generic supervision competences, i.e. statements which describe the knowledge and skills required to supervise practitioners in any psychological modality.
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(2) Modality-specific competences (e.g. of relevance to CBT).
NES contributed to this supervision-focused project and together with guidance contained within ‘The Matrix: A guide to delivering evidence-based psychological therapies in Scotland’ (NES, 2015) has made a significant contribution to the development of psychological therapies and related supervision. The Matrix (NES, 2011 p. 43) recommends that staff delivering psychological therapies should receive frequent clinical supervision in accordance with guidelines for the relevant therapeutic modality and accreditation standards. It also sets out the requirement that anyone providing supervision of psychological therapies will be a qualified psychological therapist with a working knowledge and experience of the interventions in which they are providing supervision, who have undergone training in supervision of psychological therapies.
This paper will focus on the development and delivery of NES Specialist Supervision Training in CBT (NESSST CBT) using a blended learning approach and its place in the overall provision of supervision training in NES. Following on from this, issues arising and forward planning will be outlined.
NHS Education for Scotland (NES)
NES is NHS Scotland's education and training body with a mission statement of ‘Education that enables excellence in healthcare’ (http://www.nes.scot.nhs.uk). The NES Psychology Directorate has overall responsibility for training applied psychologists for NHS Scotland and for increasing the skill base of the existing multi-professional workforce in psychological care. Within this there is a workstream with overall focus on supervision of psychological therapies.
In the supervision workstream, the development of the NES Generic Supervision Competences training, commonly known as the GSC, followed the publications of the relevant competency framework, mapping directly onto the generic competences (Roth & Pilling, 2008). There is agreement among NHS Boards (which are the bodies responsible for healthcare provision, protection and improvement in a local area) that completion of training is mandatory in order to provide supervision of psychological therapies within NHS Scotland. This was reviewed in 2014 and a blended learning training package was developed, in light of the emerging evidence on the effectiveness of e-learning, to produce a flexible and learner-centred resource.
The NES GSC course intends to model the principles of active and interactive learning (Steinert & Snell, 1999) through building on participants’ knowledge and experience with creative, inclusive participation. This includes group tasks and discussion, role play and active analysis of DVD material (Green, 2002; Milne, 2007) and ongoing two-way feedback. The participant ‘handbook’ includes the core information (slides, reading opportunities, etc.) as well as examples of supervision material. The course was designed to be delivered by two facilitators, who will have completed the NES GSC Training for Trainers course, having been identified as holding supervision experience and relevant previous training by their NHS Board. The working group's development of the training resource epitomized the supervision and learning approach, with generous, varied contributions, discussions and reflections (Bleakley, 1999).
In accordance with the recommendations of Roth & Pilling (2008), specialist supervision training must be embedded in and build on generic supervision skills, therefore attending the generic training is a prerequisite for attending the specialist training, such as the CBT supervision module. Training in specialist CBT supervision was recognized as a priority across the NES Psychology Directorate and this training was developed to ensure that the needs of the different groups both pre- and post-qualification were met.
In many ways the experiences of the working group in developing and revising the generic supervision training provided the active background for the development of the specialist CBT supervision training. This was developed from the ‘NES Clinical Supervision in CBT’ course which was piloted as a 2-day training course. Importantly, overall, a key aim was to establish a training resource that would be competency-based and increase opportunities for assessment of the supervision competence of its participants.
Specialist CBT supervision training
In 2011 and 2014 surveys were carried out by NES to gather views on and gauge readiness for training in CBT supervision among CBT therapists and clinical psychologists.
In brief, the survey results suggested that CBT therapists and clinical psychologists viewed supervision of CBT as a highly important part of their role within CBT more generally and placed high importance on receiving further specific training in CBT supervision. When asked about preferred content of training, the use of structured tools for supporting the development of CBT competences (e.g. use of the Cognitive Therapy Scale – Revised; CTS-R; Blackburn et al. 2001) was the most frequently mentioned topic, followed by supervision of complex cases and models of CBT supervision. The survey responses suggested that the use of structured CBT competency tools in supervision was viewed as important by this group of supervisors, and that there was scope for confidence in their use to be strengthened. The main perceived barrier to using such scales was time. Survey responders also highlighted the importance of applied psychology training courses continuing to place feedback based on CBT competency scales in the broad context of the full range of competences developed on training placements.
This training (in parallel with GSC) is designed to provide a consistent training across Scotland, based on the best available evidence base where design and implementation planning has a foundation in implementation science approaches and impact measurement is routinely available for scrutiny (e.g. Fixen et al. 2005). Other UK training programmes were reviewed including Milne (2010) which provides evidence of effectiveness of a manual-driven training programme for evidence-based clinical supervision. However, that was designed for clinical psychology training specifically, was delivered in traditional face-to-face delivery supported by a manual and included learning outcomes more parallel to the GSC than the NESSST CBT training.
Background to the training and learning outcomes
The content of the training package was designed to support the development of the knowledge and skills detailed in Roth & Pilling's CBT Supervision Competency Framework and to reflect current developments in the evidence base on CBT supervision. The full set of CBT supervision competences can be found at http://www.ucl.ac.uk/clinical-psychology/CORE/Supervision_Competences/cbt_skills.pdf.
The intended learning outcomes (ILOs) were:
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• To be able to identify your own competence in CBT supervision.
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• To be aware of the CBT models which inform supervisory practice.
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• To develop your understanding of what is expected in terms of the particular roles of a supervisee and supervisor in CBT supervision.
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• To increase your confidence and competence in using the CTS-R (Blackburn et al. 2001) as an example of a learning and feedback tool in CBT supervision.
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• To be able to adapt CBT supervision for varying learning needs within the context of high-intensity practice.
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• To be able to problem-solve different CBT supervision scenarios.
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• To be able to use a structured evaluation form, the Supervision: Adherence and Guidance Evaluation (SAGE; e.g. Milne et al. 2011), as an example of a tool to receive feedback on supervision (and for self-reflection).
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• To introduce self-practice/self-reflection as a recent development in CBT training and supervision (Bennett-Levy, 2003; Bennett-Levy & Lee, 2014).
Rationale for blended learning
In line with opportunities provided by e-learning and in accordance with the available evidence base regarding the acceptability and effectiveness of blended learning and the NES strategy of digital transformation, summarized as: ‘the vision of a future NES which is digital by default, and at the forefront of the use and application of digital technologies to support education for health and social care staff’ (Lamb, 2014; http://intranet.nes.scot.nhs.uk/tomorrows-nes/digital-review/) the decision was taken to develop the training into a blended learning package.
The aim was to provide an effective, time-efficient learning format with a degree of flexibility for learners to undertake part of the training at a time and place suitable for them, thus reducing some of the potential barriers to undertaking and completing the training. This is particularly potentially useful in NHS Scotland where for some NHS Boards geography is an additional challenge to training delivery, for example in remote and rural areas. The e-learning resource was designed using the LearnPro learning management platform in consultation with LearnPro web designers. Our explicit aim was also to provide a useful set of resources which would be readily available to our supervisors via the e-learning platform at any time following completion of the training.
Blended learning has been defined as ‘Learning involving multiple methods and approaches, commonly a mixture of classroom and e-learning’ (Mitchell & Honore, 2007). A recent meta-analysis of the relative impact of blended learning found a modest improvement in performance in comparison with traditional classroom teaching. This advantage was absent when comparing pure online with classroom learning (Means et al. 2013).
The content of NESSST CBT e-learning was developed by the authors based on the content of the face-to-face pilots. Focusing on high-intensity one-to-one supervision in CBT, the authors decided to move content around relevant theory and evidence base to the e-learning format, freeing up time to maximize the opportunities for experiential learning at the face-to-face training day, given the evidence base on the effectiveness of this type of learning (Burch et al. 2014) and feedback from other supervisor training developed within NES. The topics for the e-learning module are outlined below.
E-learning module
The learners, following successful application and selections were invited to complete
The pre-course e-learning module
The pre-course section constituted the bulk of the didactic material:
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• Orientation to CBT supervision including review of the functions of supervision, refresher of the NES Training in GSC and introduction to the CBT Supervision Competency Framework.
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• Self-assessment of CBT supervision competence based on the knowledge and skills detailed within the framework.
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• Review of evidence base of effective supervision strategies for CBT.
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• Introduction to the Cognitive Therapy Supervision model (CTS; Padesky 1996; Liese & Beck, 1997) and Evidence Based Clinical Supervision model (EBCS; Milne, 2009).
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• Introduction to the concept of self-practice/self-reflection in CBT training and supervision (Bennett-Levy, 2003; Bennett-Levy & Lee, 2014).
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• Overview of CBT competency assessment including introduction to the CTS-R as an example of a structured CBT competency rating scale.
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• Review of the SAGE scale (Milne et al. 2011; Milne & Reiser 2014) as a tool for assessment of CBT supervision competency and for self-reflection.
The pre-course e-learning involved participants reviewing summarized information on the above topics, with links to key documents and signposting to further references. The learning format included interactive exercises to promote engagement with the material, and regular ‘pause and reflect’ exercises designed to promote experiential processing of the information and encourage reflection on learning.
Participants then attend a face-to-face training
The face-to-face element of the training takes place over one 7-hour training day, these are delivered in locations across Scotland to reflect the population and service need. The topics covered include:
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• ILOs and Roth & Pilling's CBT supervision competency framework.
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• Introduction to the CTS-R as an example of a structured CBT competency rating scale, with an emphasis on how this could be used as a learning tool in CBT supervision and for self-reflection, including structured group reflection on a DVD clip of a CBT session.
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• Brief review of models of CBT supervision (CTS and EBCS).
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• Review of the SAGE scale with emphasis on the opportunity to use this for receiving feedback, self-reflection on CBT supervision competency and as a learning tool.
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• Development of a personalized learning plan for self-development, with reference to the SAGE and CBT supervision models.
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• Role-play practice of common CBT supervision scenarios including the opportunity to practice bringing feedback from the CTS-R into supervision, along with the opportunity to give and receive feedback using SAGE.
The post-course e-module
The post-course e-module included another brief video clip setting the context for a short multiple-choice quiz, designed to assess learning linked to the learning outcomes, and a repeat of the self-assessment of CBT supervision competences.
Currently, the team have delivered 10 courses with a further three available over the next few months. Full data analysis is planned at that time.
Evaluation method
Multiple forms of evaluation are planned in order to understand and evaluate the impact of this training project. This has been designed with a view to looking at impact across a range of points of Kirkpatrick's model (e.g. 1967, 1987) which is widely used to guide training evaluation (Fig. 1).
Kirkpatrick's model of Training Impact Evaluation.
Data is being gathered on:
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• Qualitative information regarding experience of training (level 1).
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• Face-to-face training using an adapted pre- and post-Training Acceptability Rating Scale (TARS-1; Davis et al. 1989) (level 1).
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• Self-assessment of competence in the pre- and post-e-modules (associated with Kirkpatrick level 2).
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• Post-e-module quiz (associated with level 2).
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• Three-month follow-up email, automatically generated and asking for participants to record behaviour in relation to use of the recommended resources, i.e. CTS-R and SAGE (level 3).
Further research is planned with a view to examining the wider impact of the training on the service.
Discussion
Through the process of developing and delivering the initial round of NESSST CBT training a number of, what appear to be, inter-related issues have arisen that are important to consider for future planning.
First, and focusing on the training model that has been described above, there has been a considerable process in the development of NESSST CBT that has resulted in the current blended model. Blended learning offers a number of opportunities from an NHS perspective. These include offering a flexible training model which will be available as a resource in the longer term for participants. It will also facilitate, further opportunities for data collection and analysis of changes in the participants’ self-assessment of competences and behavioural change at 3 months post-training (e.g. use of the CTS-R as an example of a structured assessment of CBT competences).
However, the challenge of delivering a highly complex e-learning module across variable IT systems has to be acknowledged. Some evidence shows that the effectiveness of e-learning can be undermined by technological difficulties (Mitchell & Honore, 2007); however, we are working to have the learners experience this in a more seamless manner. One emerging challenge is ensuring the participants and managers place equal emphasis on the completion of the e-learning component as on the face-to-face training. Further work is required to ensure that this is communicated clearly and the necessary time is protected. The view of e-learning as an essential and creative part of a learning package needs to be embedded in services. In addition, we are more reliant on learners’ self-motivation and time management than traditional modes of delivery.
The approach taken with the training model aimed to separate the theoretical components of CBT supervision for the online component, leaving the practical components largely to the face-to-face event. The training itself is based on educational learning models such as Kolb (1984) and CBT models of supervision (Padesky, 1996; Milne, 2010). To be adherent to the very principles of these underpinning models, the training should ensure that participants are taken through the learning cycle effectively and that it is coherently mapped onto CBT supervision such that participants effectively experience CBT supervision during their training. While these principles have guided efforts throughout development, the extent to which this has been achieved is unknown, and can only be borne out through data gathering and further research, comparing training models and their impact on supervisory competence development.
A wider roll-out requires more trainers and hence the competences required of CBT supervision trainers needs consideration. It can reasonably be assumed that trainers should be highly skilled in both CBT as a modality of therapy and in CBT-specific supervision. Of course, competence in therapy and supervision is not the same as training competence for CBT. These issues are important when we think about training roll-outs and fidelity to CBT and CBT supervision models
A further content issue that has arisen is with regard to developing participant competence in using the CTS-R (Blackburn et al. 2001) as a learning tool in CBT supervision. It remains a considerable challenge to develop consistency in assessing CBT competency using the CTS-R. Efforts have been made recently to improve upon the CTS-R scale itself through a systematic review and development of a new competence scale (Muse & McManus, 2013) but the issue of how to train people effectively in using a CBT competence tool that is inevitably subjective by nature and therefore significantly prone to bias remains. However, there remains, on occasions, considerable disparity across CTS-R summative and formative assessments, even amongst the most experienced assessors. Further research and development aiming to establish more effective methods of training in CBT competency assessment is required, such that consistency can be improved. This can only be of benefit to supervisors in training and ultimately the recipients of CBT supervision and thus competent CBT practice. This is resolved within the training by focusing on the tool as a formative feedback tool, rather than its use as a summative assessment.
The collective supervision resource in NHS Scotland requires some further consideration. The recent developments in supervision training in Scotland have been contextual to a major focus on delivering more efficient psychological therapy in the Scottish NHS (Scottish Government, 2012) and there are therefore very significant increased demands on the governance, and provision of clinical supervision. Training in psychological therapies for the existing NHS workforce has expanded rapidly and while the increased focus on psychological therapy provision is to be welcomed, it is very clear that the pressures on the service to govern, and specifically to provide clinical supervision in psychological therapies, is massively increased. Those professionals, who are key to the delivery of psychological therapies, and their service managers, will need to give consideration to the priorities given to clinical supervision. If it is believed that supervision is a key component of the effective delivery of therapy then supervision training and provision should ideally be given equitable status in job descriptions, Continuing Professional Development (CPD), and in individual job plans, such that supervision is recognized as a core and key clinical activity alongside the provision of therapy.
Although this training is designed explicitly to meet the competences as outlined by Roth & Pilling (2008) and there are a number of assessment opportunities built in both for the supervisors’ development and the training impact evaluation, we are unable to directly evaluate supervisor competence although the use of standardized assessments such as SAGE (Milne et al. 2011) are encouraged throughout the training for individuals to pursue in terms of their own development as CBT supervisors. It is reasonable to assume that any potential supervisor should be required to demonstrate competence in supervision if they are to function in a supervisory role. However, as quoted in Milne & Reiser (2012): ‘Somewhat shamefacedly, it has to be acknowledged that the regulation of supervisors is still at an embryonic stage, at least as far as supervision is concerned’ (p. 140).
This is a complex issue but one which is central to ensuring quality of supervision being provided. This issue is hampered by our own understanding of, and the ability to measure competence. Overall, there is a lack of evidence and robust, widely accepted assessment tools although some good measures of supervision competence have been developed such as SAGE (Milne & Reiser, 2014). Falender et al. (2004) stressed the importance of incorporating supervision of supervision and observed practice with critical feedback into the process of developing competence in supervision. This project has not been able to set up formal systems to ensure this, but rather to request that self-assessments are shared with supervisors and that people start to use assessment tools in their own supervisory practice. The need for supervision of supervision is stressed in both GSC and CBT specialist training but again no formal requirement or feedback mechanism is incorporated, leading to a major weakness in the system.
However, self-assessment is argued to be an essential step in the development of a competency-based approach and we have incorporated this both in the pre- and post-e-modules and in the use of SAGE as a self-reflection tool. The e-modules present learners with a summary of their self-assessment expressed as strengths and areas for development and these are used as part of the learning experience in the face-to-face training (Falender & Shanfranske, 2014). There are inevitable weaknesses in the use of self-assessment, particularly the requirement for reflective skills. However, Falender & Shanfranske (2014) argue that through robust and regular feedback this can be learned and this is another advantage of learners sharing their self-assessments in supervision of supervision. It will be necessary to strengthen the responses to these to ensure they are met with similar challenging and supportive feedback as other areas of skills development.
But whatever tools were developed or used, there are significant resource implications to consider in the process of evaluating competence in clinical supervision robustly and transparently. This would need to be sufficiently prioritized by those who employ supervisors. A second and closely related issue is that of the need for clarity between managers and trainers in what would happen in the event of someone being deemed as not yet competent to supervise. It would be important to consider exactly how competence development would be addressed in such circumstances. In the first instance this will involve developing a clear system of feedback to managers in the service and asking potential supervises to sign up to this in advance of the programme. Feedback could be designed to be in the form of ‘additional developmental needs’ rather than a ‘pass’ or ‘fail’.
Another potential option to providing effective governance of clinical supervision would be to ensure supervisor competence is considered equitably with practitioner competence by bringing supervision training under the governance and accreditation of academic institutions. In so doing, robust mechanisms of measuring competence and feedback as well as systems of appeal would be incorporated in the process. Such an arrangement would cover many of the issues related to governance of supervision that are discussed in this section. However, there would be significant barriers to this is terms of levels of resource, particularly in terms of time and increased bureaucracy. An alternative option is to encourage supervisors following their completion of NESSST CBT, to pursue supervisor accreditation with external supervisor accreditation such as that provided by the British Association of Behavioural and Cognitive Psychotherapies which would require them to provide and receive relevant feedback on their supervision of another's CBT practice and continue to engage in relevant CPD specific to their role of clinical supervisor.
In developing and delivering clinical supervision training programmes over approximately the last 7 years in NHS Scotland, many, perhaps inevitable questions and issues have arisen. In essence these largely revolve around the key and complicated issues of governance in psychological therapies and with these recent developments in clinical supervision training there are yet further layers added to that complexity. Clearly the governance of clinical supervision is trailing the development of the training programmes in supervision. Nonetheless, in the process of the development of these training programmes many of these issues, and their potential solutions, are now being considered and beginning to be resolved.
This paper provides a brief overview of the function of NES and its role in the development of clinical supervision of psychological therapies by establishing a comprehensive training portfolio. More specifically, a detailed description and explanation of NESSST CBT, which incorporates a blended learning component and planned evaluation in terms of understanding impact has been presented.
Ethical standards
All the required ethical standards have been met.
Acknowledgements
This paper received no financial support.
Declaration of Interest
None.
Learning objectives
By the end of this paper the reader should be able to:
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(1) Be aware of the process of the development of the NESSST CBT Supervision Training Package.
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(2) Appreciate the challenges in developing, maintaining and promoting governance of CBT supervision and training.
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(3) Recognize the role of NHS Scotland Infrastructure (NES, Boards, line managers, etc.) in progressing CBT supervisors and their training.
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