Support Groups in Nursing Practice

Nurse led support groups can help individuals live with disease, increase social support and reduce psychological burdens. The nurse can develop or expand group leading skills and maintain practice standards by working with a supervisor or skilled co-leader. Leading a group can expand the nurse's professional and clinical role. Benefits of groups include helping patients understand their problems are universal, they can support others, and they are not alone. People in support groups often learn new coping skills. Support groups are cost effective and offer multiple benefits. The concepts, types, phases and leadership of support groups are discussed and illustrated by clinical examples and sound research. Often nurses without experience in this area are asked to lead support groups, but they need skill and know how for this task. Nurses may wish to expand their skiD and knowledge in leading support groups to help patients cope with their disorders. Support groups are widely used as the context of treatment, counseling, and education for patients because they can improve emotional support, social contact, and control. However, a review of the literature found that most publications focus on support groups in geriatrics or in oncology. A meta-analysis showed that groups are at least as effective and sometimes more effective than individual treatment and more efficient because more patients are treated for the same cost (Brodaty, Green & Koschera, 2003). Support groups may improve patients' psychological and psychosomatic symptoms, coping strategies, and stress management. They have effectively provided a supportive and psychoeducational approach for patients (Nettina, 2001). Studies show that professionally led support groups can significantly reduce the number of hospitalizations and therefore may have considerable importance for health economics (Diehl, Mayer, Kurz & Forstl, 2003). Some of the texts on groups are older and classic references (Maram, 1978;Yalom 1995). In healthcare, groups offer therapeutic interaction and encouragement and enhance mental health and health education. People frequently interact in groups and depend on others for important feedback about their personal achievement and fulfillment in family, \vork and social settings. Benefits include realizing problems are universal: learning problem solving, developing social support, social skills, and altruism (Zabalegui, Sanchez, Sanchez, & Juando, 2005). Groups also offer a sense of security, belonging, and companionship. Individuals reported they attended a support group to share information, connect with and help others (Baum, 2004; Williams, Young, & McRae, 2004). A group approach is costeffective and useful for diverse individuals in various settings. Personal goals can be accomplished when people work together to reduce weight or stop smoking. A professionally led caregiver support group produced significant reductions in mood symptoms and it increased knowledge, enhanced coping, increased resilience, improved relationships, and improved performance (GanceCleveland, 2004; Winter & Gitlin, 2006). The research, literature. and program evaluation of support groups are limited (Brodaty, Green, Koschera, 2003; Diehl, Mayer, Forstl, 2003). Many nurses want to improve their knowledge of the structure, dynamics, leadership and processes of small groups. The purpose of this article is to explain the design, organization, and conduct of support groups. The leader should understand group dynamics, the disease or problem. If the group focuses on a disease or health problem, the leader needs to know about the disease, its symptoms, and how people cope with it. With an understanding of small group dynamics, nurses from diverse educational backgrounds can lead therapeutic or psychoeducational groups (Friedman, 1994; Kurtz, 1997; Maram, 1978). The principles of group dynamics help the leader decide what discussions to enhance, when to encourage a silent member's participation and when to set limits or clarify issues. Knowledge of interpersonal interaction and psychological dynamics helps the leader evaluate an individual's functioning. Understanding the situation such as bereavement helps the nurse decide how to respond to questions and issues— for instance hearing the voice of the deceased person is a common experience, so such hallucinations are normal and not typically a symptom of psychopathology. Qualified advanced practice psychiatric nurses can serve as group therapists. The effective group will accomplish its specified goals, develop cohesiveness, and manage termination while effectively supporting the members as they develop effective coping skills. Groups can focus on tasks, self awareness, support, growth, and psychoeducation (Chao, Liu, Wu, Jin, Chu, Huang, Clark, 2006; Hoffman, 2006; Milberg, Rydstrand, Helander, & Friedrichsen, 2005). Before starting a support group, leaders will find it useful to interview each of the prospective members and evaluate their symptoms, needs, concerns, and goals. This helps the leader connect with members, start a relationship, and anticipate the general topics likely to arise. However, on an inpatient psychiatric unit, the nurse wiU be expected to include all patients except for those who are disruptive to group process, so an interview may not be needed. For instance, in a support group for people with a Ufe threatening illness, the interview can suggest how open people are to talking about end of life topics, personal fears of dying, and alienation. Designing A Support Croup The leader designs the group by specifying the aims, purpose, format, participants, inclusion criteria for participation, and ground rules for the group (See Table 1). The design may refiect a need in the clinical practice setting. For instance, hospice might decide to start a bereavement group for family members. In another agency, a nurse may conduct a needs assessment and creates a group to respond to the patient's needs for information about coping with their disorder such as cancer or Parkinson's. The design ' Sharon M.Valente, RN, PhD, FAAN, 346 N. Bowling Green Way, Los Angeles, California 90049-2818, 310.472.4495, office 310.478.3711 x49442, fax 310. 268.4038, [email protected] Support Groups in Nursing Practice 27 reflects the leaders' theoretical background and philosophy, the characteristics of the client population, the agency goals and requirements, and legal or professional standards (Kurtz, 1997; Maram, 1978). The leader specifies the group goals, time and length of meetings; place for meeting, beginning and ending dates, addition of new members, attendance, confidentiality, roles of participants, and fees. In psychiatric or geriatric settings, nurses may decide to create a "current events and socialization group" where inpatients would discuss a current event, build social skills, and interact with others. The leader encourages each person's participation but understands that psychiatric symptoms may influence participation. The leader identifies the potential client base and referrals, and obtains administrative approval as needed. Another typical focus would be a psychoeducational group where people with a similar disorder (e.g., cancer, diabetes, HIV or bereavement support group) would how they cope with the disorder. (See Table 4) Croup Design and Format The leader is the architect of the design and the size, aims, length, and duration of the group. Typically one skilled group leader can manage up to 10-12 people and two leaders would be needed for 20 or more. If more than 20 members attend, it becomes difficult to ensure everyone's participation. Yalom (1995) suggests that groups with fewer than four or five members can be less effective. The leader also outlines group aim, purpose, format, ground rules and criteria for participation. In the bereavement group above, most parents agreed they had accomplished the goals in 3 months. For those who still wanted more social support, the members discussed options for joining volunteer or community activities. Some parents also planned to continue their psychotherapy. If goals are not met at the end, the leaders can recommend referrals or solutions. The leader selects the target population, the location and site of the meeting, the type of group (support, psychoeducational, etc), whether it is open or closed to new members, and the length (see Table 2). If it is closed, new members may arrive at the beginning of any meeting. In a psychiatric setting, a nurse may have open membership where patients attend after admission and leave when they are discharged. Selecting an open or closed membership depends on the purpose and goals. The bereavement group was closed because parents needed to become comfortable in order to share intense sadness, guilt, and confusion, and new members would disrupt the developing atmosphere of trust and acceptance. An open group offers more opportunity for people to attend but constantly adding new members can disrupt cohesiveness and development. Other decisions include the criteria for group membership and whether significant others may attend. The leader may need to advertise, market, or announce the group and seek referrals. An effective group will accomplish its goals, maintain cohesion, and develop or modify its structure to improve its effectiveness. In addition, taking notes or charting is typically assigned to the leader, co leader or a recorder (Kuer, Hallauer, Jansen & Diehl, 2004).The leader or co-leaders identify the criteria for membership and typically select people with similar issues who will interact effectively with others. They also provide an orientation, encourage participation, help members reflect on their feelings, and often redirect general questions to the members to encourage interaction (See Table 3).To improve collaboration, co-leaders typically meet between group sessions to compare notes, decide on approaches to specific issues, discuss dynamics, and evaluate the dynamics. For instance, if one group member monopolizes the conversation, the leaders decide how to respond and whether to redirect the conversation. The location for the meetings is important and should be free from interruption and allows confidential discussions and easy access. When conducting some groups (e.g., a bereavement group after a child's suicide) leaders should select a place without obvious references to or pictures of children so they avoid selecting a nursery school or a church with children's classes. In some instances, an agency administrator may recommend a location for a support group that is problematic. For example, one clinic administrator wanted the support group held in the clinic waiting room, which had a loud TV playing re-runs and many interruptions. This was not a suitable area for discussing private issues related to disease management. In addition, the patients viewed the waiting room as their area and complained when they had to hear someone else's personal business while they were waiting. Leadership Functions The leader maintains a functional atmosphere, oversees growth, and focuses the on the goals. For instance, the leader might call someone who had missed one or more sessions to check on that person and set limits when several people talk at once. The leader ensures that everyone has an opportunity to participate, monitors the beginning and ending time of group, and facilitates interactions.The leader may post a flyer that invites people to join who meet the criteria are set for participation. The leader notifies everyone if there is some change in the meeting time or if a meeting is cancelled (e.g., for a holiday). Other leadership functions include managing issues that arise such as a nonstop talker or one who introduces issues that are outside the goals (e.g., long discussions of political elections in a bereavement session). How this is handled reflects the leader's theoretical framework, goals, and leadership skills. For instance, if someone tends to talk nonstop, the leader may choose to bring this issue out in the open at the beginning of the session and encourage discussion about how this influences the interaction. The leader may also remind everyone of the ground rules. Alternatively the leader can tactfully interrupt and reinforce the goal of having time for everyone's participation. The leader can then redirect the discussion or call on another member for comments. For example, in a suicide bereavement support group, one woman wanted to share long stories from Russian literature about suicide and this was outside the goals. The group leader agreed this was very interesting and then skillfully redirected the discussion to the "here and now" issues about coping with their child's suicide. Another leadership task is to facilitate interaction among members. The leader may invite a quiet member who has listens intently to share his or her response. The goal is to stimulate useful exchange and interaction and allow people to share their feelings and concerns. For instance, in the same suicide bereavement group, one couple agonized and asked the leaders how to respond to strangers who asked, "How many children do you have? Because the parents did not want to explain that one child died and disclose the mode of death, which was suicide. Since all members had some 28 Support Groups in Nursing Practice experience with this issue, the leaders encouraged everyone to respond. The leaders asked other parents how they handled this emotionally-laden situation and a productive discussion of this shared problem ensued. The leader can be designated, but members can also provide leadership and can sometimes serve as co-leaders. Co-leaders do not necessarily need to know each other well but they do need to respect and trust each other and have some agreement about the goals and format. Co-leaders need to be motivated and able to work together as a team. The advantages of a co-leader are several: when one leader focuses on an individual, the other can observe the group members, each co-leader may notice different issues; both can compare notes about interactions in a post-group discussion, and they can divide leadership tasks. For example, in a bereavement group, the parents of a teen who committed suicide brought in an article from the school paper. The headline said, "Poor Parenting Causes Suicide." This distracted one of the leaders who was busy imagining writing a rebuttal. The other leader ran the session initially until the other one refocused on the group. In the analysis after the session, the leaders discussed what happened. In another example, an HIV group had one leader who was particularly skillful with chemical dependency issues while the other was more knowledgeable about HIV and lifestyle issues. Some cancer bereavement groups typically have one nurse and one lay or parent co-leader who has been a member of previous groups. Group members often appreciate having a lay member who shares their particular problem and who can serve as a role model for sharing experiences and learning new approaches. To establish and maintain a group, the leader needs to know principles of group process and psychosocial adaptation in small group settings. Basically, theory suggests that people symbolically reenact their past relationships. Therefore, groups provide a learning laboratory where members can challenge some of their assumptions and experiment with new behaviors. For instance, a member who typically keeps silent and always goes along with others because he or she fears rejection can experiment \vith speaking up, self disclosure and some confrontation. After trying the new behavior, the person can ask the others for feedback about fears of rejection or whether the behavior was offensive. Although the preparation for leadership is often diverse, most leaders recommend professional training. Training in interpersonal theory, communication, and group dynamics is useful. Supervision can be extremely valuable and help the new leader analyze their theoretical foundation, motivation, strengths and limitations as a leader. It also can provide constructive feedback about their interaction and leadership activities (Maram, 1978). Discussing challenges and interventions with a supervisor can improve one's perception of the interactions. A supervisor can help a ne\v leader see how an intervention went awry or how to respond more effectively to highly etnotional situations. Process and Development Although many theorists assert that groups are in a constant state of flux. They also grow and develop as members build trust, establish connections, confront issues, negotiate authority and intimacy, conduct work, and resolve termination. Each member arrives with expectations and may compete with others for time to talk. Sometimes, personal expectations conflict. For instance one member may constantly want to ask "Why did this happen to me? but others may fmd this frustrating and want to move on to other issues. Individuals may have different needs for intimacy, control and authority. For example, members may decide to be supportive and so nice to everyone that they never confront issues about conflict or disagreement. The leader needs to distinguish between the healthy and unhealthy behaviors and identify what activities help facilitate growth. In one organizational training group, there were two members who constantly argued with each other about everything. One person would say, "let's discuss this" and the other would say, "No! I want to discuss a different topic." Initially members were immobilized, the leaders were passive, and the consultant's advice about the problem was ignored. This could have continued to make the meetings worthless as two strong people continued to argue. The consultant spoke to everyone and described the conflict between the two participants and said the competition for control was frustrating and preventing any work froin going forward. The two fighters loudly ridiculed that idea and started a fight that monopolized the meeting. However, another member expressed distress with this fighting and suggested that everyone discuss how they wanted to proceed. This started a productive discussion. Developing Croup Leadership Skills Often the leader also needs to break down complex concepts about symptoms into concrete examples and sometimes humor helps. For example in one group when people were discussing depression, the leader explained that if you find that you no longer enjoy your favorite activity (e.g., watching the ball game, sitting on the porch watching the sunset, or gossiping with friends) that should indicate that you are feeling depressed and you should seek assessment and treatment. This concrete example finally made sense to everyone. A sense of humor is always useful. In another group, where the members were worried that their friends told them they were going "crazy" because their behavior had changed (they had become more assertive and were saying "no"), the nurse leader asked if anyone was "seeing or hearing things that were not there" or "walking down the street naked and peeing on the flowers." These examples cause several giggles and allowed the members to go past their immobilizing fear to exatnine criteria for being crazy as opposed to being difficult or changing their typical passive behavior. Summarizing Progress One leadership task is to help the individuals refiect and review their progress. In a suicide bereavement group, the members took several important steps toward growth that the leader summarized. After one member's guilt stalled her vacation, the others suggested that her deceased daughter would not want her to suffer, and they gave permission for a good time. The leader emphasized that the decision to take and enjoy a vacation was a major step forward. In another instance, one parent worried about her depressed son, who wanted to leave therapy and move into her tiny apartment. She feared this would increase their conflicts and his suicidal risk. The members helped her plan to tell him that both leaving therapy and moving home were bad ideas. She reinforced that she loved him and that he needed to continue therapy and find other living arrangements. Both the freedom to enjoy pleasure and the prevention of suicide risk were important growth Support Groups in Nursing Practice 29 experiences that might have gone unrecognized without a leader's summary and emphasis. Supervision and mentorship are important. Whether the nurse is a heginner or a seasoned practitioner, supervision and mentorship provide important support, encourage reflection, and help evaluate the dynamics and discuss challenges. The nurse who wants to develop these skills is wise to work with a skilled colleague and take a course in group dynamics, leadership skills, or Tavistock group relations meetings. A senior colleague can role model interventions and discuss issues and how to resolve them. Challenges may occur when a member stops attending the meetings prematurely, when difficult interactions occur, and when members do not progress with building norms, trust, intimacy, sharing, and confronting issues. Supervisors can help co-leaders work coUaboratively and reflect on their interactions. Discussing issues of referrals, increasing pathology or crisis management in supervision is helpful.