Outcomes of psychological support skills training for cancer care staff: Skill acquisition, work engagement, mental wellbeing and burnout

Psychological support skills training has the potential to improve both the ability of cancer staff to help their patients, and staff wellbeing. However, few recent studies have assessed both these outcomes or incorporated current developments in psychological skills training, such as deliberate practice, which includes the use of iterative, corrective feedback to identify and improve individualised skill deficits. No studies have evaluated the contribution that psychological skills training could make to cancer care staff wellbeing and expertise in the wake of the COVID‐19 pandemic. This study aimed to evaluate staff skill acquisition and work‐related wellbeing following psychological support skills training that applied deliberate practice principles.


| INTRODUCTION
Work within cancer care is identified as particularly stressful with high risk of adverse impacts, such as burnout, staff turnover, workrelated stress, and poorer staff wellbeing. 1,2This problem has worsened since the COVID-19 pandemic, with more than half of UK staff surveyed meeting criteria for a mental disorder. 3,4Burnout can be defined as a syndrome encompassing exhaustion, low self-efficacy, and negative attitudes towards work. 5Burnout often results from a high stress working environment with few resources that mediate the impact. 6eater work engagement is identified as a resource that can reduce the risk of burnout, and improved staff wellbeing is associated with lower burnout and better patient safety. 7,8There can be an interaction between work-related stress and staff ability to perform psychological support, where those who have more effective psychological support skills report lower burnout. 9Thus, developing psychological support skills may benefit both staff and their patients, given that psychological support offered by cancer nurses can improve patients' mental and physical health, functioning, and quality of life. 10,11Taken together, this evidence underlines the importance of cancer care staff training in psychological assessment and intervention skills, supported by supervision, as is recommended in current clinical guidelines ( 12 ; CSG4).
Some studies have identified a potential dual benefit of psychological support skills training in cancer care.Training may improve both confidence in psychological support skills and improve staff wellbeing. 13However, no large-scale studies addressing both skills and workplace wellbeing outcomes have been conducted since the COVID-19 pandemic, so available literature does not fully reflect current issues faced in cancer care. 14In particular, problems with post-pandemic demand have been identified in both COVID-19related and non-COVID-related healthcare, leaving the system especially stretched. 15Consequently, the required length of training time in previous studies (e.g., 105 h; 16 ) is also unlikely to be replicable in current routine care.Furthermore, previous studies primarily focused on communication skills alone, when wider psychological support skills may be required. 17Many studies therefore have not accounted for recent developments in psychological skills training methods.For example, ongoing coaching or supervision is an important component of current best practice in improving psychological support skills, particularly using deliberate practice: An emerging approach to developing expertise in psychological support skills involves practice of specific therapeutic skills, focused on addressing individualised skill deficits using corrective feedback. 18However, use of deliberate practice with coaching or supervision has been variably applied in training. 19More recent studies have either had smaller pilot samples, little training follow-up, or have measured only skills or wellbeing outcomes (e.g., 20 ).
This study aimed to build on existing evidence to better understand the effects of psychological support skills training and supervision on ability to perform taught skills and work-related wellbeing among cancer care staff.The current study also applied some of the key principles from deliberate practice training methods.Specifically, this included creating space for imperfect microskills practice, separate from performance: where iterative, corrective feedback could be used to identify, evaluate, and improve individualised skill deficits.
Importantly, this study evaluated implementation of training and supervision into routine care in the wake of the COVID-19 pandemic, to account for the escalation in work-related stress and deterioration in mental wellbeing reported among staff in this timeframe. 4e study objectives were to:  current concern, in unprepared conversations).This was followed by skills practice and refinement by participants using corrective feedback from observers.Training focused on techniques that could be applied in 5-15 min, reflecting consistent feedback about time limitations being a barrier to implementation.

| Training and supervision
Training content drew on specific techniques from contemporary cognitive-behavioural therapies, adapted for brief consultations.
Motivational Interviewing skills were taught to improve overall counselling and behaviour-change skills 22 ; scaling techniques from solution-focused brief therapy were used to enhance the therapeutic value of assessment 23 ; values-based action identification and goal setting was drawn from Acceptance and Commitment Therapy 24 and the ADAPT model from Problem-Solving Therapy. 25ainers participated in deliberate practice themselves, using evaluations completed by training participants to help identify their own skill deficits as trainers.Trainers then practiced and developed their training skills across cohorts, mirroring the processes that participants were encouraged to use.

| Skills performance ability
Previous studies have assessed staff confidence in use of psychological skills as a post-training outcome. 17However, this is potentially problematic, given that confidence may increase independently of ability. 26Consequently, we assessed key psychological assessment and intervention skills using 1-10 Likert scales of self-reported ability to perform specific activities.For example,: 'How certain are you that you can recognise the symptoms of anxiety, depression and trauma?' Responses were rated from 1 ('cannot do at all') to 10 ('highly certain can do').Four key assessment skills and four key intervention domains were assessed (Supplementary Table S1).The eight itemscores were totalled into a single factor scale, which showed high internal consistency in the study sample (Cronbach's alpha = 0.87; where alphas ≥0.70 are considered acceptable, reflecting moderateto-high inter-item agreement).

| Oldenburg Burnout Inventory (OLBI; 27 )
Work-related burnout was assessed using the OLBI, assessing exhaustion and disengagement sub-scales and a total score.All items are rated on a four-point scale from 1 (strongly agree) to 4 (strongly disagree).Four items on each sub-scale are phrased positively (e.g., 'I always find new and interesting aspects in my work') and four negatively (with reverse-scoring, e.g., 'sometimes I feel sickened by my work tasks').Total item scores were then averaged alongside exhaustion and disengagement sub-scores.The OLBI has shown high convergent and discriminative validity as well as good internal consistency in previous research among healthcare professionals. 9(In the current sample, Cronbach's alpha = 0.81).
2.4.3 | Utrecht Work Engagement Scale (UWES; 28 ) Work engagement was assessed using the 9-item UWES, measuring vigour (e.g., 'at my job, I feel strong and vigorous'), dedication (e.g., 'I am proud of the work that I do') and absorption (e.g., 'I get carried away when I am working').Items were rated on a seven-point scale from 0 ('never') to 6 ('always').The UWES-9 has good construct validity and a high rank-order stability of factors in work engagement. 29,30The current sample indicated Cronbach's alpha = 0.85.

| Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS; 31 )
Mental wellbeing was assessed using the SWEMWBS, a unidimensional seven-item measure of positive mental states (e.g., 'I have been feeling relaxed').Each item is measured on a five-point scale from 1 ('none of the time') to 5 ('all the time').Score cut points have been established for high wellbeing (>27.4) and low wellbeing (<19.6) using English national survey data. 31The SWEMWBS is sensitive to changes in symptoms of common mental problems with higher scores within items reflecting overall improved mental well-being. 32,33In this study sample, Cronbach's alpha = 0.78.

| Training evaluation
Five questions were used to evaluate participants' experience of each training day on five-point Likert scales.These comprised an overall evaluation of the training day (scored very poor [1] to excellent [5]) and four questions assessing perceived likelihood (scored extremely unlikely [1] to extremely likely [5]) of participants: improving work practices, using skills taught, attending similar training in future, and recommending training to colleagues.The five items were combined into a single evaluation scale score with Cronbach's alpha = 0.85.Anticipated impact was also assessed using a 0-100 scale where participants were asked to rate how much improvement in their psychological skills and personal wellbeing they anticipated as a result of the initial training day.Evaluation assessments were taken directly after the first training day and the second training day 3 months later. -154 addition, training evaluation and impact assessments were taken after the training days that directly followed baseline assessment and 3month follow-up assessments.Those attending the initial training day but not the second training day were sent 3-month follow-up assessments by email.The 8-month follow-up survey was emailed to all those who attended at least one training day.Participants were offered a £10 voucher for completing the 8-month follow-up.

| Method of analysis
As normality assumptions were met, paired t-tests were used to compare outcomes from baseline to 3-month and 8-month followup.For clinically classifiable outcomes (mental wellbeing and burnout), we further tested for significant changes over time in classification (whether participants met criterion for low wellbeing or high burnout) using McNemar's Test.As a secondary assessment of outcome, Multi-level Modelling (MLM) was used to account for missing data by including all participants.In MLMs, repeated outcome assessments were nested within reporting participants in a two-level structure with random intercepts and fixed slopes.
MLMs were not used as the primary outcome assessment due to reasonable follow-up rates (60%) and a comparatively small sample. 34ltiple linear regressions were used to assess predictors of 8- Aligned with UK Health Research Authority assessment criteria, this study was deemed to be a service evaluation that did not require ethical approval.This was because participants were not allocated to conditions different to usual service delivery, data were collected as part of routine clinical practice, and the study was not designed to be generalisable.The evaluation was registered with the host NHS organisation.

| Staff demographics
Of the 145 participants, 101 (72%) attended both training days and 39 (27%) attended at least one supervision session (Figure 1).Seventy-eight percent of the sample were Clinical Nurse Specialists with the remainder made up of service leads, allied healthcare professionals, and paraprofessionals.Five staff were male (2.7%) with the remainder female (Table 1).At baseline, participants rated their skill level at a mean 5 out of 10 across rated psychological support areas.Mean work engagement was close to the mean in previous samples at 36.06 (SD = 5.94) on the UWES, 28 and scores for mental wellbeing on the SWEMWBS were close to the mean for England at 22.13 (SD = 2.80). 31Twenty-four participants (17%) fell in the established clinical range for low wellbeing (<19.6) and 21 participants (15.1%) met criteria for high burnout on the OLBI (Table 1).

| Training evaluation
Overall, 82% of participants rated the initial training day as 'excellent' and 80% rated the second day as 'excellent', with the remainder rating the training as 'good'.Directly after the initial training day, participants reported anticipating a mean 71% improvement in their psychological support skills and 64% improvement in their own wellbeing because of the training.These ratings were moderately correlated with reported improvements in psychological support skills and wellbeing at 3-and 8-month follow-up (r (89) = 0.46, p < 0.001).

| Relationship to previous literature
Previous studies of similar training have been unclear about durability of effects in routine practice (e.g., 20 ).This study suggests that effects can be retained for several months, but also indicates that a 1-day training may not be sufficient for longer-term skill acquisition.
The unanticipated finding that those reporting poorer mental wellbeing were more likely to fully engage in the training programme, and experienced greater improvement in psychological support skills, may suggest staff used training both for their own wellbeing and that of their patients; a personal application identified as lacking in previous research. 36Furthermore, observed effects pertain to outcomes beyond psychological support skills, as lower burnout and greater work engagement can improve patient safety, reduce sickness absence, and support lower staff turnover. 8is study did not identify a predictive benefit of attending (vs. not attending) supervision, whereas previous research has emphasised the benefits of supervision both to staff skill and workplace wellbeing. 37,38

| Limitations
Too few participants took up supervision to assess whether supervision acted as a means of consolidating learning and supporting staff wellbeing. 39Nonetheless, this study highlights the challenges faced when trying to engage cancer care staff in supervision across settings and services in routine care.In particular, the lower attendance at supervision reported by Clinical Nurse Specialists highlights that they may find incorporation of supervision into their roles more challenging.Self-reported ability to carry out specific skills may address concerns with self-reported confidence ratings, but observation of skills in practice remains the gold standard of skills assessment. 26erefore, uncertainty remains as to the degree of change in participants' practice that occurred because of training.Furthermore, patient outcomes were not assessed in this study, so the impact on patients cannot be estimated.
The longest outcome follow-up timepoint varied from 6-month to 12-month, which may have affected the results received due to imprecision.However, when length of follow-up was controlled in prediction models, it did not significantly impact on outcome.
As a routine service evaluation, this study is inherently contextspecific.Nonetheless, our findings afford practice-based evidence and insights from real-world implementation of psychological support skills training.

| Conclusion
Overall, this study indicates that psychological support skills training for cancer care staff may contribute to improvement in clinical skills as well as improvement in mental wellbeing, work engagement, and burnout.Therefore, the use of deliberate practice principles in training and supervision for a range of cancer care staff could be effective in supporting skill acquisition and building workplace resilience.

1 . 1 2. 2 |
Evaluate acquisition and retention of psychological assessment and brief intervention skills following training and regular supervision applying principles of deliberate practice.2. Assess work-related burnout, work engagement, and mental wellbeing across the training period and at follow-up.3. Identify predictors of the outcomes assessed.2| METHOD 2.1 | Design A non-randomised, prospective, longitudinal, timeseries design was employed, in which cancer care staff offered two psychological skills training days and supervision were assessed prior to training, at 3month (directly prior to the second training day) and 8-month follow-up.Participants Participants were 145 cancer-care staff from six organisations supporting UK National Health Service (NHS) patients across the Midlands region.They were offered 2 days of psychological support skills training, across 11 training cohorts between November 2021 and July 2022, plus monthly supervision.
The training offered was a development of Barrett Naylor et al.'s 20 deliberate practice model.An initial training day was offered with half the day focused on assessment skills and half focused on intervention skills.Three months later, a second day's training was offered, building upon skills taught in the first day.Participants were also offered monthly, one-hour group supervision remotely via video conferencing after completing the initial training day.By design, supervision comprised three 20-min components: a self-compassion care space, 21 discussion of a specific patient and associated issues, then deliberate practice of identified skill deficits.Training included but intentionally minimised didactic teaching, to focus on 'real-play' demonstration of evidence-based therapeutic skills by training facilitators (applying skills to address a genuine 1540 -MALINS ET AL.
Baseline measures were completed by participants in the week prior to training via an online survey or paper survey for those unable to access the online method.Participants were informed via the online platform that assessment data would be anonymously reported as part of a service evaluation and completion of measures would imply consent to involvement.Participants completing measures on paper forms were told the same information in person and verbal consent given instead.All measures were completed at baseline, 3-and 8-month follow-up, with training evaluations scored directly after training days.In MALINS ET AL.
month follow-up outcome.Models included attendance at both training days; attendance at supervision; training evaluation; expected impact of training, job role (Clinical Nurse Specialist or other role); baseline skill level, and baseline outcome scores.A covariate that accounted for the number of days between baseline and follow-up assessment aimed to address any effects associated with the range of time across which follow-up assessments were collected.Logistic regressions were used to evaluate predictors of attendance at the follow-up training session and attendance at supervision, with the aim of identifying factors associated with training engagement.Pearson's correlations were used to assess associations between anticipated impact of training and later retrospective reports of training impact.Statistical analyses were conducted using SPSS (version 28) and R (version 4.2.1).
Flow of participants from initial training day to follow-up assessment.*Of those who attended, 4 had not attend the initial training day.**Of those completed surveys, 7 were from participants who attend the initial training session but did not attend the update training session.***A median 8 months follow-up was collected, ranging from 6-12 months follow-up overall.1542 -MALINS ET AL.

F I G U R E 2
Psychological support skills and burnout over time.Burnout measured with the Oldenburg Burnout Inventory (summary scores are item means, scaled from 1 to 4); psychological support skills measured with 1-10 ratings of ability to perform eight core assessment and intervention skills (summary scores are item means, scaled from 1 to 10).This study indicates that psychological support skills training focused on practising (more than describing) brief techniques, with feedback, can improve self-reported skill acquisition and retention among cancer care staff in routine care.This links to established methods of therapeutic training that emphasise the importance of both didactic and procedural learning with the ability to reflect on both. 35Such training may also reduce burnout alongside supporting improvements in mental wellbeing and work engagement in ways that continue beyond the training period.There were indications that early responsiveness to training (e.g., skill development and anticipated impact on wellbeing after the first training session) predicted longer-term gains, supporting the notion that improvements at follow-up were partly attributable to the training.For cancer care services, this suggests that psychological skills training may contribute to both upskilling the workforce and improving staff resilience and engagement.Furthermore, the implementation of the programme in UK routine care gives an indication of utility and application to usual practice.

Future research should involve
randomised controlled trials comparing different types of training and supervision interventions.Deconstruction studies are required in future to identify the key ingredients of training and mechanisms of change, particularly when training methods used in practice are so diverse.Future research should also use rated observations of skills practice pre-and posttraining as an outcome assessment: to evaluate observable changes in skill and establish the reliability of self-reported ability as a proxy for observed practice.Research is also required to understand barriers and facilitators to training and supervision attendance from an individual and system perspective, particularly given the low uptake of supervision in this study.Given that training effects were maintained for several months in this study, longer-term follow-up is warranted in future research to better understand the durability of effects.

4. 4 |
ImplicationsThis study suggests that 1 day's training is not sufficient to support development and retention of psychological support skills among cancer care staff.Therefore, cancer care services should consider ongoing continued professional development programmes for staff across patient-facing roles.Given improvements in skill and wellbeing experienced by those reporting the poorest wellbeing at baseline, psychological support skills training could form part of a support programme for staff at risk of poor wellbeing or low work engagement.
Work engagement and mental wellbeing over time.Work engagement measured with the Utrecht Work Engagement Scale; mental wellbeing measured with the Short Warwick-Edinburgh Mental Wellbeing Scale.
from psychological skills training in cancer care across staff groups.F I G U R E 3 1544 -MALINS ET AL.