Improving the psychological knowledge of stroke teams: its role in person-centred care Melanie George Kent Clinical Neuropsychology Service
Apr 15, 2017
Improving the psychological
knowledge of stroke teams: its role
in person-centred care
Melanie George
Kent Clinical Neuropsychology Service
Overview of talk
• A brief overview the workshops (paper is
provided).
• The findings in the context of current policy.
• Implications for our profession.
Background
• Kent Clinical Neuropsychology Service ‘Stroke Best
Practice Group’- a focus upon service development.
• In January 2011, we developed an ‘MDT
Questionnaire’ to capture the direct and indirect ways in which we were contributing to stroke services.
See George (2013).
Background
• Example of direct contributions question:
• Q6. How useful have you found the psychologist’s input
regarding the assessment and management of patients
affected by stroke who present with cognitive
difficulties?
• 1)Poor 2)Satisfactory 3)Good 4)Excellent 5)Don’t Know.
Background
• Example of indirect contributions question:
• Q11. How useful has the psychologist’s input been with complex discharge planning for patients affected by stroke? (i.e. providing recommendations regarding referrals for post discharge intervention and support).
• 1)Poor 2)Satisfactory 3)Good 4)Excellent 5)Don’t Know.
Background
• The results suggested a high level of overall satisfaction
with our service. However, it highlighted that our MDT
colleagues lacked sufficient knowledge and
confidence in addressing the emotional and cognitive
consequences of stroke.
• They were keen to be provided with formal training.
This fits with the
literature…
• Research suggests that nurses working in stroke care
view themselves as having little experience in
required capabilities (Forbes & Fitzsimons, 1993) and
that they lack confidence in working with stroke
survivors (Gibbon & Little, 1995).
And with what
patients say…
• Previous research has indicated that people are
dissatisfied with the content and quality of
information provided to them following their stroke
(O’Mahony et al., 1997).
• In particular, psychological aspects are poorly
addressed (Doswell et al., 1999).
The workshops
• A series of two-day training workshops, aimed at enhancing and supporting other MDT members’ knowledge in relation to the neuropsychological consequences of stroke.
• Teaching methods included didactic presentations, case studies and discussion
The topics:
1. Cognitive difficulties following stroke.
2. Mood and adjustment.
3. Understanding personality and behaviour changes post stroke.
4. Fear of falling (now psychogenic stroke).
Method
• Questionnaires were designed specifically for the study. These were completed by participants both immediately prior to and after the two-day workshop.
• They comprised scale items and open-ended questions. Scale items focussed upon knowledge and confidence in working with stroke survivors and their families.
Method
The Workshop Evaluation Questionnaire (WEQ; Milne & Noone, 1996) was incorporated; nine scale items asked about perceived outcomes of training, in terms of satisfaction.
Profile of participants
• Fifty MDT members chose to take part in the evaluation
Professional discipline Number of participants
Occupational therapists 18
Physiotherapists 9
Nurses 7
Speech and Language Therapists 6
Other (unqualified staff) 6
Dieticians 4
Work setting and experience
• Twenty eight participants worked in community
settings, while 13 worked on inpatient units. Nine
worked across these settings.
• The mean length of time participants had worked
in their service was three years and four months.
Previous training
• 40 / 50 participants had not received any prior
training in this area.
• Six had attended Brain Tree Training. Four had
participated in privately funded counselling
courses (e.g. CBT).
Difficulties reported
Category
Number of
respondents
Example
Patients’ lack of insight /
unrealistic expectations
11
When stroke survivors lack insight into the severity
of their condition
Staff members’ lack of
knowledge / confidence
8
I battle with my lack of confidence at times
Issues related to
families
7
A lot of times it’s not just the patient, it’s the family
situation that I find most challenging
Behaviour
6
Working with patients who are sometimes angry or
aggressive can be very challenging
Mood and adjustment
6
I sometimes find it difficult working with people who are
really struggling to cope
Service-related issues
4
In the past it has been hard to access psychological
support for our patients
Difficulties reported
Findings
• There were no significant differences in pre-training
level of knowledge and confidence between those
from different professional disciplines or clinical work
settings.
• Pre-training level of knowledge and confidence was
not associated with time worked in the clinical
setting.
Findings
• Participants’ pre-training responses to scale-
item questions suggested a moderate level of
self-reported knowledge and confidence in
working with stroke survivors / their families.
• This increased significantly when re-assessed
following the training.
Addressing attribution errors
Category
Number of
responden
ts
Example
Addressing attribution errors
7
Because of the training, I realise that challenging behaviour of
stroke patients is because of deficits and processes, not only
the person’s personality
Better understanding
of patients’ points of view
6
It has given me greater insight into patients’ views and how
they perceive their problems
Re-considering when
to make referrals
5
I am thinking about how to address the topics covered with
individuals in greater depth rather than referring them to
psychology right away
Person-centred care
Category
Number of
respondents
Example
Given strategies / tools to use in
clinical practice
13
It’s prepared me better to use standardised tools to
help inform the assessment process
Increased knowledge of
(neuro)psychologists role
7
I have a better understanding of how to refer to
neuropsychology services and which clients might
benefit the most from their input
Increased confidence
6
It has given me more knowledge which has in turn
given me more confidence in working with clients and
their families or carers
Summary of findings and
implications
• Participants reconsidered attribution errors they had
previously held in relation to patients’ behaviour.
• People felt more confident to raise psychological
issues with patients and families.
The Five Year Forward View
• Calls for a shift from curative models of care to
person-centred relational (psychological) care.
• The idea is that this will support self-care and
curtail the rising tide of multimorbidity.
Person-centred,
relational care
What Sir Simon Stevens failed to consider was
whether the workforce have the:
1) Skills
2) Knowledge
3) Emotional resources
….to translate his vision into practice.
Why we should be ‘giving psychology
away’ (Miller, 1969):
1) The development of psychological skills within
stroke MDTs.
2) The mental health of staff working within stroke
services.
Why we should be ‘giving
psychology away’ (Miller, 1969):
1) the development of skills
• Clinical staff in the NHS are still selected on the
basis of technical, rather than people skills (NHS
employers, 2013).
• Doctors’ and clinicians’ treatment decisions are
often shaped by a “bio-physical paradigm of
medicine” (Rasmussen et al., 2014, p.122).
The medical model
encourages emotional
distancing
• The traditional medical (or bio-physical) model
means that the person is defined by their problem,
rather than being treated in a holistic way.
• This has been linked to depersonalisation in
healthcare settings- patients with brain damage
are particularly vulnerable (Kinsella et al., 2015).
This is in the context of a
lack of specialist knowledge
• In a highly regarded study of compassionate care,
Professor Maben and colleagues (2012) noted a lack of, or
inadequacy of, staff training in “specialist care skills”.
• In the absence of this, “staff continued to manage the
particular challenges of caring for patients with complex
emotional and psychological needs by drawing on
their own experience” (p. 88).
What’s wrong with this?
• Attribution errors are common amongst care staff
(Bromley and Emerson, 1995).
• A lack of experience (Hastings, Reed and Watts,
1995) and training (Grey, McClean and Barnes-
Holmes, 2014) is known to be associated with their
development.
• The beliefs that staff hold about the causes of
personality and behaviour changes are known to
influence their responses to it (Hastings, 1997).
• Some attributions can lead staff to dehumanize
and reject patients (Greenhill, 2011).
A lack of specialist
knowledge
A lack of knowledge
patient-centred care
• The impact is also indirect: when cognitive or
behavioural changes are attributed solely to an
individual’s mood or personality, other contributory
factors (i.e. environmental) can be overlooked.
• This may give rise to a vicious circle, whereby the
patient’s frustration and anguish are compounded over
time (Rana and Upton, 2008).
• A crucial aspect of patient-centred care is
understanding patients’ perspectives
(Staniszewska & West 2004).
• Only then is it possible to tailor
interventions/interactions around patients’ needs.
Our role in providing
specialist stroke training
• Person-centred care within stroke services, is
predicated upon staff acquiring specialist
knowledge of the organic and neuropsychological
underpinnings of cognitive, behavioural and
personality changes.
• As our research shows, this is not gained by
experience.
Our role in providing
specialist stroke training
Why we should be ‘giving
psychology away’ (Miller, 1969):
2) the mental health of staff.
• The past five years have seen escalating pressures
for frontline employees (Wilde, 2014).
• NHS England are worried- this has been mirrored by
spiralling rates of burnout (Maben, 2014), mental ill
health (Cooper, 2015) and suicides (Rajan, 2014).
A lack of ‘Psychological
Responsibility’ for staff
(Mowbray, 2015)
• Like us, frontline staff have to contend with a
high degree of ‘emotional labour’, defined as
“Supressing private feelings in order to show
desirable work-related emotions” (Mastracci
et al. 2012, p.4).
A lack of support
• Unlike us, there is not a culture of clinical
supervision or psychological support in the NHS.
• Staff are expected to just ‘get on with it’ in the
face of reduced length of stays (which increase
emotional labour) and continuous
redeployments.
Heightened emotional
labour in stroke services
• “Proper healthcare has to go beyond the
physical care of the patient. Crucially, it has to
help the patients and their families manage the
profound anxieties associated with illness,
dependency, death and psychological
disturbance” (Evans, 2015).
Heightened emotional
labour in stroke services
• Many of the people with whom we work,
experience personality changes and some exhibit
challenging behaviour, secondary to disinhibition.
• We know that this is highly stressful for staff
(Bersani and Heifetz, 1985; Quine and Pahl,
1985).
Adding to this……
• People may experience communication
impairment.
• Furthermore, following frontal lobe damage (i.e.
MCA stroke), it is common for people to have
problems with mentalization and empathy.
“It is all stick
and no carrot”
• “Some people exhibit behaviours that can be really
challenging….
• …we might face a barrage of abuse from a patient
but have to remain polite and friendly. We could be
called upon by the same patient later in the day to
wipe their bottom…only to face another barrage”.
Staff nurse on EKNRU
Staff stress and person-
centred care
• It is now recognised that there is an
“unassailable link” (NHS England, 2014, p.12)
between compassion shown to patients and that
shown to staff.
• This is mediated by psychological defences
that are not widely understood by NHS policy
makers.
What Sir Francis (2013) revealed
• Sir Francis (2013) brought to public attention a
process that was first identified by the
psychoanalyst Menzies Lyth, in 1960: in the
absence of support, staff employ avoidant
psychological defences, such as withdrawal
and the dehumanization of patients.
The impact on patients
Kitwood (1997) found that depersonalization can lead to:
1. Disempowerment (not allowing people to complete actions
they have initiated)
2. Infantilisation (treating people as children)
3. Labelling (as the main basis for interaction and explaining
behaviour).
4. Stigmatisation (treating the person if they are a diseased
object).
We have a vital
contribution to make
• Frontline staff are experiencing extraordinary
levels of anxiety.
• Many cope by withdrawing and employing
avoidant coping strategies.
We have a vital
contribution to make
• As we have shown, a lack of specialist knowledge
can undermine confidence levels amongst
frontline staff in stroke services.
• Increasing evidence suggests that this damages
the ability of staff to provide person-centred care;
the mediating factor is attribution errors.
A barrier to overcome:
• We are under pressure to focus upon direct
activity data. However our indirect work is vital.
• The MAS (1989) review recommended working
with other team members to enhance their
knowledge.
• New Ways of Working; working psychologically
with teams(2007).
We must grasp the
mantle
• The solution: we need to evidence the importance of
this aspect of our role:
• “Many studies suggest that training can increase
knowledge, but the extent to which this carries
over into adopting good practice, remains
uncertain” (The Health Foundation, 2014, p. 9)
References
• Kinsella et al. (2015) I felt let down by psychology. The
Psychologist, 28 (2), pp.128-130.
• Maben, J. (2014) “Care, compassion and ideals.” In Shea, S.,
Wynyard, R. and Lionis, C. (eds.) Providing Compassionate
Healthcare, challenges in policy and practice. London:
Routledge. pp. 117-138
• Menzies Lyth, I. (1960) Social systems as a defence against anxiety:
An empirical study of the nursing service of a general hospital.
Human Relations. 13 (2): 95-121
• Mowbray, D. (2014) Psychological Responsibility [online].
Available from:
http://www.mas.org.uk/uploads/articles/Psychological%20Responsib
ility.pdf [Accessed 24 June 2015]
References
References
• NHS England, Care Quality Commission, Health Education
England, Monitor, Public Health England and Trust Development
Authority. (2014a) NHS Five Year forward View [online]. Available
from: http://www.england.nhs.uk/ourwork/futurenhs/ [Accessed 25
October 2014]
• NHS England (2014a) Building and Strengthening leadership
Leadership with Compassion [online]. Available from:
http://www.england.nhs.uk/wp-content/uploads/2014/12/london-
nursing-accessible.pdf [Accessed 2 August 2015]
References
• Rasmussen, E., Jørgensen, K. and Leyshone, S. (eds.) (2014)
Person Centred Care [online]. Available from:
http://www.dnv.com/binaries/PersonCentredCare_web_Final_tcm4-
611086.pdf [Accessed 5 April 2015]
• Rana, D. and Upton, D. (2008) Psychology for nurses. London:
Routledge.
• Wilde, J. (2014) Cultures of Transparency and Openness: The
imperative from the Francis report [online]. Available from:
http://foundersnetwork.uk/wp-content/uploads/2014/11/Joanna-
Wilde-Article.pdf [Accessed August 2014]
BACKGROUND
• Stroke services are required to deliver standards of
care in accordance with specific guidelines and
strategies
For example, the National Stroke Strategy; DOH, 2007
and National Clinical Guidelines for Stroke; RCP, 2004
• A workforce equipped with specialist knowledge in
stroke is necessary to meet required standards (Craig
& Smith, 2007)
Objectives:
1. To provide a supportive learning environment for staff from different professional disciplines to explore stroke from a psychology perspective.
2. To share principles of good practice.
3. To provide case studies to encourage reflection.
Knowledge
• Educational preparation of nurses for their role in
stroke care is “minimal and largely ineffective”
(Booth et al., 2005, p. 46).
• More widely, training opportunities for professionals
in stroke rehabilitation in the UK are viewed as
limited (RCP, 2004).
Pre-training evaluation
• Profile of staff members who attended the workshops
(role within the MDT, work experience and previous
training).
• Participants’ expectations / what they hoped to gain
from training.
• Whether there were improvements in participants’
knowledge and confidence in this area, following
training
WHAT PARTICIPANTS HOPED TO GAIN
Category
Number of
respondents
Example
Strategies / tools
to use in clinical practice
10
I hope for practical strategies to help me
help patients and their families deal with
difficult issues
Increased confidence
5
Increased confidence to enable me to be
a better nurse with stroke patients
Increased knowledge
of psychological aspects
5
Increased knowledge of the impact that
stroke has on psychological aspects
Hopes for training
Increased knowledge of
(neuro)psychologists role
4
To understand about psychologists role
Increased knowledge
of referral pathways
4
Knowing better to whom to refer
Increased understanding
of patients point of view
2
Understanding of the patients view
Hopes for training