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

Professional role

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.

An analysis of the findings in the

context of national policy

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.

Where do we fit in?

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).

Conclusion

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)

QUESTIONS?

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]

Additional slides

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

Limitations

• Participants may have under-estimated their pre-

training knowledge and over-estimated the post-

training knowledge in an attempt to justify

participation (Conway & Ross, 1984)

• MDT members who chose not to take part in the

evaluation or workshops may have held opposing

views