Patient Centred Care – Your Actions Today by John McGoldrick

A wee story.

George ‘Geordie’ ‘Specs’ Hastings was 72 when he died on 29 January 2017 after a short illness.

George was one of the town’s characters, seen and greeted by many as he sat on the doorstep of his flat in Assembly Street, Dumfries. George had a very full and active life, working in many of the key establishments in and around Dumfries. He was a family man, a much loved Dad, Granpa, Great Granpa, a big football fan and just a popular guy who always had a smile, ‘hello’, quick quip and happy chat. He amused many with his stories and his legendary sun tan was achieved he claimed in (on) ‘Door Steppie’, many puzzling where that exotic place was. The volume of family and friends attendance at his funeral service reflected the status he had in our community.

George ‘took ill’ and was in painful, deteriorating health for a number of weeks in late 2016, culminating in his attendance at the Emergency Department, DGRI on 15 December 2016.  George had been under the care of his GP(s) and District/Practice Nurses, with little apparent improvement in his ‘sciatica’ as George intimated to folks.

His attendance at ED saw him immediately admitted to hospital, the duty ED Doctor recognising a significant deterioration in George having seen him some 3 weeks earlier and the review of George’s ‘on line’ recent blood test results indicating a significant health problem –news to his family. From then George was submitted to a range of checks, tests and treatments for what was quickly identified as tumours on his spine, bladder and lung. The immediate response and care provided by the ED medical and nursing staff was exceptional.

He was admitted to ward 7 and the medical team contacted the Oncology team in Edinburgh. This resulted in George being transferred to the Western General Hospital for a spell of treatment before returning to DGRI ward 12. It was here that he and his family experienced ‘Open Visiting’ which made life easier for all of them. Unfortunately though, due to bed pressures, George was transferred to a Cottage Hospital that did not have the same visiting freedoms. This led to extreme frustration for Georges family and friends as they had to travel some considerable distance to visit him only to find they had to wait for some time in an area they didn’t know to get ‘access’.

Why was George moved to a Cottage Hospital some distance from friends and family? Well this is sometimes necessary when beds are tight but is not seen as good practice however we must remember the need of the patients at the ‘Front door’ who need admission and maybe extremely ill. However in this case something was missed….George was dying, this was beyond doubt. There were no beds in the Alex unit but was he the best person to move to a CH? This is answered when it became apparent that George ‘needed’ a blood transfusion and required transferred back to DGRI to receive this.

Following this George was moved to a Nursing home where he died one week later on 29th January 2017, 45 days after initially presenting to ED. This last week was not the best for him as caring staff did their best with a dying man who was in pain and discomfort. This raises some questions; did George require a trip to Edinburgh in what was to be the last month of his life? Was it fair to move him so many times, 6 overall, when he was dying and needed a little comfort, love and continuity? Did he require the final move in his last days? DGRI was busy, it was the Christmas and New Year spell that often leads to real pressures but what happened to George? He just disappeared in the busyness and ended up being passed from pillar to post, not the best way for such a kind, respected man to end his life.

There may be no easy answers but there are some things we can do – our New Hospital will have open visiting on all wards and we can replicate this in all our hospitals. We can have more realistic discussions with patients and their families to prevent unnecessary trips either to Edinburgh or other major centres and for other treatments that may only prolong death rather than life. But the main thing we can do is remember George, and all the other patients like him. They are not simply ‘bed blockers’ or ‘the stroke in bed 3’, they are people, with lives, families, friends and stories. They matter and as such should be treated with kindness and respect.

Thought for today

George was a ‘Ten out of Ten’ chap.  His end of life care and treatment did not reach that standard.

We often hear that lessons learned and procedures put in place will make sure no repeat of the identified problem events.  As you go about your professional business today – will you really make sure that you listen to patients views and wishes, that you ask Whose Needs are Being met? and What Matters to Them? to do our best to ensure that there will be no other terminally ill patients who have to suffer a similar journey to that of George Hastings?

John McGoldrick was a friend of George Hastings

The man With The Tea Trolley by Alison Wren

Hello! My name is Alison! I work as a Clinical Psychologist in the Clinical Health Psychology Service; the final member of the team to blog this month as part of our service promotion! Part of my role within this job is to help individuals and their families manage psychological distress caused by or maintained by physical health problems. Of course as a psychologist I do this at a professional level, but do we always need to be a psychologist to provide psychological care to those who need it?

 
This is the story of a man with a tea trolley; an ordinary chap who made a big difference to me at a particular moment in my life when the chips were down. I didn’t know him and he didn’t know me. We only met once and we don’t keep in touch. He probably doesn’t even remember me. He didn’t need to do what he did; it definitely wasn’t in his job remit and he probably bent the hospital rules.

The story starts on a Saturday afternoon several years ago when my husband unfortunately had a heart attack and was admitted to our local coronary care unit. It all came as a bit of a shock as he had none of the typical risk factors. He wasn’t overweight; he didn’t have high cholesterol, and had never smoked. He drank sensibly and walked miles every week. The event itself was fairly low key; just a burning sensation from throat to stomach followed later by an aching jaw. Symptoms so low key that he still went off to a football match that afternoon as planned. Twelve hours later after a trip to A&E (“just to be on the safe side”) our worst fears were confirmed. I’m happy to say that after a successful angioplasty he made a great recovery, but at the time we both pretty devastated. I was beside myself with worry. My stomach churned and my thoughts raced out of control “Was he going to die?”, “Would he have another?”

“Would he be able to stay active?”, “Would he still be able to work?”

I felt overwhelmed. How would I help my husband to cope if I was struggling myself? I had no one to talk to and could not voice my fears to my husband who needed me to be strong. As a Clinical Psychologist with many years experience working with people who have experienced distressing life events, I knew that my thoughts and feelings were normal but I was at a loss as to how to help myself.

The coronary unit that my husband was admitted to was located in another region in the UK and has now closed. My husband received excellent medical care, but as a worried spouse I felt alone. Nurses and doctors were busy. Visiting hours were limited (I was not permitted to stay longer than an hour). I wanted to be near my husband and to feel that others understood that we were in this together. I wanted reassurance. I wanted information. I wanted someone to ask me if I was alright. I felt that I needed looking after too.

One afternoon with all this weighing heavily on my mind, the man with the tea trolley came into my life. I had seen him before on and off during my visits serving hot drinks and biscuits to the patients. He was always cheerful and took the time to have a chat with people. He bustled passed me as I sat in the visitor’s room. I guess he must have noticed my forlorn expression through the window, because he doubled back and came into the room. What he did next was a small act of kindness that changed my day, and helped me feel a little better.

He simply smiled, gave me a cup of tea and said, “It’s hard isn’t it? How are you doing?”

We chatted for a short while about this and that, and he listened to me as I told him what had happened. Of course he couldn’t answer my medical questions, or give me any assurances about the future. He couldn’t really do anything as such, but he was there for me at the right moment and he seemed to understand. He knew I needed a friendly ear. I never saw him again, so I didn’t get chance to thank him. So whoever you are, thank you! That cup of tea made all the difference.

Dr Alison Wren is a Clinical Psychologist for the Clinical Health Psychology Team at NHS Dumfries and Galloway

The Buzzzzing Fridge was Back! by Elaine Ferguson

 

 

 

 

 

Bzzzzzzzzzzzzzzzzz

 

How does being asked to do a blog remind me of a buzzing fridge? Well simply, a buzzing fridge was the image, along with the above facial expression, that came to my mind when Dr Ross Warwick, Lead for the Clinical Health Psychology Service, asked me to write a blog as part of our service promotion. His request provoked feelings of anxiety accompanied by forgotten memories of a much wanted, all singing, all dancing fridge purchased years earlier to make my life complete. Instead, it had left me feeling bewildered and anxious with all my attention and behaviours being taken up trying to fix the BUZZ that emanated from inside the fridge. Automatic thoughts predicting my imminent failure resurfaced: the BUZZ was back!

My initial catastrophic thoughts, images, feelings and behaviours reminded me of how uncomfortable it is when we are asked to do something that feels overwhelming or out of our comfort zone. Avoidance is often how I try to resolve these feelings of distress and discomfort but I can’t think of a time when that solution has actually helped! So with Ross’s words of encouragement ringing in my ears (“It’s good for your development”) and a reminder to myself that “avoidance doesn’t help” I decided to feel the fear and do it anyway. (Practise what you preach Elaine!).

For the past three years I have worked as a Psychological Therapist in the Clinical Health Psychology Team. Prior to this I worked as a Mental Health Nurse in busy wards and community settings. During my career I have not always been given the opportunity or support to look after my own psychological and emotional needs in the workplace. On reflection this impacted on the enjoyment and satisfaction I gained from my job. This affected my ability to live true to the values that had brought me into the field of mental health, i.e. helping and supporting the psychological wellbeing of my patients. From this experience grew a passion to look after not just my patients but also the emotional wellbeing of my fellow workers.

Part of the Clinical Health Psychology Team’s values and philosophy is the inclusion of colleagues in the work we do to develop and facilitate lasting psychological change in patients with long term health conditions. Crucially this includes helping staff think about their own emotional wellbeing and how we can do this in busy, chaotic and at times distressing working environments. In a nutshell if we look after ourselves, our patients get a better service.

This takes me back to my buzzing fridge. It too was meant to add something to my life but like some of my earlier working experience it became a source of annoyance, frustration and sadness with all my attention focused on the aspects I disliked about it. My attention drifted to the high pitch buzz and it started to taint my entire view of it. The pleasure and excitement began to be replaced by frustration that no matter what I did, I couldn’t stop the buzzing. Shaking it, turning it on and off, opening and closing the door, and finally shouting at it made no difference. Thoughts rushed in “I can’t even pick the right fridge!”, “The shop has sold me a broken fridge, I’ve been conned!”

 

    

It was at this point my friend popped in for a cuppa (too early for a cocktail). She admired the new fridge. How dare she!  I pointed out the buzzing and she said “Sounds fine to me; how are you?”  We got talking about family, friends, work, hobbies, and nights out and generally putting the world to rights. When she left I suddenly remembered the buzz from the fridge. I tuned in and yes it was still there. Curiously it didn’t seem so loud and it didn’t seem to annoy me as much as it had done earlier. What had changed? I realised that I had stopped focusing in on the buzzing because talking and sharing with my friend was of much more value and importance than listening to my new fridge. I had put my energy into doing what mattered. The more I had talked about what was important to me and my friend, the less I had noticed the buzzing.  I had enjoyed sitting in my kitchen with the fridge that buzzed. The buzz eventually became a low level necessity which assured me all was in working order with my new, shiny fridge.

My buzzing fridge has once again melted into the background. Why? Well simply because I have chosen to get on and write this blog and whilst doing so I have remembered why I enjoy coming to work every day. I get the opportunity to work with people like you who are passionate about their jobs but like me have buzzing fridges of their own which can leave them feeling distressed, disillusioned and unable to do more of what matters to them in their working days and home life. My job allows me to remind you that you are important.

If you and your team would like to know more about the training and consultation we offer, that may improve your own personal psychological wellbeing which in turn assists us to care for our patients and each other, please get in touch.

To quote my boss “you don’t need to be a psychologist to provide psychological care”. My friend wasn’t. So maybe I would add another question to Robert Barton’s list from his blog, the one that my friend asked me … How are you?

Elaine Ferguson is a Psychological therapist for the Clinical health Psychology Service at NHS Dumfries and Galloway

 

 

 

 

 

Questions Are the Answer by Robert Barton

Patients often feel overwhelmed and intimidated when they attend hospitals and clinics. These are busy places, time can be tight and, as professionals, we can unwittingly send out signals that might prevent patients from engaging. Unsurprising then that on many occasions patients say little and ask few questions. An unpublished American study showed that from the time they arrive until they leave, men ask an average 1.4 questions, including asking about parking!

 

This post is about questions, using them to encourage patient’s to actively engage in their healthcare and things we could ask to help shine a light on the complex mix of physical and psychological issues accompany illness.

 

This topic is particularly close to home for me.  My elderly mother has recently attended outpatient clinics in Edinburgh where she felt unable to ask questions during her appointments and was left no clearer about her condition. What’s more, because some questions were overlooked the professionals involved had a very sketchy picture of what was happening to her and this affected the success of treatment.

 

In Clinical Psychology we tend to start asking questions at the beginning of a consultation so the patient can understand why they are there and what to expect from the appointment.  This includes setting the agenda, a practice that could have value in other clinical settings as it ensures we have common goals for the available time and promotes collaboration (and involved patients tend to have better outcomes, Redding, 2017)

 

To set the set the agenda and make constructive use of time we might ask questions such as:

• What would you like to get from this appointment?
• Why have you come along today?
• What would be helpful to you today?
• This is why I think you are here and this is what we need to do, are there any questions before we begin?

I couldn’t attend appointments with my mother so we set her agenda by writing an outline statement of her problem giving clear information about her condition. This approach proved to be a great help to the outpatient clinic, helping them to understand her problem more clearly and how it manifested day to day, helping her achieve better outcomes.

 

Patients in clinics may have many questions about their treatment that are primarily used to gather information: what is this test for? When will I get the results? How do you spell the name of that drug? Can I park in the ambulance bays?  We may ask similar closed questions in the course of a consultation like “is this the worst it’s been in the past month?”  Using closed questions are useful when we want factual information and can create opportunities to ask open questions or invite a broader reply like “can you tell me a bit more about that?”

 

My mother was attending outpatient appointments to address poor mobility caused by an arthritic condition. During the appointments she was examined, her medication checked and the appointment would end with something they hoped was helpful. Questions about how she was feeling, what she thought and how her behaviour had changed were overlooked. If they had been asked they would have realised she felt a bit low and useless, had thoughts like “nothing is working so what’s the point” and her behaviour had changed; she went out less and stopped enjoying life. This all affected her condition which continued to deteriorate.

 

When patients are suffering from a health problem they can experience a whole range of unhelpful emotions that could affect their treatment. These emotions can be grouped under three headings.

• Loss: sadness, down, and depressed.
• Fear: anxiety, panic and terror.
• Anger: rage, frustration or irritation.

Emotions can lead to unhelpful thoughts about health that can often be untrue. Feelings and thoughts can lead to behaviour changes the patient makes often with the intent of helping matters but in reality can have the opposite effect.  So making small changes in our routine practice can help us become more familiar with our patient’s condition by understanding how it makes them think, feel, and act.

 

Involved patients have better outcomes. But if they are less likely to ask questions because of the environment, what open and psychologically-aware questions might we ask to help us have a better understanding of their problems?

Thoughts:
What does that make you think?
What runs through your mind when that happens?
When you feel like that what does it make you think?
What images come to mind when that happens?

Feelings:
How does that make you feel?
How do you feel when that happens?
When you think that how do you feel?

Behaviour:
What did you do when you thought that?
What did you do when that happened?
Is there anything you do that you find helpful / unhelpful?

Physical sensations:
When you feel that way do you notice any physical sensations?
Do you notice any physical changes when that happens?
Have you noticed any physical changes when you get those thoughts?

In psychological therapy it is important to invite people to make changes to their usual practice. So, with that in mind, which of the above questions will you commit to try at your next clinic?

References
Don Redding (2017) Patient engagement: A ‘win-win’ for people and services NHS England Publication.

Robert Barton is a Psychological Therapist with the Clinical Health Psychology service

Take Two Bottles Into The Shower? Not me, I’m a Clinical Health Psychologist by Ross Warwick

Because you’re worth it

Bang! And the dirt is gone!

Eat fresh

I’ve been thinking a lot about advertising these past few weeks as September is a significant time for my team in Clinical Health Psychology. This month we will be making a concerted effort to promote our service, raise our profile and increase our contact with the people we aim to help.

As part of this, Ken has kindly allowed us to take over the blog for a few weeks. I’m kicking things off with an account of what the service does and I thought I would take inspiration from psychological tricks used in the world of advertising to help draw you in and get the message out there.

I’ll start, then, with a summary of the service that follows the advice of a Professor of Experimental Consumer Psychology at the University of Wales, Jane Raymond. Prof Raymond advises that rather than bombard the audience with information I should break it into chunks to allow the brain time to process each component:

• Chunk 1: The Clinical Health Psychology service helps people who have a psychological problem that is caused and maintained by a physical illness.
• Chunk 2: These problems usually involve unpleasant feelings and unhelpful thoughts about the illness that keep someone from doing things that matter to them.
• Chunk 3: This can cause distress, affecting overall well-being, medical treatment, self-management and health outcomes

An article in a social psychology journal showed that a wide range of people respond well and are persuaded by stories (Thompson and Haddock, 2012). So to illustrate chunks 1-3 here’s a fictionalised case based on real events:

“Jane is a young teacher who has type 1 diabetes. Her condition and the things she must do to keep on top of it are often accompanied by feelings of shame, anger and loneliness. She has frequent thoughts that her condition means she is abnormal and that it must be hidden from others. Because of these unhelpful thoughts and feelings she avoids testing her blood, guesses her insulin levels, is inconsistent with her diet and keeps problems to herself.

She has been absent from work and in and out of the DGRI several times within the past twelve months. Because of this she believes friends, family and colleagues are annoyed with her for not taking proper care of herself and landing them with more responsibility. As a result, she avoids seeing people and has become more and more isolated.”

The next steps for Jane are chunked below:

• Chunk 4: In therapy we would work with Jane to live well with her condition by addressing her unhelpful thoughts, feelings and avoidant behaviour
• Chunk 5: As therapy is all about collaboration, Jane’s most likely to have a good outcome if she’s motivated to participate and make changes to her life
• Chunk 6: Jane can be referred to Clinical Health Psychology by anyone who is involved in her care, be it her GP, Practice Nurse, Dietician, Diabetes Specialist Nurse or Consultant.

In Jane’s story, she’s in and out of DGRI because thoughts and feelings stop her from acting in a way that would help keep her well. So psychological therapy would add value by reducing her distress and unplanned contact with services (and by highlighting that sentence your attention has been focused on a key message about how psychology makes a difference to both the person and the hospital; Pieters and Wedel, 2004).

But would you believe that individual therapy expertly delivered by members of our experienced, compassionate, and, yes, attractive, team is but one feature of our service? In Clinical Health Psychology we also provide training, teaching, supervision and consultation because you don’t need to be a psychologist to provide psychological care (worth mentioning because (a) it’s completely true and (b) according to Goodman and Irmak, 2013, audiences are likely to prefer multi-featured products).

Already the Diabetes and Cardiac Teams are benefitting from increasing their psychological knowledge and skill through participating in Emotion Matters training, and a group of local GPs have recently completed training to introduce CBT techniques into their routine consultations. Recruitment of a second cohort will be underway soon.

Time for pictures of the product:

By now thanks to my evidence-based and scientifically informed techniques of persuasion, you will no doubt want to know how you can benefit from working with our wonderful service.

You can contact us by email or by calling us at the psychology department to talk about matters psychological, be it complex cases, potential referrals, or training your department. Find out more about making referrals by consulting our service leaflets which are available absolutely FREE through Beacon by searching for ‘Clinical Psychology’ or looking under ‘Documents’ after following the link below. And as the Patient Information Leaflet can also be found there, you enjoy a 2 for 1 bonus!

http://hippo.citrix.dghealth.scot.nhs.uk/sorce/beacon/?pageid=Sitesearch&searchCriteria=clinical%20health%20psychology

Keep your eyes open for opportunities to attend training events we’re delivering this month and enjoy the blog posts written by the Clinical Health Psychology team over the next few weeks. Finally, to eke this advertising ruse out just a little further, comment below to be part of a Clinical Health Psychology virtual focus group.

Just do it.

Ross Warwick is a Consultant Clinical Health Psychologist and Lead for Clinical Health Psychology at NHS Dumfries and Galloway