Psychological skills for practice nurses Sue Savory Consultant Clinical Psychologist GHNHSFT Susan.Savory@glos.nhs.uk 03004 228523

Overview Aims of session: developing your patient - centred communication toolkit Context psychological impact of cancer NICE (2004) – what is your role? Key communication skills what do you do? facilitative skills cues driven conversations

Overview Cues for low mood/depression Cues for uncertainty/anxiety

Psychological impact of cancer and cancer treatment In the first year after early diagnosis: 15% of patients experience mild to moderate levels of distress in the first year after diagnosis of early disease that requires generalist intervention 10% experience more severe levels of psychological distress that requires specialist psychological intervention all levels of psychological distress are higher for patients with advanced disease distress continues into the survivorship period

Don’t forget the family impact: In the UK, 10% of all new cancer cases occur in adults aged between 25 and 49 years there may be young family members experiencing the impact of cancer or treatment on a parent USA, 18.3% of recently diagnosed cancer survivors and 14% of all survivors live with a minor child

Continuum of Psychological Distress in Cancer 50% 30% 15% 5% Adjustment difficulties with depressed anxious symptoms Normal responses to cancer/terminal illness People who do not fulfil stereotypes fall into the the ‘bonkers category Normal reaction – wait and understand the context and meaning of their distress Just because you are normal doesn’t mean you might not benefit from help May be psychological reasons for psychiatric presentation Continuum – evolution of distress Moderate to severe psychological problems requiring mental health expertise ‘Major psychiatric illness and personality disorder’

Presenting Psychological Problems: Adjustment, coming to terms with, acceptance Anxiety, worry, panic, dealing with uncertainty, fear about the future Depression, sadness, loss of role , hopelessness, guilt, shame Relationship problems impact of the health problem on partner or other family members between the patient and care team Isolation or loss of relationship with peer group as a result of cancer

Presenting Psychological Problems: Trauma - when treatment or the condition have been psychologically traumatic e.g. isolation for BMT, adverse reactions to chemotherapy Significant disruption to body image Existential concerns e.g. meaning of life and relationships post cancer Psychological preparation for treatment interventions Complex or complicated bereavement (when the deceased was known to the palliative care services)

Level 1 of Nice Guidance Four Level Model Group Assessment intervention 1 All Health and Social Care Professionals Recognition of Psychological Needs Effective information giving, compassionate Communication and General Psychological Support 2 Health and Social Care Professionals with additional experience Screening of Psychological Distress Psychological techniques such as Problem Solving 3 Trained and accredited Professionals Assessment of Psychological Distress and Diagnosis of some Psychopathology Counselling and specific psychological interventions such as anxiety management and solution-focused therapy, delivered according to an explicit theoretical Framework 4 Mental Health Specialists Diagnosis of Psychopathology Specialist psychological and psychiatric interventions such as psychotherapy, including cognitive behavioural therapy (CBT) Self Help and Informal Support Lynne

Understand the patient’s situation/needs/ perspective/feelings Communication Tasks: Compassionate Communication & Psychological Support Understand the patient’s situation/needs/ perspective/feelings Communicate that understanding & check its accuracy

  Act on that understanding with the patient in a helpful way eg information giving, asking them what has helped before, discussion about possible interventions

Communication Practice Amanda Blake, 56, a school teacher, has recently had successful treatment for non-invasive ductal breast cancer. She is normally chatty, but today she seems more pre-occupied and tense when you meet her.

Facilitative behaviours Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al 2003; Del Piccolo et al 2011; Gathering information Open questions Open directive questions Screening questions Clarification Exploration Pauses Pauses/silence Minimal prompts Picking up cues Active Listening skills Reflection (acknowledgment) Paraphrasing (acknowledgement and checking) Summary Empathy Educated guesses BLUE SLIDE So don’t go through it . “So we have seen a lot of these are there any that we have not mentioned yet you would like me to clarify? ” Version 3: July 2008 12

Facilitative skills (Info giving skills) Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al 2003; Giving information Checking what person already knows Giving information in small chunks Using clear and simple terms Avoiding detail unless requested Checking Pausing and allowing info to sink in Waiting for a response BEFORE continuing Checking understanding Checking impact THIS BLUE SLIDE we DO NEED TO go over but NOT in detail Ok … we’ve mentioned and seen those skills which help us gather information, the other skills we need in our kitbag are those one which help us give information. SUGGEST simply summarising eg “Things that help us identify what someone knows, making sure we can chunk info into small enough pieces to digest, and deliver it clearly and simply without too much detail and also how we check what someone has really taken on board we will focus on these skills in the role-plays”. Version 3: July 2008 13

Additionally Heritage J et al 2006 Silence or minimal prompts most likely to precede disclosure Eide H et al 2004 Giving information reduces likelihood of further disclosure Zimmerman et al 2003 Polarity of words important: Screening questions: “something else” elicited significantly more concerns than “anything else” Heritage J et al 2006 What it is important to recognise is that there is a huge evidence base underpinning theses things. Just 3 studies here - first 2 picked out as used more modern robust techniques to study conversations which support the key facts we have talked about. LAST - Interesting finding from a sharp RCT done a few years ago NB: You CAN change the references on this slide, but know why you are selecting the studies you mention . Make sure they deliver important key messages, and are interesting.

Facilitative Skills GATHER BEFORE YOU GIVE! Useful acronyms: O – Open questions A – Affirmation (valuing what they say) R – Reflective listening S - Summary P - Pause E - Empathy A - Acknowledgement S - Summary

CUES SUGGESTION: bring on the pictures ask the group to say what they see . Draw out the fact that each picture could be interpreted differently physically, socially or emotionally different things can be seen. This then identifies what a cue is - something which we know someone is telling us something but NEEDS clarifying , we CANNOT assume we know what it means.

Cues A verbal or non verbal hint which suggests an underlying unpleasant emotion and would need clarification from the health provider Del Piccolo et al, 2006 Definition now accepted across Europe. Unpleasant because people rarely CUE pleasant emotions … they mention them outright. Version 3: July 2008 17

Cues Verbal Non-Verbal Hints at feelings “I’m a bit unsure about that”, it was odd” Emphasis or metaphor “it was bloody awful” “no light in the tunnel right now” Repetition of things “He lost his job , he lost his job” or “it was cancer - he said it was cancer” Non-Verbal Clear expression of a negative or unpleasant emotion (e.g. crying, restlessness) Hints to hidden emotions (e.g. sighing, silence, frowning, negative body posture) Further clarification of definition . IF you want to put in examples from the DVD that is fine.

Importance of cues Facilitative questions linked to cues increase the probability of further cues and are key to a patient-centred consultation Zimmerman et al 2003 Open questions linked to a cue are 4.5 times more likely to lead to further significant disclosure than unlinked open Questions Facilitating the first patient cue appears to be important 20% drop in cues during consultation if first cue is not facilitated Fletcher PhD thesis 2006 Key message: WHY ARE CUES IMPORTANT SUGGESTION: Notice how many time the relative tried to cue the nurse in the “blocking DVD” - patients try more than once. BUT Ian Fletcher thesis shows that there is an impact from the first occasion .

Context

Recognising low mood What do you see or hear? Thoughts, feelings, behaviours, physical sensations?

Grieving or mourning the loss or expected loss of something Loss/grief Sadness Depression Grieving or mourning the loss or expected loss of something Imagined or expected Grieving for someone who is still present but changed – eg living with relative with poor prognosis, or spouse with increased cognitive impairment Grieving the loss of an aspect of self eg ‘indefinite’ future, body part, role. Low mood may not be continuous, will periods of restorative activity and focus (dual process model of grief) about an event or situation may result in distress and a deep sense of loss may be difficult to contain by individual experiencing it but does not usually trigger suicidal behaviour feeling eventually passes with support and emotional processing /problem solving (psychological adjustment) may be triggered by event or events and result in feelings of loss may not pass with time eg more than 2 weeks duration events activate firmly and deeply held negative beliefs about self, world and future, that may have been formed in childhood negative beliefs skew day to day thoughts, negatively negative thoughts feature guilt, self blame and self criticism restrict the view of the future and prevent the individual from problem solving may result in suicidal thinking or actions

Recognising Depression Listen out for Loss of appetite/ weight (?other causes) Changes in sleep pattern Loss of enjoyment and pleasure in things Loss of concentration Lack of energy/motivation (?other causes) Guilty or self-blaming or self-critical thinking A loss or change in recent history Of more than two weeks duration, causing an impairment in functioning Key words – hopeless, pointless, worthless, low If so – CHECK SUICIDE RISK

Recognising uncertainty or anxiety What do you see or hear? What thoughts, feelings, behaviours, physical sensations?

Recognising Anxiety Anxiety Panic Uncertainty Persistent stress response associated with threat of harm, actual or imagined in future, to self or those close to us. Stress response – physiological arousal eg heart rate and bp increase, rapid shallow breathing, pupils dilate, hearing sharpens, reaction speeds up, decreased appetite, increased alertness and focused thinking Associated with panic, avoidance coping, fearful thinking – negative predictions, worry, difficulty in focusing on present, poor sleep, irritability and feeling overwhelmed/hopeless Focus on impending catastrophe and loss of control; intense anxiety Very strong bodily reactions e.g. pounding heart, can’t breathe, overwhelmed and powerless. Catastrophic misinterpretation of bodily sensations e.g. I’m dying; I’m losing control; I’m going mad. Associated with vicious circle of arousal, bodily sensations and catastrophic mis-interpretation Focus on bodily sensations Associated with avoidance coping of situations associated with panic Person may have actual symptoms e.g. breathlessness associated with lung problems, which are then exacerbated by panic. Not knowing what the future might hold; lack of clarity about the future, difficulty tolerating not knowing; experiencing a loss of control and power. May be associated with anger, anxiety and physiological arousal, worry, fears, hopelessness

Cancer and Palliative Care Psychology in Gloucestershire Hospitals NHS FT – Who’s Who? Susan Savory Service lead Cancer, Palliative Care GRH based - west of county Diana Crossley Cancer and Palliative Care CGH based - east of county Rachael Edge Cancer and Palliative care GRH based – west of county Nicky Dobbin and Rachael Edge Haematological Cancers GRH and CGH Small service – 2.6 wte overall

Cancer and Palliative Care Psychology 2.0 wte cancer and palliative care + 1.0 wte haematology (0.8 LINC funded) clinical psychologists (HPC registered and BPS chartered) . Sit within the trust’s Health Psychology Department. Referrals accepted from any member of the healthcare team – primary and secondary, as well as self referral. Referrals accepted for adults (usually 18+) patient and/or close family members. Where the patient does not have cancer, but a life threatening LTC, we would normally ask if they are known to the palliative care team or would benefit from their support as well. N=350+ referrals per year and 2000+ contacts

Cancer and Palliative Care Psychology Psychological difficulties must be related to coping with cancer, haematological condition or the complexities of a life threatening health condition Referrals accepted at any point in the care pathway for cancer and haematological malignancy e.g. pre-diagnosis, diagnosis, treatment, post-treatment, recurrence or palliative phases Referrals for other life threatening conditions – usually end stage when significant reduction to quality of life. May also be in touch with neurology, stroke, brain injury psychologists for those conditions; but no respiratory or diabetes psychology. Children of patients are seen, when psychological work with the parent to continue parenting is insufficient, and where the difficulties are related to coping with the health problem. Referred person(s) must consent to the referral

Cancer and Palliative Care Psychology Psychologists provide NICE IOG (Supportive and Palliative Care for Adults with Cancer, 2004) Level 3 and 4 assessment and interventions Evidence based interventions e.g. CBT, third wave CBT, systemically oriented work with couples and individuals, brief psychotherapeutic interventions Work closely with specialist nurses, haematology, cancer and palliative care teams to improve psychological understanding and support of patients via consultation, clinical supervision, and training.