1. Psychological skills for practice nurses
Sue Savory
Consultant Clinical Psychologist
GHNHSFT

2. 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

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

4. 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

5. 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

6. Continuum of Psychological Distress in Cancer
50% % % 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’

7. 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

8. 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)

9. 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

10. 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

11. 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.

12. 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? ”
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13. 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”.
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14. 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.

15. 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

16. 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.

17. 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.
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18. 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.

19. 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 .

20. Context

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

22. 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

23. 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

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

25. 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

26. 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

27. Cancer and Palliative Care Psychology
2.0 wte cancer and palliative care 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 contacts

28. 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

29. 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.