06. developing a renal clinical - health in wales. developing a renal clinical… · 22 health...

Developing a Renal Clinical Developing a Renal Clinical Psychology Service from ScratchPsychology Service from Scratch

Dr Beth ParryDr Beth Parry--Jones & Dr Paul GardnerJones & Dr Paul Gardner

Consultant Clinical PsychologistsConsultant Clinical Psychologists

Renal Services, BCUHBRenal Services, BCUHB

All Wales Renal Audit Meeting, LlanelliAll Wales Renal Audit Meeting, Llanelli

2020thth September 2013September 2013

Aims of PresentationAims of Presentation

�� To explain the background, vision and To explain the background, vision and process of setting up a Renal Clinical process of setting up a Renal Clinical Psychology ServicePsychology Service

To provide a flavour of the service To provide a flavour of the service �� To provide a flavour of the service To provide a flavour of the service provided, including service user provided, including service user experiencesexperiences

�� To present future directionsTo present future directions

BCUHB Renal Psychology (Service History)BCUHB Renal Psychology (Service History)

�� Prior to 2009: 0.5 wte Renal Consultant Clinical Psychologist post Prior to 2009: 0.5 wte Renal Consultant Clinical Psychologist post in Cardiff. No service in N Wales. in Cardiff. No service in N Wales.

�� Designed to Tackle Renal Disease in Wales (2007) Designed to Tackle Renal Disease in Wales (2007) –– Renal MDT Renal MDT to include Clinical Psychology; follows guidance in UK Renal to include Clinical Psychology; follows guidance in UK Renal Workforce Plan (2002)Workforce Plan (2002)Workforce Plan (2002)Workforce Plan (2002)

�� Sept 2008: Proposal to establish Clinical Psychology provision to Sept 2008: Proposal to establish Clinical Psychology provision to North Wales Renal Services submitted and agreedNorth Wales Renal Services submitted and agreed

�� April 2009: 0.6 wte NW Wales NHS Trust Renal Consultant April 2009: 0.6 wte NW Wales NHS Trust Renal Consultant Clinical Psychologist post established (now BCUHB West)Clinical Psychologist post established (now BCUHB West)

�� January 2010: 1.0 wte Renal Consultant Clinical Psychology post January 2010: 1.0 wte Renal Consultant Clinical Psychology post for BCUHB Central & East establishedfor BCUHB Central & East established

Renal Clinical Psychology ProposalRenal Clinical Psychology Proposal

Assessment & therapy

Liaison with other Services

Eg Mental Health

Renal MDT liaison

Audit/evaluate service

ResearchTraining, supervision

& consultancy

Contribute to renal service/network

planning

Renal Clinical Psychology

VisionVision



Eg Mental Health

Renal MDT liaison

Renal Clinical

Integrated renal



& consultancy


planning


renal psychological

care

Setting Up A ServiceSetting Up A Service

�� Develop a referral proforma & organise clinics Develop a referral proforma & organise clinics (or not!)(or not!)

�� Educate teams about what the service can Educate teams about what the service can provideprovideprovideprovide

�� Accept referrals & liaise with MDT colleaguesAccept referrals & liaise with MDT colleagues

�� Audit baseline levels of depression, anxiety & Audit baseline levels of depression, anxiety & quality of life of dialysis patientsquality of life of dialysis patients

�� Collect activity dataCollect activity data

�� Consider outcome measuresConsider outcome measures

Total Referrals by YearTotal Referrals by Year

80

100

120

0

20

40

60

Year 1 Year 2 Year 3

N= 261 Average waiting time = 18.8 days

Number of Appointments Offered Number of Appointments Offered By YearBy Year

500

600

700

800

0

100

200

300

400

500

Year 1 Year 2 Year 3

N = 1,656 appointments offered

Number of referrals by renal statusNumber of referrals by renal status

80

100

120

140

0

20

40

60

80

CKD2 CKD3 CKD4 CKD5 AKI Other

Referral Numbers byReferral Numbers byRRT Status at Time of ReferralRRT Status at Time of Referral

40

50

60

70

80

0

10

20

30

40

Hosp

HD

Home

HD

PD Tx Cons

Mgt

Reasons Cited For ReferralReasons Cited For Referral

Mental Health Label

Psychological/Emotional

Behavioural/Concordance

Acceptance/AdjustmentAcceptance/Adjustment

Decision Making

Physical SymptomManagement

Other

Service ProvidedService Provided


MDT liaison

Assessment only

Referred onReferred on

Liaison with family

No service

Patient died beforecompletion

Patient Experience (1)Patient Experience (1)

�� “I can talk to you about anything that’s bothering me. You listen, “I can talk to you about anything that’s bothering me. You listen, don’t interrupt me or tell me what to do. I trust you completely don’t interrupt me or tell me what to do. I trust you completely because I don’t feel judged. I don’t have this with anyone else in because I don’t feel judged. I don’t have this with anyone else in the renal team or my family.”the renal team or my family.”

�� “We discuss things that affect me outside of just specific renal “We discuss things that affect me outside of just specific renal things… [and]… you realise its not just dialysis that affects how you things… [and]… you realise its not just dialysis that affects how you feel.”feel.”

�� “I can get very negative about things and then get quite angry, “I can get very negative about things and then get quite angry, down and difficult to deal with. Talking these over with you helps down and difficult to deal with. Talking these over with you helps down and difficult to deal with. Talking these over with you helps down and difficult to deal with. Talking these over with you helps me put things in perspective and then think about how I might deal me put things in perspective and then think about how I might deal with them better next time. When you have a success you feel good with them better next time. When you have a success you feel good about yourself…. I definitely don’t get so down as I used to.”about yourself…. I definitely don’t get so down as I used to.”

�� “You act as a buffer between me and the renal service.. I know I “You act as a buffer between me and the renal service.. I know I need them but I don’t always like them.”need them but I don’t always like them.”

�� “I used to see a psychologist when I was in child [renal] services.. “I used to see a psychologist when I was in child [renal] services.. there wasn’t one for adults and I missed it. Its definitely needed.”there wasn’t one for adults and I missed it. Its definitely needed.”

�� Home Haemodialysis PatientHome Haemodialysis Patient


�� “When we first met, I said is this going to help me.. is talking going “When we first met, I said is this going to help me.. is talking going to help me.. and two years going on.. of course it’s helped me! It to help me.. and two years going on.. of course it’s helped me! It helps things in my mind to.. er.. settles them down in my mind. To helps things in my mind to.. er.. settles them down in my mind. To other people I talk a lot of rubbish.. I can trust you, where there’s other people I talk a lot of rubbish.. I can trust you, where there’s no information going to come from you to anyone else. It’s helped no information going to come from you to anyone else. It’s helped me a lot.. it’s helped me through some bad things.. over the past me a lot.. it’s helped me through some bad things.. over the past two years. There’s things gone on in my life you have gladly two years. There’s things gone on in my life you have gladly accepted.. where it’s helped me to talk about.. and helped me to accepted.. where it’s helped me to talk about.. and helped me to get through it.. you know, I’ve had a couple of bad things.. I can’t get through it.. you know, I’ve had a couple of bad things.. I can’t get through it.. you know, I’ve had a couple of bad things.. I can’t get through it.. you know, I’ve had a couple of bad things.. I can’t tell anyone else.. I could tell you. You’ve been very useful.”tell anyone else.. I could tell you. You’ve been very useful.”

�� “Right at the beginning.. will talking do any good for me.. you said, “Right at the beginning.. will talking do any good for me.. you said, try it, and I’m still here two years on. It’s helped me quite a lot or try it, and I’m still here two years on. It’s helped me quite a lot or else I’d have binned you!”else I’d have binned you!”

�� “Plus you’ve helped me to get in different places, like Pain Clinic.. “Plus you’ve helped me to get in different places, like Pain Clinic.. you stuck at it to get me in there.” you stuck at it to get me in there.”

�� Transplant RecipientTransplant Recipient

Carer ExperienceCarer Experience

�� “You’ve helped me a lot because you’ve given “You’ve helped me a lot because you’ve given me other ways to think of it.. Talking to you.. me other ways to think of it.. Talking to you.. because I’m talking to you.. and your because I’m talking to you.. and your responses.. are allowing me to work out the responses.. are allowing me to work out the responses.. are allowing me to work out the responses.. are allowing me to work out the answer for myself.. which is what it’s.. therapy.. answer for myself.. which is what it’s.. therapy.. is about, isn’t it.”is about, isn’t it.”

�� Carer of Haemodialysis PatientCarer of Haemodialysis Patient


�� “I would not be here today if I had not met you and had “I would not be here today if I had not met you and had help with the breathing.. you know how low I went and help with the breathing.. you know how low I went and seeing you really helped.. I have lost all my fear. I seeing you really helped.. I have lost all my fear. I couldn’t deal with blood or needles.. had it not been for couldn’t deal with blood or needles.. had it not been for what I learnt.. I did the breathing and I went what I learnt.. I did the breathing and I went somewhere [selfsomewhere [self--guided visualization] and I got through guided visualization] and I got through it.”it.”

�� “When I had a blockage in my fistula.. they took me “When I had a blockage in my fistula.. they took me down.. put a stent in it.. I didn’t know I was having the down.. put a stent in it.. I didn’t know I was having the procedure.. I thought I’d die.. it was in a theatre.. I just procedure.. I thought I’d die.. it was in a theatre.. I just turned away from it [my arm].. I decided to move house turned away from it [my arm].. I decided to move house in my mind and plant a garden.. I got a bit annoyed in my mind and plant a garden.. I got a bit annoyed when they woke me! It took all the pain away, all the when they woke me! It took all the pain away, all the fear.”fear.”

�� Hospital Haemodialysis PatientHospital Haemodialysis Patient


�� “I’ve been really low at times and I’ve thought: ‘This is “I’ve been really low at times and I’ve thought: ‘This is the time for me to stop dialysis’.. you came to see me the time for me to stop dialysis’.. you came to see me recently.. what you said.. look what you’ve been through recently.. what you said.. look what you’ve been through before and got through it, that I must have some inner before and got through it, that I must have some inner strength.. it must have been the meditation practice. I strength.. it must have been the meditation practice. I said to them [dialysis unit staff], ‘I’m not having dialysis said to them [dialysis unit staff], ‘I’m not having dialysis anymore’.. and then I saw you a couple of days later.. anymore’.. and then I saw you a couple of days later.. and I thought it wasn’t going to work [eye operation].. and I thought it wasn’t going to work [eye operation].. and I thought it wasn’t going to work [eye operation].. and I thought it wasn’t going to work [eye operation].. and you talked of times when I’d thought of giving up and you talked of times when I’d thought of giving up and you said to me don’t be overconfident but that look and you said to me don’t be overconfident but that look what I’d got through before.. you reminded me of what what I’d got through before.. you reminded me of what I’d got through before.. I’m not scared anymore.. I can I’d got through before.. I’m not scared anymore.. I can take myself away [selftake myself away [self--guided visualization] and it’s guided visualization] and it’s given me this confidence.. you helped me to see that. given me this confidence.. you helped me to see that. It’s saved my life. It’s the truth.”It’s saved my life. It’s the truth.”

�� Hospital Haemodialysis PatientHospital Haemodialysis Patient

Indirect Work (1)Indirect Work (1)



Eg Mental Health

Renal MDT liaison



& consultancy


planning


Audit & Research ActivityAudit & Research Activity

�� Audit/evaluationAudit/evaluation�� Mapping psychological need in dialysis patients: distress level and Mapping psychological need in dialysis patients: distress level and

quality of life baseline surveyquality of life baseline survey

�� 2 Trainee Clinical Psychologist Service Related Research Projects 2 Trainee Clinical Psychologist Service Related Research Projects (SRRPs)(SRRPs)

�� Referrals & activity auditReferrals & activity audit�� Referrals & activity auditReferrals & activity audit

�� 1 complete SRRP; 1 on1 complete SRRP; 1 on--going SRRPgoing SRRP

�� ResearchResearch�� Current research:Current research: The lived experience of dialysis in young adults: The lived experience of dialysis in young adults:

using Interpretative Phenomenological Analysis to explore the impact using Interpretative Phenomenological Analysis to explore the impact of treatment on the physical, emotional, and social self.of treatment on the physical, emotional, and social self.

Principal Investigator: Lucy Piggin, Trainee Clinical PsychologistPrincipal Investigator: Lucy Piggin, Trainee Clinical Psychologist

Levels of Distress: Levels of Distress: HADS Data on Dialysis Patients in BCUHADS Data on Dialysis Patients in BCU

Distress level Distress level

(by base)(by base)

*West*West

YGYG

**Central**Central

YGCYGC

EastEast

WMWM

Above HADS cutAbove HADS cut--off off (score (score ≥ 10)≥ 10)

27%27% 40%40% ?40%?40%(score (score ≥ 10)≥ 10)

Borderline HADSBorderline HADS

(score 8(score 8--9)9)

10%10% 11%11% ?11%?11%

nn 45/12045/120 48/9448/94 ?51/100?51/100

Systematic review: 27% of patients with End Stage Renal Failure have depression and 38% have anxiety (Murtagh et al. 2007)

Surveys conducted: *Sept – Dec 2010 & **Dec 2010 – Jan 2011

Indirect Work (2)Indirect Work (2)



Eg Mental Health

Renal MDT liaison



& consultancy


planning


Training & Service Development ExamplesTraining & Service Development Examples

�� Training/educationTraining/education�� Clinical Psychology in the Renal Service Clinical Psychology in the Renal Service –– Renal MDT; Renal MDT;

ward staffward staff

�� Postgraduate Renal Nurse Module teaching: Postgraduate Renal Nurse Module teaching: Psychological Care for Renal PatientsPsychological Care for Renal Patients

�� Introduction to Stress Management & Mindfulness Introduction to Stress Management & Mindfulness ––staff, patients & carersstaff, patients & carersstaff, patients & carersstaff, patients & carers

�� PrePre--dialysis Modality Decision Makingdialysis Modality Decision Making –– Renal MDTRenal MDT

�� Service developmentService development�� All Wales Conservative Management Work StreamAll Wales Conservative Management Work Stream

�� Development of Healthy Living Programme (HLP) with Development of Healthy Living Programme (HLP) with Dietitian and Sports PhysiologistDietitian and Sports Physiologist

�� Development & implementation of Carers’ Group with Development & implementation of Carers’ Group with dialysis/home therapies Nurses & Renal Social Workerdialysis/home therapies Nurses & Renal Social Worker

Levels of psychological careLevelLevel Staff groupStaff group AssessmentAssessment InterventionIntervention

11 All renal health & All renal health &

social care staffsocial care staff

Identify psychological Identify psychological

needsneeds

Information giving, empathic Information giving, empathic

communication, communication,

psychological supportpsychological support

22 Health & social care Health & social care

professionals with professionals with

additional expertiseadditional expertise

Screen for psychological Screen for psychological

distressdistress

Problem solving & informal Problem solving & informal

counsellingcounselling

33 Trained & accredited Trained & accredited

psychological psychological

professionalsprofessionals

Assess distress & devise Assess distress & devise

basic formulation & basic formulation &

interventionintervention

Counselling & specific Counselling & specific

interventions (interventions (e.g.e.g. anxiety anxiety

management, systematic management, systematic

desensitization)desensitization)

44 Highly specialist Highly specialist

psychological psychological

professionalsprofessionals

Devise complex Devise complex

formulations & formulations &

interventionsinterventions

MultiMulti--theoretical frameworks theoretical frameworks

used to create & deliver used to create & deliver

unique interventionsunique interventions

Adapted from Improving Supportive Palliative Care for Adults with Cancer, NICE (2004)

Future DirectionFuture Direction

�� Renal Psychological Care Planning GroupRenal Psychological Care Planning Group

�� Identifying and training staff (levels 1Identifying and training staff (levels 1--2)2)

�� Introduction of psychological screening Introduction of psychological screening measuresmeasuresmeasuresmeasures

�� Further evaluation Further evaluation -- eg patient experience, renal eg patient experience, renal MDT experience, teaching/mentoring evaluationMDT experience, teaching/mentoring evaluation

�� Research Research –– patient & carer experience; staff patient & carer experience; staff wellbeing; psychological interventions wellbeing; psychological interventions

06. developing a renal clinical - health in wales. developing a renal clinical… · 22 health...

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