evaluating the input of a clinical psychology service into ... · through to acute trauma care and...

Evaluating the input of a clinical

psychology service into a major

trauma ward

“Sometimes people will hear ‘Psyc’ and think ‘you're telling me I'm crackers’”

Steven Mayers

Commissioned by Dr Nigel Wainwright and Dr Chloe Miller

With support of the staff working at the Leeds General Infirmary Major Trauma Ward

Contents

Background 1

Aims 3

Method 3

Design and analysis 3

Research setting 4

Participants 4

Procedure and analysis 5

Results 5

Part 1. Who, out of the patients admitted to the MTC, is 5

referred to clinical psychology and why?

Part 2. What is the staff experience of the clinical psychology 7

service and how can it be improved?

Discussion 12

Limitations 15

Implications 16

Recommendations 16

Next Steps 17

References

Appendices

Appendix 1 – Topic guide for semi-structured interview

questions asked to MTC staff

Appendix 2 – Poster presentation of results

Background

A major trauma typically refers to multiple injuries that can include life threatening

wounds, head injury and severe fractures that may result in death or morbidity for the

person involved (NHS Clinical Advisory Group, 2010). This type of injury is the most

common cause of death in people aged under-45 and as a result, the National Health

Service (NHS) has identified major trauma as a problem for public health (NHS

Commissioning Board, 2013). In the past, the acute and follow-up care for patients with

major trauma in the UK has been criticised for a lack of regional organisation and poor

leadership around decision-making (NCEPOD, 2007). In other parts of the world, the

introduction of major trauma systems, designed to address these problems with

organisation and decision-making, have been shown to result in a 15-20% decrease in

hospital mortality for patients with major trauma (Mann et al., 1999; Celso et al., 2006). It

was estimated that of the average of 5400 deaths per year from major trauma in the UK,

450-600 lives could be saved with the introduction of a UK Major Trauma Network

(National Audit Office, 2010).

The UK Major Trauma Network was implemented in 2012 and has resulted in

improved regional organisation with the introduction of 26 regional Major Trauma

Centre’s (MTCs) across the UK. A major trauma centre is a multi-speciality hospital on

one site that is well resourced to provide the optimum level of care and is the hub of the

trauma network in that region. Since these changes were introduced in 2012, there has

been a 30% improvement in the chance of surviving a major trauma (TARN, 2013). The

Leeds MTC is based at Leeds General Infirmary (LGI) where there is a specialist Major

Trauma Ward. The MTC at the LGI is the centre for trauma care in the Yorkshire and

Service Evaluation Project Clinical psychology and major trauma

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Humber region and 79% of people can access it within 45 minutes, helping to increase

chances of survival. The process of care for a major trauma requires excellence during

each part of the pathway: from initial contact with the patient and pre-hospital assessment,

through to acute trauma care and both acute and general rehabilitation (NHS, 2014). As

part of the design of the Major Trauma Network, it was proposed that each MTC should

have immediate access to specialist services with a view to improving the quality of

patient care during the acute and general rehabilitation parts of the pathway. These

specialist services include dietetics, speech and language therapy, physiotherapy, liaison

psychiatry, occupational therapy and clinical psychology.

The guidance for clinical psychology was developed in consideration of the

Department of Health guidelines for psychological care for patients who are involved in

disasters, emergencies and major incidents (Department of Health, 2009). Psycho-social

care should be delivered by the whole team with clinical psychologists leading more

specialised interventions and clinical psychologists should respond to the psychosocial

needs of the staff that are involved in major trauma care (NHS Clinical Advisory Group,

2010).

The focus of this report is to evaluate the input of clinical psychology in the Leeds

MTC. At the time of the evaluation, the Leeds MTC had five clinical psychologists who

each spend half a day per week on the MTC, providing a total input of two and a half days

per week to the major trauma ward. Until now the contribution of clinical psychology to

the MTCs has not yet been explored in detail, providing the primary rationale for this

service evaluation. The report was commissioned by Nigel Wainwright


2

and Chloe Miller who are clinical psychologists working at the Leeds Major Trauma

Centre.

Aims

The service evaluation is separated into two distinct parts; understanding the nature of

patient referrals to psychology and understanding staff experiences of the clinical

psychology service within the MTC. Amongst other things, this will enable exploration of

how well the psychological care in Leeds MTC complies with the national guidance for

psychological care in major trauma centres (NHS Clinical Advisory Group, 2010).

Part One: Who, out of the patients admitted to the MTC, is referred to clinical psychology

and why?

Part Two: What is the staff experience of the clinical psychology service and how can it be

improved?

Method

The evaluation of the clinical psychology service input into the Leeds MTC provides an

opportunity to understand patterns of referrals within the service; explore the staff

experience of clinical psychology and consider areas for development. Approval for this

evaluation was obtained via email from the Leeds Teaching Hospitals NHS Trust.


3

Design and analysis

A mixed-A mixed-method design was utilised for the service evaluation. A

qualitative method of data collection based on Microsoft Excel was used to evaluate Part

One and descriptive statistics were used to analyse the data. Qualitative data collection and

analysis through individual semi-structured interviews was used to evaluate Part Two. In

order to analyse the data after collection, a thematic analysis was used (Frith & Gleeson,

2004), the result of which are themes that are used to describe the data (Patton, 1990).

Other methods of qualitative analysis were considered, however, thematic analysis was

considered the most suitable as it allows for a descriptive interpretation. An alternative

design using questionnaires to obtain information from the staff was also considered, but

was discounted as it could have potentially resulted in a poorer response rate and less

opportunity to fully explore responses.

Research setting

The Microsoft Excel databases were stored on the Leeds Teaching Hospital NHS

Trust computer network. The individual semi-structured interviews were completed on the

major trauma based at the LGI in the available office space. The staff took part in the

interviews during their shift breaks.

Participants

The interviews with MTC team members (n=15) lasted between 5 minutes 11

seconds and 11 minutes 22 seconds (mean=7 minutes 48 seconds). An opportunity sample

of participants was selected based on the presence and availability on the ward. Some

potential participants were unable to take part because of time restrictions. The


4

participants who took part were from a range of professional backgrounds, including junior

doctor (n=1), staff nurses (n =4), occupational therapists (n=2), physiotherapists (n=2),

major trauma case manager (n=1), advanced nurse practitioner (n=1), senior charge nurse

(n=1), MTC services lead (n=1), orthopaedic consultant (n=1) and ward sisters (n=2). All

participants (n=15) were aware of clinical psychology; they had worked at the MTC for

between 15 and 22 months (mean=15 months).

Procedure and analysis

The quantitative data was collected over a 12-month period between April 1st 2014

and March 31st 2015 for patients admitted to the MTC (recorded by the Trauma Audit

Research Network) and those referred to clinical psychology (recorded by the clinical

psychologists working as part of the MTC). The data recorded included the following

patient information: gender, mechanism of injury, severity of injury and reason of referral

to clinical psychology. The qualitative interviews were completed in January 2015 (11

interviews) and February 2015 (4 interviews). The individual semi-structured interviews

followed a topic guide (Appendix 1). The interviews were audio-recorded and then

transcribed anonymously. All data is presented anonymously.

Results

Part One: Who, out of the patients admitted to the MTC, is referred to clinical

psychology and why?

The data collected for patients admitted to the MTC and those referred to clinical

psychology was collected over a 12-month period between April 1st 2014 and March 31st

2015. 575 people were admitted to the MTC during this time and 25% of these (n=144)


5

were subsequently referred to clinical psychology. The mechanism of injury of those

admitted to the MTC and those referred to clinical psychology varied. Figure 1 shows the

number of people admitted to the MTC (left) and those referred to clinical psychology

(right) from April 1st 2014 to March 31st 2015. The most common mechanism of injury for

those admitted to the MTC was due to some type of fall. The most common mechanism of

injury for patients referred to clinical psychology was a vehicle collision. For patients

admitted to the MTC and those referred to clinical psychology, the majority had been

experiences of fall or vehicle collision.

Figure 1. Number of patients admitted to the MTC (left, total n=575) compared with those

referred to clinical psychology (right, total n=144) in relation to mechanism of injury

(falls, vehicle collisions, blows, stabbing, crush and other including shooting) between

April 1st 2014 and March 31st 2015.

When gender is considered, a greater proportion of women were referred to clinical

psychology (38%) than were admitted to the MTC (26%). Figure 2 shows the reason that

patients who were admitted to the MTC between April 1st 2014 and March 31st 2015 were

subsequently referred to clinical psychology. The most common reason


6

40

82

123 6 1

253

180

461 4 8 6

for referral is low mood (34%) and adjusting to the incident and impact of injuries (19%).

The other referrals were for post-incident trauma, anxiety, flashbacks or nightmares,

family support, cognitive assessment and other.

Figure 2: Primary reason for referral to clinical psychology for patients admitted to the

MTC between April 1st 2014 and March 31st 2015.

Part 2: What is the staff experience of the clinical psychology service and how can it be

improved?

The individual, semi-structured interviews (n=15) revealed that the experience of

clinical psychology by the staff was overall very positive. Staff who had worked in the

MTC for longer had greater familiarity with the clinical psychology service and had more

experience of referring and suggestions for improvements. The positive experience of

clinical psychology was reflected by one staff member who said ‘[we are] really lucky to

have it. It is really valuable. I think it's great, I'm used to having it now, I think I'd really


7

Anxiety8%

Flashbacks ornightmares

8%

Family support7%

Post-incidenttrauma

12%

Cogax 5%

Other7%

Adjusting toincident &impact ofinjuries

19%

Lowmood34%

miss it if it wasn't there’. Another staff member acknowledged that other services do not

have access to clinical psychology, saying ‘we are privileged to have such a service’ and

one person compared it with their other experience working in an acute service without

clinical psychology, saying ‘I've come from other wards were we don't have this service.

It's just a really slick service, I think it's great’. Another commented on how valuable

clinical psychology is as part of the major trauma team, saying ‘the whole trauma service

is better than ever. Psychology is part of this’. The thematic analysis revealed two key

themes and a number of sub-themes (Figure 3) relating ‘referrals to clinical psychology’

and ‘support from clinical psychology’.

Figure 3: Key themes (blue boxes) and sub-themes (orange boxes, relating to each key

theme) from the thematic analysis of the individual interviews (n=15)

Referrals to clinical psychology

Who to refer. The reason for referral to clinical psychology varied greatly and

there was a lack of clarity about who should be referre. Some staff said that they refer


8

when people are ‘not coping well’, they have ‘low mood’, ‘flashbacks’, ‘anxiety’ or

‘suicidal thoughts’ where as others were less specific about the reason for referral, such as

when ‘something’s not right there’ or the person is ‘not progressing as expected’ or their

response is ‘disproportionate to what you would expect’. This inconsistency was

summarised by a participant who said ‘I know how I refer people but I'm not sure how

everyone else does’. When asked how many people were referred to clinical psychology,

the estimates ranged from 15-50%. This was echoed by some of some of the comments

people made about the perceived prevalence of referrals to clinical psychology. One staff

member said that they are ‘not very good at asking everybody’, whilst another said that

they ask ‘everyone on here [the ward], pretty much’.

How to discuss referrals. Some staff were unsure of how to discuss the referral to

psychology as they perceived it as a sensitive issue for patients. One staff member said,

‘sometimes people will hear ‘psyc’ and think ‘you're telling me I'm crackers” and another

spoke of how ‘clinical psychology is an intimidating word’. This seemed to be

exacerbated by the confusion between the role of clinical psychology and that of liaison

psychiatry. One staff member said ‘do we refer to psychology or liaison psychiatry? We

referred someone once [to psychology] who was psychotic but that wasn't appropriate.

Psychology saw him and referred on’. There were some suggestions for how the clinical

psychologists might be able to address this. One staff member said ‘Psychologists could

possibly go around and introduce themselves to patients. Sometimes people's thoughts

about what psychology does are very different to what you do’.

Concerns about missed referrals. Another difficulty that was discussed related to

identifying people for referral who may not be as obviously distressed. Some staff were


9

aware that this could be an issue and said things like‘[we could be] missing people who

don't seem like they're having anxieties about things’ and another said, ‘There could be

personalities that are not as open, some people don't scream or shout as much’. Another

staff member said that ‘the downside is potentially missing patients that don't display

outward signs but may benefit from it [clinical psychology]’. One person wondered if this

is something that could be developed in collaboration with the clinical psychologists, they

said ‘it's something we might be able to improve on and look to you guys for what we can

explore’.

Improving the process. When asked about potential improvements, some

advocated a move to a paperless system of electronic referrals, ‘It would be nice to get in

the 21st century and do it all electronically’ and it was thought that this could facilitate the

referrals for major trauma patients who are not being treated on the major trauma ward.

One person said ‘[Clinical Psychology] could improve referral process for people who are

MTC but on different wards, like surgical and critical care’.

Additional support from clinical psychology.

Training: the role of psychology and psychological skill. A number of

participants requested more training for ward staff to help increase awareness of clinical

psychology and provide information about the referral criteria. To make junior staff aware

of what clinical psychology is’. Some staff spoke about the benefits of education from

clinical psychology, particularly in relation to newer members of staff, ‘education will

help, with new staff, maybe that should be a rolling program’. This was echoed by some of

the newer staff members who said, ‘if you haven’t come across it on other


10

rotations it would be good to know about what you do’. Some participants thought that

education sessions would enable staff to develop more psychological skills and increase

the teams’ awareness of how clinical psychologists work, such as ‘staff education on

dealing with challenging behaviour’. Others wanted support ‘for times when psychologists

have been to talk about things and then leave and there are repercussions because of what

they've spoken about’.

Support for emotional trauma. Some participants requested support for staff that

visit A&E and often witness traumatic events (primarily case managers and nurses). One

person said, ‘I want to speak to them about how they [the clinical psychologists] can look

at supporting staff who are dealing with trauma’, another described what the experience of

staff trauma can be like, saying ‘you can come on the ward having just seeing someone

have their chest opened and die and immediately someone is asking you a question and

pulling you off to something else’.

More opportunity for feedback and discussion. A number of participants suggested

that the clinical psychologists attend the board round (the morning meeting) to discuss

each patient on the ward. One person said ‘they could attend the ward round in the

morning, all of the consultants go’ but others were unsure how beneficial this would be,

one person said ‘I’m not sure how valuable it would be to go to board roundsÉthe

[psychology] team did used to come to board round’. There was a suggestion that ‘meeting

more regularly, discussing and evaluating what we’ve done and what we've achieved and

meeting as a group as well, with physio [physiotherapy], OT [occupational therapy],

doctors, nurses and yourselves [clinical psychology]. The more interaction we have the

more regular the feedback the better’. This was echoed by another person, who


11

said ‘hopefully there will be more opportunity for them to feed into the ward as a whole.

Some staff gave more specific examples of what they would find useful, such as ‘a crib

sheet saying who is and who isn't appropriate for referrals’.

Discussion

The results suggest that the proportion of patients that are admitted to the MTC is

different to those referred to clinical psychology. The most common admission to the

MTC is those who have been involved in a fall, whereas the most common referral to

clinical psychology is for vehicle collision. This could result from the nature of the

accidents and the prevalence of trauma. For example, it may be that people experiencing

vehicle collisions have a more traumatic experience of their accident. The same could be

true for the trend between people that were stabbed and those that received a blow as their

mechanism of injury. Proportionally more people that have been stabbed are referred to

clinical psychology, which could result from the trauma experienced in those incidents.

However, it could also result from staff pre-conceptions of how someone may react to such

an incident i.e. staff may be more likely to ask somebody who has been stabbed to see

clinical psychology compared to someone who has had a blow to the head.

It would seem that proportionally more women are referred to clinical psychology

(38%) than are admitted to the MTC (26%). This could be for a number of reasons e.g.

cultural stereotypes make it more difficult for men to express their feelings. This could

mean that clinical psychology is missing some of the men that could benefit from clinical

psychology input. The reason for referral to clinical psychology varies but the most

common primary reason for referral is low mood, followed by adjustment to incident and


12


impact of injuries. It would seem that most of the referrals relate to a difficulty coping

following the incident for the individual and some relate to support required for the family

(7%). It may be that this data does not accurately represent the patients’ primary concerns

and rather the perception of the staff. Data from the initial interviews with patients could

help to determine if the initial reason for the referral to clinical psychology is the same as

what the patient needs.

The thematic analysis of the individual interviews produced a number of clear

findings, based on two key themes relating to ‘referrals to clinical psychology’ and

‘support from clinical psychology’. Generally there was a positive perception of clinical

psychology from a range of staff. There was evidence of some inconsistency in when the

ward staff make a referral to clinical psychology and a discrepancy between how well the

staff thought that the team were able to identify patients who were suitable for referral to

clinical psychology. This was mirrored by staff uncertainty about how to discuss a referral

to clinical psychology with a patient. It was suggested that it might be beneficial if

psychologists were able to introduce themselves to patients on the ward, without the

patient’s prior consent. A number of staff members were concerned that patients who

mask their distress may not be identified for referral to clinical psychology. However, they

were unsure of how to address this in a consistent way for all patients, and they asked for

support from clinical psychology in doing this. In relation to the referral process, it was

suggested that this could be modernised with a paperless system, which may also help

with referrals for major trauma patients who are on other wards and do not have access to

the referral book on the major trauma ward.

In relation to additional support, there was a request for clinical psychologists to

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provide more support for staff who are experiencing emotional trauma because of the

nature of their work. It was suggested that clinical psychology could attend board round to

increase their presence in the team, although everyone did not share this view. However,

there was a sense that more opportunities to share information more frequently would be

beneficial. One way that this could be facilitated is through increased opportunity to

provide education for staff. Specific requests were made about ways to manage

challenging behaviour, difficult conversations (sometimes after a clinical psychology

session) and how to discuss a referral to clinical psychology. There was a sense that a

rolling program of orientation training would help staff who were unfamiliar with clinical

psychology to better understand what they have to offer, how clinical psychologists work

and how the service is different to liaison psychiatry. The results of the interviews have

implications for how the clinical psychologists work with the MTC team in relation to

supporting other staff to deliver psychologically informed care and their role in supporting

staff with their own psychosocial needs (NHS Clinical Advisory Group, 2010). The

practicality of these implications is considered in greater detail below.

In reference to the guidance for psychological care of patients who are involved in

disasters, emergencies and major incidents (NHS Clinical Advisory Group, 2010), there are

some relevant findings. Specifically, in relation to psychosocial care being delivered by the

whole team, it appears that that service delivery is often inconsistent as staff are unsure

which patients require psychosocial support and there is inconsistency between staff

members. Clinical psychologists are receiving referrals for specialist intervention these may

be inconsistent as it is dependent on the staff perceptions of psychological need. Staff have

explicitly requested more psychological support, and gave specific


14

examples of when this is required. These findings will now be considered in relation to the

limitations, implications, recommendations and next steps.

Limitations

This evaluation has a number of limitations. The information recorded on the databases

was different for those admitted to the MTC and those referred to clinical psychology.

The databases were created and stored separately which may account for some of the

inconsistencies in the recorded mechanism of injury. To improve this, the psychology

referral database could be edited to match the TARN database. It was difficult to

interview more senior staff, consultants in particular as they were on the ward for less of

the time. As a result, the sample may not be representative of all team members. A more

in-depth analysis of interviews could have been more interpretive and less descriptive. I

explained to interview participants that I was not working as part of the clinical

psychology team but the clinical psychologists introduced me and this may have impacted

on the openness of the responses given.


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Implications

Clinical Psychology is well received by MTC staff. Participants who were interviewed

made a number of specific recommendations, which are summarised below. There are

differences between the people that are admitted to the MTC and those that are referred

to clinical psychology. This relates to mechanism of injury and gender. It may be that

some groups are being referred to clinical psychology less readily despite their need. It is

important for the clinical psychologists to help the team to identify those in need of

psychological support and to monitor the referral process.

Recommendations

1. Clinical psychologists to introduce themselves to patients more frequently to

improve awareness and understanding of the service

2. Providing more education to staff regarding referrals to clinical psychology, how

to discuss a referral with a patient and how to identify people who may be less

obviously distressed

3. Providing education about how clinical psychologists work and how that differs

from other services i.e. liaison psychiatry

4. Providing staff training for managing challenging behaviour and having difficult

conversations with patients

5. Providing more support to staff following their own emotional trauma

6. To consider attending board round

7. To consider a paperless referral system to improve access from patients on other

hospital wards

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Next steps

The next practical steps that will take place in relation to this service evaluation are:

• The initial proposal was to collect data from patients but it proved difficult to

obtain the forms once they have been completed. This may be because the paper

forms easily get lost amongst the other paperwork and very few were returned to

clinical psychology. A future evaluation could focus on the patient experience of

the clinical psychology service and the staff experiences following the changes

made as a result of this evaluation.

• The poster displaying the key findings of the research has been presented at the

University of Leeds Doctorate in Clinical Psychology Service Evaluation Project

Conference on 30th October 2015.

• The poster will now be displayed on the major trauma ward so that staff can see

the results of the evaluation.

• Key findings from the evaluation will be presented at a multi-disciplinary

team meeting within the final quarter of 2015.

• The MTC clinical psychology team will meet to discuss the findings of the report

and consider the key implications, presented above.

• A ‘you said, we did’ poster will be completed to complete the evaluation process

and clearly communicate what changes have been made to the ward staff.

• The findings of this research will be written for publication in the British

Psychological Society’s Division of Clinical Psychology Forum Magazine.

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References

Celso, B., Tepas, J., Langland-Orban, B., Pracht, Etienne., Papa, L., Lottenberg, L., Flint,L. (2006). A Systematic Review and Meta-Analysis Comparing Outcome of SeverelyInjured Patients Treated in Trauma Centers Following the Establishment of TraumaSystems. Journal of Trauma-Injury Infection & Critical Care, 60(2), 371-378.

Department of Health. (2009). Emergency Planning Guidance: Planning for thepsychosocial and mental health care of people affected by major incidents and disasters:Interim national strategic guidance. London: Department of Health.

Findlay, G., Martin, I.C., Carter, S., Smith, N. Weyman, D & Mason, M. (2007) Trauma:Who Cares? A report of the National Confidential Enquiry into Patient Outcome andDeath. Available from:http://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf Retrieved on 11tth

November 2015.

Frith, H. & Gleeson, K. (2004). Clothing and Embodiment: Men Managing Body Image

and Appearance. Psychology of Men & Masculinity 5(1), 40.

National Research Ethics Service (2013). Definig research. NRES guidance to help you decide if yourproject requires review. Available from http://www.hra.nhs.uk/documents/2013/09/defining-research.pdfRetrieved on 12th January 2016.

Mann, N.C. Mullins, R.J. MacKenzie, E.J., Jurkovich, G.J. & Mock, C.N. (1999)Systematic Review of Published Evidence Regarding Trauma System Effectiveness.Journal of Trauma-Injury Infection & Critical Care, 47(3), 25-33.

National Audit Office. (2010). Major Trauma Care in England. London: The StationaryOffice

NHS Clinical Advisory Group. (2010). Regional Networks for Major Trauma. NHSClinical Advisory Groups Report. Available from:https://www.rcn.org.uk/__data/assets/pdf_file/0008/353096/Major_Trauma_Report_FINAL1.pdf Retrieved on 10th November 2015.

NHS Commissioning Board. (2013) NHS Standard Contract For Major Trauma Service.NHS England. Available from https://www.england.nhs.uk/wp-content/uploads/2014/04/d15-major-trauma-0414.pdf Retrieved on 11th November 2015.

Patton, M.Q. (1990). Qualitative evaluation and research methods, second edition. Sage,

London.


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Appendices

Appendix 1 – Topic guide for semi-structured interview questions asked to MTC staff

Are you aware of the input into MTC from clinical psychology?

What has been your experience of this service?

Could you tell me what you know about the referral process?

If you have made a referral, can you give me the reasons for the referral?

How did you decide to refer?

What happened as a result?

Who responded to the referral and how?

How did that make you feel?

Can you give examples of times when this has and hasn’t worked well?

If you didn’t make a referral, what would make it easier for you to make

one in the future?

What additional support can the Clinical Psychology service offer to the MTC in

the future?

Do you have any other ideas of input that may be useful from the Clinical

Psychology service?

What would make the team feel that the Clinical Psychology service were more

involved in the MTC team?

Do you have any other comments or suggestions?


19


Appendix 2 – Poster presentation of key findings

40

% 30

20

10

0

Evaluating Clinical Psychology input intoLeeds Major Trauma CentreSteven Mayers, Chloe Miller and Nigel Wainwright

Background & aimsThe introduction of major trauma systems around the world has resulted in a 15-20%decrease in hospital mortality (Celso et al., 2006; Mann et al., 1999). It was estimated thatof the 3000 deaths per year from major trauma in the UK, 450-600 lives could be savedwith the introduction of a national major trauma network (National Audit Office, 2010).Leeds Major Trauma Centre (MTC) is based at Leeds General Infirmary and opened in April2013, following a large financial investment. The centre receives patients from Yorkshireand the Humber region which is home to 6 million people. 79% of people in Yorkshire andthe Humber can access the MTC within 45 minutes.

As part of the design of the UK Major Trauma Network, it was established that each centreshould have funding for specialist service input, including dietetics, speech and languagetherapy, physiotherapy, occupational therapy and clinical psychology. The input of clinicalpsychology has not been evaluated to date in any centre. There were two key aims of theSEP:

1. Who, out of the pa<ents admi>ed to the MTC, is referred to clinical psychology andwhy? This was established by collecting one year of data for patients seen by MTC andpsychology from April 1st2014 - March 31st2015.

3. What is the staff experience of the clinical psychology service?This was explored through 15 interviews with MTC team members; 1 Junior Doctor, 4 StaffNurses, 2 Occupational Therapists, 2 Physiotherapists, 1 Major Trauma Case Manager, 1Advanced Nurse Practitioner, 1 Senior Charge Nurse, 1 MTC Services Lead, an OrthopaedicConsultant and 2 Ward Sisters.

Falls Vehiclecollisions

Blows Stabbing Crush Otherincluding

shoo?ng

Fig 1. Graph to show the mechanism of injury of pa9ents admi;ed to theMTC and referred to Clinical Psychology

60g

50

MTC

Clinicalpsychology

ResultsPart 1. Quan+ta+ve575 people were admitted to the MTC between April 1st 2014 and March 30th 2015. 25%

(n=144) of these were referred to clinical psychology. A greater proportion of women werereferred to clinical psychology (38%) than were admitted to the MTC in general (26%). Fig 1

compares the mechanism of injury of those admitted to the MTC with those referred to

clinical psychology. Fig 2. Shows the primary reason for referral to clinical psychology.

Part 2. Qualita+veAll participants (n=15) were aware of clinical psychology; they had worked at the MTC for anaverage of 15 months (range=3-22 months). The experience of clinical psychology was verypositive, overall. As you’d expect, more established staff were the more familiar with theclinical psychology service. The participants responses to the interview questions aresummarised below in relation to the two main areas of discussion.

“Really lucky to have it. It is really valuable. I think it's great, I'mused to having it now, I think I'd really miss it if it wasn't there!”

Referrals to clinicalpsychologyThe reason for referral varied greatly and there is a lack of clarity regarding who should bereferred to clinical psychology. Some staff refer when people are “not coping well”, have“low mood”, “flashbacks”, “anxiety” or “suicidal thoughts”. Others said they would refer if“something’s not right there”. When asked how many people are referred to clinicalpsychology, the estimates ranged from 15-50%.

It was clear that the referral process was familiar to all staff. Some advocated a move to apaperless system of electronic referrals. Some staff were unsure of how to best discuss thereferral to psychology as they perceived it as a sensitive issue. Others spoke of someconfusion between the role of clinical psychology and that of liaison psychiatry.

“Sometimes people will hear ‘psyc’ and think ‘you'retelling me I'm crackers’"

Addi9onal support from clinical psychologyA number of participants requested more training for ward staff to increase awareness ofclinical psychology and provide information about the referral criteria. Some participantsrequested support for staff who visit A&E and often witness traumatic events (primarilycase managers and nurses).

A number of participants suggested that the clinical psychologists attend the board round(the morning meeting to discuss each patient on the ward). Clinical psychologists haveattended these in the past. Some participants thought that education sessions wouldenable staff to develop more psychological skills and increase the teams awareness of howclinical psychologists work.

Flashbacksornightmares

8%

Anxiety8%

lectusFamilysupport

7%

Post-incidenttrauma12%

apn toOther

Cogax 7%5%vi

Adjus.ng to incident& impactof injuries

19%

Lowmood34%

Fig. 2. Primary reason for referral to Clinical Psychology

“You can come on the ward having just seeing someone havetheir chest opened and die and immediately someone is askingyou a question and pulling you off to something else. So I want tospeak to them about how they can look at supporting staff whoare dealing with trauma”

Summary and implica9onsClinical Psychologists are referred proportionally less people who have suffered a fall andmore people who have been in vehicle collisions that are admitted to the MTC. This couldresult from the potential level of psychological trauma associated these incidents. Morewomen are seen by clinical psychology than are referred to the MTC. This suggests thatmen are accessing clinical psychology less readily. It is important for the clinicalpsychology help the team to identify those in need of psychological support.

Clinical Psychology is well received by MTC staff. A number of specific recommendationswere made by participants who were interviewed. This included attending board round,providing more information to staff about referrals and more education about howpsychologists work. In addition there was a request to provide support to staff followingtheir own emotional trauma. To facilitate these recommendations, these findings will bepresented to the team and a ‘you said, we did poster’ will be completed.

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evaluating the input of a clinical psychology service into ... · through to acute trauma care and...

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