‘Medical and nursing colleagues saw us as very much sitting upstairs in our ivory tower. We were, essentially, waiting for referrals to come to us. It wasn’t how we felt we should be working.’ So says Martin Riley, Head of Counselling Support Services (CSS) at the Hospice in the Weald, one of the winners of the BACP 2012 Improving Access to Counselling and Psychotherapy Award.
The Hospice in the Weald is based in Pembury, Kent. Surrounded by orchards, deep in the Kent countryside, it serves a 400-mile catchment area, and offers a Day Therapy Centre, a Hospice in the Home Service, carer support, and respite, palliative and end-of-life care in its 17-bed inpatient unit (IPU). Its counselling service works with patients, families and carers, and includes outreach counselling in the community and bereavement counselling. The counselling team has always been well established: Martin currently manages four permanent counsellors (one full-time, three part-time), 18 volunteer counsellors, a part-time music therapist and a full-time administrator.
Two years ago Martin, then a counsellor in the team, launched a review of how they were meeting needs on the inpatient unit (IPU). ‘My sense was that counselling was seen as detached, removed from the hands-on day-to-day work of the IPU,’ he says. The nurses were also having to hold patients’ emotional distress, simply because they were there with the patients, day and night. ‘For us the issue was how could we better hold some of the pain and alleviate some of the anxiety of the nurses’ role and how could we make ourselves more accessible. If a nurse felt a patient would benefit from counselling they had to fill out a form, email it to us, and they had no control over how quickly we responded.’
Another challenge was the stigma attached to counselling. ‘We wanted to normalise emotional support, to convey the message to patients that having counselling isn’t a sign that you aren’t coping or that you’re mentally ill. There are a lot of false beliefs about counselling and, while we need to recognise that counselling isn’t for everyone, we also need to communicate that we are there to support people through what is a normal response to their situation – who wouldn’t be upset if they had a terminal diagnosis?’
Martin initiated a review of how the counselling team worked in relation to the IPU. He set up separate focus groups with the hospice doctors, IPU nursing staff, with the chaplain, occupational therapist and physiotherapist and with the counsellors. He also interviewed the Nursing Director. He taped and analysed the hour-long discussions and from the transcripts identified the key themes, which he used to inform his recommendations for change.
A major theme was access to and availability of counselling: how did the IPU multi-disciplinary team (MDT) deal with situations where they felt a patient might benefit from counselling but refused it; was there a way in which the counselling team could offer less formal support that might be more acceptable to a patient? How too could it better support non-counselling colleagues who were fulfilling this role informally? Nursing staff in particular talked about the necessity of being able to work with patients’ psychological needs when they arose. Multi-disciplinary team (MDT) members talked of their anxieties about ‘opening a can of worms’ if they engaged with a patient’s psychological distress.
Formal referral to counselling was largely considered too slow and difficult; the nurses said the counsellors felt ‘a long way away’ and ‘strangers on the ward’. The clinical staff wanted a less formal introductory/referral process.
There was also recognition that the counsellors had much of value to contribute to the wider MDT and its holistic approach to care. There were comments about ‘psychological aspects being missed in MDT’, and ‘Counsellors will give a bit of insight into somebody that helps us all’. One nurse commented: ‘… we do hear some quite sad and worrying things... We probably go for a more clinical point of view rather than a psychological point of view, so support there would be helpful.’
Increased ward presence
Based on the feedback, and drawing on the research and reports of good practice in other palliative care organisations, Martin developed a new way of working. Counsellors would be allocated to the ward on a six-week rotation and would attend the MDT weekly meetings and the weekly ward rounds. This was piloted over four rotations: one for each of the counsellors. After each rotation the counsellor was interviewed and feedback was invited from IPU colleagues via a questionnaire. When all the rotations were completed the MDT team was re-interviewed collectively about the benefits of the new way of working and ideas for further improvements.
Counsellors said they liked feeling part of the wider team and working more closely with clinical staff. They felt they now had a better understanding of the IPU, how it operates and how decisions are made about patient care. They felt that the proactive approach relieved clinical staff of the responsibility for deciding who might benefit from counselling.
There was a mixed response to attending handovers and MDT meetings: some counsellors saw this as an opportunity to learn more about the needs of the patients; others felt less comfortable and confident in a clinical team context. However, routinely attending ward rounds was seen as advantageous in improving MDT working. The counsellors also felt that patients were more receptive to the idea of counselling if they met the counsellor in person, rather than being given a referral to an anonymous service.
The IPU clinical team welcomed the contribution of the counsellors to ward rounds, and in particular when they offered to take the lead or stay behind to talk with patients and relatives if something came up during the ward round. They also welcomed the increased presence and availability of counsellors.
There was clearly some emotional impact on the counsellors from being on the ward and in closer and regular contact with patients and relatives; the ad hoc role was more demanding. The traditional 50-minute counselling session had, effectively, been replaced by a Monday to Friday, 9–5 counselling week, the counsellors pointed out.
The quantitative results from the questionnaires and from patient contact statistics told a similar, positive tale. In 26 returned questionnaires, the benefit listed by most was the improved MDT working and holistic care, followed by the speed and ease of access. The majority felt that the amount of time that the counsellors now spent on the ward was ‘just right’. And, in comparison with the same periods in 2009 and 2010, the counsellors recorded seven times more contacts with patients and relatives – an average of 22.75 face-to-face contacts over the six-week rotation, compared with 3.5 in 2009 and 3.75 in 2010.
Removing the stigma
Dr Helen McGee, the hospice’s Medical Director, is delighted with the changes. ‘It always was a very accessible team but it did feel as though you had to make a formal referral. Now, with the counsellors on the ward round, it’s much more informal and it removes that stigma – that sense that if a patient needs to see a counsellor there must be something wrong.’
A major benefit is that the anxiety about dealing with patients’ emotional distress has been lifted. ‘It really helps me out when I find myself outside my comfort zone, if we are exploring lots of emotional issues with a patient. Doctors are used to asking questions, finding out what’s wrong and fixing it. Here you can’t fix everything so it’s good to have the counsellor there, if you do take the lid off.’ There has been, she says, an overall improvement in the emotional articulacy of the MDT. ‘Sometimes we’ll come out of a patient’s room and have a little debrief. Having the counsellor there helps us acknowledge that sometimes it’s not all about what we have or have not done; sometimes it’s about where the patient is now.’
Paula Wilkins, Nursing Director, is similarly happy with the way the counselling service now operates. ‘The role of the counselling service on the ward has become far more embedded since the project. It’s helped to demystify their role and given staff more confidence in their own skills and abilities.’
In response to the feedback, the counsellors now do a four-week rotation, not six, in recognition of their more emotionally demanding role. Says Martin: ‘The work can be very draining, very intensive. It’s important not to underestimate the impact of this way of working.’
What made such a radical change possible? ‘Right from the start it was a collaborative endeavour – we thought it through very carefully; we consulted with our MDT colleagues to find out what they felt and wanted,’ Martin says. ‘This was about how we all contribute to get the best outcomes for our patients.’
For more details, visit www.hospiceintheweald.org.uk