Evaluating the Input of a Clinical Psychology
into a Regional Spinal Injury Rehabilitation Service
“Having a spinal cord injury changes, in a moment, all aspects of one's life forever.
There is a lot to cope with all at once”
Patient, 5 years post spinal injury
Author: Alex Puchala
Commissioned by Dr Nigel Wainwright and Dr Rebecca Ellis
With support of the SPINE
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Table of Contents
Background 3
Yorkshire Regional Spinal Injuries Centre 4
Clinical Psychology in Spinal Injuries Rehabilitation 4
Aims 5
Method 6
Part One: Clinical Psychology at a Regional Spinal Injury Centre: Patients’ perspective 6Survey Procedure and Analysis 6Survey Results 8Summary of the survey results 11
Part Two: Clinical Psychologists at YRSIC: whom do they see and what do they do? 11Procedure and analysis 11Results 12Clinical Psychology workload 16
Limitations of this Evaluation 19
Implications and Recommendations 19Next steps 20
Appendices 24Appendix 1 –Notification of local Research and Development Department at Mid YorkshireHospitals NHS Trust 24Appendix 2 – Survey for ex-patients of the YRSIC 25Appendix 3 – Sample thematic map 28Appendix 4 – Poster presentation of results 29
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Background
What do we mean by spinal injury?
The term ‘Spinal injury’ refers to any insult to the spine which results in complete or partial
interruption of spinal cord function (NHS England, 2013). Spinal Cord Injuries (SCI) can be caused
by trauma, such as a road traffic accident or a fall from heights (this type of SCI is referred to as
‘traumatic’), or by a range of medical conditions, such as tumors, infections or arthritis (referred to as
‘non-traumatic’ SCI). Spinal Cord Injuries can occur at any level of the spinal cord: cervical (neck),
thoracic (chest and upper back), lumbar (low back) and sacral (behind pelvis); and can be classified as
‘complete’ (i.e. total loss of sensation and muscle control), or ‘incomplete’ (i.e. some sensation and/or
muscle function is preserved). It is the location and severity of the damage to the spinal cord that
impacts on symptoms, which can vary greatly from pain or numbness to complete loss of sensation,
paralysis, and bowel and bladder dysfunction (Grundy & Swain, 2004).
Due to advances in medicine, i.e. improved care immediately after the trauma and better
management of the long-term medical needs, such as prevention of pressure sores and urinary tract
infections, survival rates among spinal injury patients are much higher than several decades ago.
Sadly, there is still no cure to reverse the damage to the spinal cord (Kim & Ament, 2017). Once the
initial injury or disease stabilizes, all medical efforts are focused around the prevention of secondary
problems, such as bowel and bladder issues, respiratory infections and blood clots. From the
emergency departments patients are typically transferred to local trauma centers, and once well
enough they can be referred to regional centres for inpatient rehabilitation.
According to the latest statistics, approximately 1000 people sustain a new spinal cord injury
each year in the UK (NICE, 2017). Young and middle aged men are at the highest risk of injury due
to traumatic causes, followed by older people, where spinal injuries are associated with degenerative
spine conditions. In the UK alone there are approximately 40,000 people living with long-term
disabilities caused by Spinal Cord Injuries (NICE, 2017).
Figure 1. Spinal Cord Injuries (SCI) Factsheet
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Yorkshire Regional Spinal Injuries Centre
The Yorkshire Regional Spinal Injuries Centre (YRSIC) based at Pinderfields Hospital in Wakefield
is a 32 bed rehabilitation centre with a large catchment area. It was first opened in 1957 and it is now
one of 11 Regional Spinal Injuries Centres in Great Britain (See Figure 1. below). It treats patients
with traumatic and non-traumatic spinal cord injuries from Yorkshire, Humberside and beyond.
Figure 2. UK’s Regional Spinal Centres
The Yokshire Regional Spinal Injury Centre centre is led by the consultants. In October 2015 two
Clinical Psychologists (1.6. whole time equivalent) were added to the YRSIC multidisciplinary team,
consisting of spinal surgeons, doctors, nurses, physiotherapists and occupational therapists.
International and national guidelines on best practices in spinal injury rehabilitation recognise clinical
psychology as a ‘vital part’ of the healthcare provision (WHO, 2013; NHS England, 2013; DoH,
2005). It is now widely known that spinal injuries can result in total disruption of the person's life and
that optimal emotional adjustment is vital to successful recovery and rehabilitation.
Clinical Psychology in Spinal Injuries Rehabilitation
Over the last two decades researchers have investigated the psychological, social and health
consequences of SCI (Dezarnaulds & Ilchef, 2014). It resulted in a rich source of information
describing both the immediate and enduring psychological and social phenomena characteristic of
people with spinal cord injury and these around them.
3
4
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For most individuals SCI is a result of significant trauma (Kennedy, 2001). Subsequently, the
majority of literature focuses on negative impact of SCI on mental and physical health.
The most common finding is that individuals with SCI are more at risk of depression and anxiety
(Middleton & Craig, 2008). According to some estimates over 25% of individuals with SCI have
clinically significant levels of depression and anxiety (Craig, Tran &Middleton, 2009). Some authors
even claim that a ‘psychiatric diagnosis’ can be made in nearly 40% of individuals with a traumatic
onset spinal cord injury (Dezarnaulds & Ilchef, 2014). Not surprisingly, people with SCI report
significantly lowered quality of life following their injury (Kennedy, Lude, & Taylor, 2006). Suicide
rates amongst SCI sufferers are five times higher as in the general population in the fist several years
post injury (Stanford, Soden, Bartrop, Mikk, & Taylor, 2006).
One of the well researched conditions linked to SCI is the Post-traumatic stress disorder (PTSD).
PTSD is a common complication following SCI, especially when the injury was caused by a traumatic
life events, such as road traffic accident or assault (Radnitz, Schlein, & Hsu, 2000).
Research into rehabilitation and psychological phenomena that influence adjustment and
adaptation to SCI has been increasing (Middleton, Tran, & Craig, 2007). It suggests that certain
aspects of sufferer’s personality, lifestyle, and cognitive styles can predict better outcomes following
SCI. Amongst the main factors mentioned in literature are: self-efficacy, tendency toward solution-
focussed attitude, optimism and sense of humour (Berry, Elliott, & Rivera, 2007). Higher levels of
pre-injury education and younger age have been identified as factors that support a development of
acceptance and better long-term adjustment following a SCI injury (Hsieh, et al., 2013). Additionally,
older age has been recognized as a factor that can increasing the risk of depression following SCI
(Ahn, et al., 2015).
An interesting new theme in SCI rehabilitation literature is a phenomenon called the
posttraumatic growth, which has been recognised in people with chronic health problems and
disabilities. Posttraumatic growth involves finding deep meaning and purpose despite negative
consequences associated with spinal cord injury (Kalpakjian et al., 2014). Literature review further
highlighted the need for robust outcome measures that are designed specifically for SCI populations
(Chan, Miller, Querée, & Noonan, 2017). Additionally, there is a plea for more rigorous longitudinal
studies looking at long term adjustment (Dezarnaulds & Ilchef, 2014).
Aims
The focus of this report is to evaluate the input of clinical psychology into the YRSIC. This
evaluation should provide an opportunity to understand the work of clinical psychologists; explore the
ex-service users’ experiences and expectations of clinical psychology and consider areas for
development. Approval for this evaluation was obtained via email from the Mid Yorkshire Hospitals
NHS Trust. The evaluation was commissioned by Nigel Wainwright and Rebecca Ellis who are both
Clinical Psychologists working at the YRSIC.
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The service evaluation is separated into two distinct parts:
1) Part One aims to capture patients’ experiences, thoughts and expectations of Clinical
Psychology as a part of their spinal rehabilitation.
2) Part Two aims to describe the population of YRSIC and the work undertaken by Clinical
Psychologists working there since their introduction in October 2015.
Method
A mixed-method design was used for this service evaluation. Qualitative data collection and analysis
through an online survey was used to evaluate Part One. Here descriptive statistics were used for
analysis of closed-ended questions (i.e. demographic, rating scale, forced choice and dichotomous
questions) and content analysis (Elo & Kynga, 2007) and comprehensive data description (Wolcott,
1996) to describe and make sense of open ended and free text questions.
Part two was evaluated using a qualitative method of data collection based on Microsoft Excel, with
descriptive statistics used to analyse the data. An alternative design using interviews to obtain
information from the staff and current inpatients was also considered, but was discounted as it could
be biased by subjects’ familiarity with the person conducting the evaluation, who at the time was a
member of the YRSIC team.
Part One: Clinical Psychology at a Regional Spinal Injury Centre: Patients’ perspective
Survey Procedure and Analysis
The survey was hosted on the Bristol Online Survey system and a link to the survey was sent through
SPINE, a charity working on the ward, which holds a database of 800 email addresses of ex-patients
of YRSIC. Due to the fact that the person conducting this evaluation was a trainee Clinical
Psychologist on placement at the YRSIC we decided against including current patients into the survey
to avoid bias. The survey was live for two weeks in October 2017, the response rate was 7.5 percent,
which considering the complex health needs of the survey population was deemed sufficient. Given
that for most ex-patients of YRSIC Clinical Psychology was not available, we had two versions of the
survey: one for patients who did not have access to psychology (65% of the survey sample, n=39) and
one for more recent service users, who did have access (35%, n=21).
The survey was made of both closed-ended and open-ended question, please see the structure of the
survey below (Figure 3).
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Figure 3. The design of the survey
Content analysis is a popular research method used to describe data in a systemic and objective
manner used in nursing, psychology and medicine (Sandelowski 1995, Elo & Kynga, 2007). Content
analysis used with answers to open ended survey data can enrich the understanding and condense
words used by individual participants into categories. The process of content analysis following the
original model by Weber (1985) involved several steps:
1. Determining the main unit of analysis,
2. Defining categories,
3. Coding on a sample of text,
4. Coding on all of the text,
5. Testing for Inter-Coder Agreement,
6. Revision and re-testing.
In this study the content analysis was fairly straightforward as responses to each of the 8 open-ended
survey questions were analysed separately. There were 211 responses (total of 4,288 words), which
varied in length from 1 to 222 words each and an average length of 20 words per response.
Data type
Survey Item Question type
Dem
ogra
phic
Ev
alua
tio
no
fse
rvic
ere
ceiv
ed
Exp
lora
tion
ofne
ed
1. Gender Closed-ended •
2. Age Closed-ended •
3. Length of inpatient stay Closed-ended •
4. Time since discharge Closed-ended •
5. Time since injury/illness Closed-ended •
6. While you were admitted do you think that seeing a ClinicalPsychologist might have been of any help to you?*
Closed-ended,dichotomous choice: y/n •
6a. If yes, why? If not, why?* Open-ended, free text •7. How important it is to have psychological support as a part of spinal
injuries rehabilitation?Closed-ended, Likert-type scale (0-5) • •
7a. Why do you think that is? Open-ended, free text • •8. What is missing from available services that could make a
difference?Open-ended, free text
•
9. Can you select forms of psychological support that you personallywould be interested in if they were available to you?
Closed-ended, multipleresponse options •
9a. If other, please specify Open-ended, free text •10. Any other comments? Open-ended, free text •11. Please rate the outcome of seeing a clinical psychologist working on
the ward**Closed-ended, Likert-type scale 0 to 5 •
12. What has been good about seeing a clinical psychologist?** Open-ended, free text • •13. What was less good about seeing a clinical psychologist?** Open-ended, free text • •14. What could be improved?** Open-ended, free text • •
*question unique to version 1 of the survey (ex-service users who did not have access to clinical psychology)**question unique to version 2 of the survey (ex-service users who had access to clinical psychology)
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Initially, the responses were read several times. Following this answers to one of the questions were
coded according to main topics (categories) described by participants. To reduce the risk of bias the
initial codes were consulted with two fellow researchers (i.e. academic supervisor and a trainee
clinical psychologist), who were not familiar with the study. Feedback from these consultations was
used to code the rest of the data. All codes were recorded and divided into groups (i.e. themes), which
were then named (See Appendix 3, showing an example of this process). This was then consulted
with the same group of fellow researchers. Following second consultation codes were refined. Four
open-ended questions did not generate enough data to perform a content analysis, a comprehensive
dataset description was used instead (i.e. Questions 9a, 15, 16 and 17).
Survey Results
In total we received 60 responses (61% male, 31% female, 8% prefer not to say/not specified). 65% of
our respondents did not have access to clinical psychology whilst an inpatient. When asked whether,
in retrospect, seeing a clinical psychologist might have been useful for them, there was an equal split
in responses, See Figure 3.
Figure 4. Answers to question from the version 1 of the Survey (i.e. ex-service users who did not have
access to clinical psychology)
Main reasons why ex-patients would not consider psychology support:
• Receiving support from family, friends and other members of staff: “Didn’t feel the need to
yes50%
no50%
While you were admitted do you think that seeing a Clinical Psychologist mighthave been of any help to you?
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speak to one. I have an excellent support network of friends and family”
• Not being ready at the time: “I wasn’t ready to talk about anything at the time”
• Not considering their spinal injury as requiring psychological support: “[It] didn’t
affect me mentally”
Main reasons why ex-patients would consider seeing a psychologist:
• Having someone to talk to: “[For] general discussion. Reassurance that my feelings of
apprehension were normal.”
• Feeling isolated at the time: “People didn’t think to communicate with me because they did not
want to upset me but it made me feel a little isolated”
• Recognising the mental health aspect of their condition: “I was struggling massively (…), it
might had [sic] also been picked up that I had PTSD and was developing anxiety”.
Initial thematic map, showing five main themes is presented in Appendix 3.
Interestingly, despite 50% of respondents initially stating they did not feel they needed psychological
support, 84.2% of the same sample rated having Clinical Psychology as a part of YRSIC as either
‘very important’ or ‘absolutely essential’ (See Figure 5).
Figure 5. Total Sample Survey Answers
Main reasons why participants considered psychology as a ‘very important’ or ‘absolutely essential’
part of spinal rehabilitation:
• ‘Coming to terms’ and adjusting to change following their injury: “Because after a huge life
changing experience some people need a little help coming to terms with this”
1
2
3
18
14
6
13
Not important at all
Of little importance
Of average importance
Very important
Absolutely essential
How important it is to have psychological support as a part of spinalinjuries rehabilitation?
Ex-patients who did not have access to psychology Ex-patients who did have access to psychology
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• Being able to receive help and support: “Having support around mental wellbeing is as
important as having access to physical therapy”
• Having space to express their emotions: “[having] help with negative mental states, talking
always helps”
Only 10% of the overall sample rated psychology as ‘of little/average importance’ or ‘not important at
all’, reasons being:
• Individual resilience/qualities: “I am a positive person”
• Individual preference: “Not for me. Never considered anything in that field”
• Prioritising physical side of rehab: “it seems the physical side takes priority”
Interestingly, all of the respondents in this 10% cohort were from the group that
did not have access to psychological support during their admission.
The last question of the survey explored the the needs and expectations of patients regarding clinical
psychology (See Figure 6). Overall, respondents selected multiple types of interventions that they
would be personally interested in receiving. Respondents seemed to value both the services offered to
inpatients and services available after discharge. The most frequently selected type of support was
help around emotions, such as depression and anxiety, followed by support with adjustment following
SCI.
18
19
17
20
17
17
18
16
13
19
13
22
12
14
11
9
3
5
2
9
14
9
13
12
11
11
11
8
12
7
9
10
11
9
8
3
0 5 10 15 20 25 30 35
Support with emotions, such as anxiety and depression during my inpatient stay
Support with emotions, such as anxiety and depression after discharge
Support with adjustment during my inpatient stay
Support with adjustment after discharge
Education around psychological effectsof spinal injury during my inpatient stay
Education around psychological effectsof spinal injury after discharge
Support for my family members to adjust during my inpatient stay
Support for my family members to adjust after discharge
Offering support groups to share my experiences with othersduring my inpatient stay
Offering support groups to share my experiences with others after discharge
Education around chronic pain during my inpatient stay
Education around chronic pain after discharge
Teaching coping techniques such as relaxation or mindfulness during my inpatient stay
Teaching coping techniques such as relaxation or mindfulness afterdischarge
Offering support groups for family membersand carersduring my inpatient stay
Offering support groups for family membersand carersafter discharge
None of the above, neither me or my my family needed psychological support during myinpatient stay
None of the above, neither me or my my family needed psychological support afterdischarge
Other, please specify:
Can you select forms of psychological support that you personally would be interested in if they were available to you?Select as many options as you wish.
Survey 1 - no prior psychologyinput Survey 2
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Figure 6. Total sample Survey Answers (Question 5 from Survey 1 and Question 8 from Survey 2)
Summary of the survey results
There was a clear difference in the answers from ex-patients who did not have access to
Clinical Psychology and those who did. The first group seemed less aware of the role of Clinical
Psychology or the potential benefits of psychological support, which may explain why some
respondents in this group suggested psychological support may not even be necessary. The second
group however was very positive about the service, and felt that more extensive service provision
would be beneficial. A strong theme appeared regarding a need for ongoing psychological support
following discharge. Multiple respondents commented that they felt very well supported during their
inpatient stay, but that continuing support following discharge from the unit would be especially
helpful (“...this is often when reality sets in and you feel most vulnerable and ostracised”).
Participants also commented on the busy environment of the spinal unit, and that physical
rehabilitation took priority over psychological support, when ideally it should be treated as equally
important. It is inevitable that physical rehab takes priority over psychological recovery during an
inpatient stay. There are also multiple practical reasons why psychology might be sometimes less of a
priority. Firstly, many patients are physically unwell and following intense rehabilitation session they
might lack in time and energy to attend additional sessions. Secondly, the YRSIC has an open door
policy, meaning that people can visit patients when they wish. This proves extremely valuable for the
patients, however it can also become an obstacle when additional psychology support sessions are
being held on the ward at the same time. Lastly, for the majority of the inpatients the time since injury
is less than 3 months, and so the extent of disability caused by the injury might be still unknown.
These patients might not understand the consequences of having a spinal injury and/or not be ready to
process this change.
Part Two: Clinical Psychologists at YRSIC: whom do they see and what do they do?
Procedure and analysis
The data on the type of work undertaken by clinical psychologists and the people they see was
collected via an Excel spreadsheet, by clinical psychologists working at the YRSIC. The data was
collected between October 2015 and September 2017. The patients’ demographic data recorded
included the following information: gender, age, ethnicity, date of admission, type of injury (i.e.
cause, level, complete/incomplete, traumatic/non-traumatic), outcome measure scores on admission,
discharge and follow up, number of contacts, and the type of psychological need identified.
Additionally, operational documents, such as leaflets and reports were analysed to describe the job
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role of the clinical psychologists. All data is presented anonymously. Descriptive statistics were used
to analyse the data, the results of this analysis are presented below.
Results
When age is considered the population of the ward reflects recent trends in incidence of spinal injuries
(NICE, 2017). In the past the majority of cases were younger males, however there has been an
increase in middle aged males and older people (See Figure 7).
Figure 7. YRSIC Patients by age
I wondered whether younger YRSIC patients are more likely to suffer from traumatic SCIs and older
patients more likely to experience non-traumatic SCI. According to recent statistics the occurrence of
SCI is increasing among the elderly (Singh et al., 2014). The literature also suggests that the aging
population can be at higher risk of SCI secondary to falls, which can be seen as a future public health
challenge (Singh, Tetreault, Kalsi-Ryan, Nouri, & Fehlings, 2014). The main reason for this,
according to Singh et al. (2014) is that this group is more at risk of SCI due to spinal degenerative
changes. The data does seem to reflect this trend (i.e. more traumatic injuries in younger patients, and
more non-traumatic injuries in older patients, see Figure 8). However, I did notice inconsistencies in
the recording of the type of traumatic injury; e.g. ‘road traffic accident’ and ‘fall down the stairs’
would both be coded as ‘traumatic’ regardless whether there were any underlying degenerative
changes or not. Therefore, any conclusions regarding age and type of injury based on the data
available need to be treated with extreme caution.
0
10
20
30
40
50
60
70
18-24 25-34 35-44 45-54 55-64 65-74 75 plus
Patients by age
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Figure 8. YRSIC patients by age and type of injury
When gender is considered, the split between males and females was similar to incidences quoted in
literature (NICE, 2017), See Figure 8 below.
Figure 9. YRSIC patients by gender
When I initially looked at ethnicity of YRSIC inpatients I was surprised by the low numbers of ethnic
groups other than ‘White British’. Comparing these numbers with regional statistics however showed
that YRSIC was generally representative of the patient catchment area (Office for National Statistics,
2008).
Patients by Ethnicity
69% 63%55%
66%
46% 35% 45%23%
26%
35%
30%
50%
65%
51%
8%
11%
10%
4%
4%4%
0
10
20
30
40
50
60
70
24 and under 25-34 35-44 45-54 55-64 65-74 75 and over
Patients by age and type of injury
Traumatic Non-traumatic Unknown
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2015-2017 2015 2016 2017
Patients by gender
males females
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Figure 10. YRSIC Patients by ethnicity
The majority of the inpatients were admitted during the first three months following their injury (See
Figure 10 below). This is a very important observation, as time since trauma can influence the
provision and course of psychological interventions for conditions such as Post-traumatic stress
disorder or grief (NICE, 2013).
Figure 10. YRSIC Patients: time since injury
The majority of inpatients could be described as ‘newly admitted’, which means that this was a new
injury as opposed to patients who were ‘re-admitted’ for a ‘top-up’ surgery or help with SCI
management, See Figure 11.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
White English/Welsh/Scottish/NorthernIrish/British
Asian/Asian British Pakistani
Any other white background
Black Caribbean/Black Brtish Caribbean
BlackAfrican/Black British African
Asian/Asian British Indian
0 20 40 60 80 100 120 140
< 1 month
1 -3 months
more than 3, less or equal than 6 months
more than 6, less/equal than 12 months
more than 12 months , less/equal than 18 months
more than 18 months, less/equal than two years
more than 2 years, less/equal than five years
more than 5 years less/equal than 10 years
more than 10 years less/equal than 20 years
more than 20 years
Time since injury
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Figure 10. Types of admissions to YRSIC
Spinal Cord Injuries can be described by the level of the spine at which the injury occurred and an
ASIA score (American Spinal Injury Association Impairment Scale). Below is description of YRSIC
population by level of injury and ASIA grades (See Figure 11 and 12).
Type of admission
Readmission for top-up/surgery New admissions
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Figure 11. YRSIC Patients by level of injury and ASIA Score
Figure 12. YRSIC Patients by ASIA Score
The most common mechanism of injury for those admitted to the YRSIC was some type of fall. The
most common mechanisms of traumatic injury were: falls, road traffic accidents. The most common
mechanisms of non-traumatic injury were infections, degenerative condition of the spine and
spinal/surgery complications.
Clinical Psychology workload
Clinical Psychologists working at the YRSIC will have at least some contact with every SCI patient
who is admitted to the unit, thereby communicating that Clinical Psychology is a normal and
integrated part of the MDT. The work undertaken by Clinical Psychology is summarised in Table 2.
0
20
40
60
80
100
120
Cervical (C1-C7) Thoraic (T1-T12) Lumbar (L1-L5) Sacral (S1-S5)
Level of injury and ASIA Score
Complete (ASIA A) Incomplete (ASIA B,C &D)
A
29%
B
2%C
32%
D28%
E
9%
ASIA Scores among patients
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Table 2. Clinical Psychologist at YRSIC: Brief Job Description
Psychological Outcome Measures used in routine practice
Using outcome measures in clinical psychology is a part of good clinical practice. However, in the
field of spinal cord rehabilitation clinicians face several difficulties in collecting outcome data (Cole
et al. 1994; Deathe et al. 2002; Skinner et al. 2006). Good clinical practice relies upon comprehensive
data and sound measurement. It enables practitioners to describe, predict and evaluate their
interventions and ensure the best care of individuals with spinal cord injury. Clinical Psychologists at
YRSIC use several outcome measures listed and briefly described in the Table below (See Table 3).
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Outcome Measures used as a part of routine practice of Clinical Psychologists working at YRSIC
– Hospital Anxiety and Depression Scale (HADS; Min-Max Scores 0–21, higher scores
indicate more psychopathology). HADS enables detection of clinical cases and assessment
of severity of Anxiety and Depression.
– The Patient Health Questionnaire for Depression and Anxiety (PHQ-4, Min-Max Scores 0-
12, higher scores indicate more psychopathology), used here as an ultra- brief screener
for depression and anxiety interchangeably with HADS.
– Appraisals of Disability: Primary & Secondary Scale (ADAPSS). ADAPS looks into
individual’s initial evaluation of an event or situation and their own coping resources.
– Scale of Perceived Manageability (SPM). SPM assesses the degree to which an individual
believes that they have control of a situation and is able to manage a stressful life event.
Table 3. Outcome Measures used by Clinical Psychologists
It was my intention to compare the pre and post outcome measure scores of YRSIC patients, however
I was faced with high levels of missing data, which made it impossible to make any comparisons. It
seemed that collecting the outcome measures was more difficult at discharge. In light of this I present
here a snapshot of HADS scores at the point of admission, divided by gender.
Figure 13. HADS Total Scores in males at admission. Clinical cut-off scores: no difficulty scores (less
than 8), mild difficulties (8-10), moderate difficulties (11-15) and severe difficulties (16 and above).
0
5
10
15
20
25
30
35
no difficulty mild moderate severe
HADS Scores in Males at Admission
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Figure 14. HADS Total Scores in females at admission. Clinical cut-off scores: no difficulty scores
(less than 8), mild difficulties (8-10), moderate difficulties (11-15) and severe difficulties (16 and
above).
Limitations of this Evaluation
This evaluation has a number of limitations. Part One of the Evaluation (Online survey) had
a response rate of 7.5% (n=60), which could be seen as low. However, I suspect that amongst the 800
email addresses that the survey was sent to the actual number of ex-patients might in fact be much
lower. The survey population can be described as ‘difficult to reach’ due to complex healthcare and
support needs. Alternative ways of distributing the survey, e.g. paper version of the survey, telephone
version of the survey, face to face survey, could have been used to reach more respondents. This was
considered initially, yet had to be rejected due to limited resources available to carry out this service
evaluation. Part Two of the Evaluation (database analysis) also has some limitations. Missing data
made it impossible to compare the pre and post outcome measure scores.
Implications and Recommendations
Survey participants were clear about their expectations from Clinical Psychology:
– There is a need for ongoing psychological support following discharge. This could take many
forms, the most desired by patients were: help around emotions, such as depression and
anxiety, followed by support with adjustment following SCI and more education on
psychological effects of SCI.
– Provision of psychological services available for the family both during the inpatient stay and
following discharge,
– Raising the profile of Clinical Psychology on the ward and among patients, as suggested by
patients Clinical Psychology should be seen as an important part of spinal rehabilitation.
0
2
4
6
8
10
12
14
no difficulty mild moderate severe
HADS Scores in Females at Admission
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Analysis of the psychology database produced a vast amount of useful information. It was noted that
sharing this information with other members of the MDT and service management might prove
beneficial for various operational reasons, such as staff training, better monitoring of outcomes and
improved interventions.
Next steps
The next practical steps that will take place in relation to this service evaluation are:
• 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 27th of October 2017.
• The poster will now be displayed on the YRSIC ward so that patients and 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 2017.
• The YRSIC 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 produced to complete the evaluation process and clearly
communicate what changes have been made.
• The findings of this evaluation will be written for publication in the SPINE newsletter.
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References:
Ahn, H., Bailey, C. S., Rivers, C. S., Noonan, V. K., Tsai, E. C., Fourney, D. R., . . . Rick Hansen
Spinal Cord Injury Registry Network. (2015). Effect of older age on treatment decisions and
outcomes among patients with traumatic spinal cord injury. CMAJ : Canadian Medical
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Appendices
Appendix 1 –Notification of local Research and Development Department at Mid Yorkshire HospitalsNHS Trust
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Appendix 2 – Survey for ex-patients of the YRSIC
Have you had any contact with Rebecca Ellis, Nigel Wainwright or any other Clinical
Psychologists or Clinical Psychology Trainee, working on the ward?
If your answer is no, please click here: (link to Survey 1)
If your answer is yes, please click here: (link to Survey 2)
If you cannot remember, please click here: (link to Survey 1)
Survey 1 designed for ex-service users who did not have access to clinical psychology
Demographics:Gender: …… Age: ………. How long have you been on the ward: ………………
How long since you have been discharged: …………How long has been since your injury/illness: ………..
1. While you were admitted do you think that seeing a Clinical Psychologist might havebeen of any help to you?
If yes, why?
If not, why?
2. How important it is to have psychological support as a part of spinal injuriesrehabilitation?
0 = Not Important at all1 = Of little importance2 = Of average importance3 = Very important4 = Absolutely essential
3. Why do you think that is?4. What is missing from available services that could make a difference?5. Can you select forms of psychological support that you personally would be interested in
if they were available to you?
support with adjustment during my inpatient stay support with adjustment after discharge support with emotions, such as anxiety and depression during my inpatient stay support with emotions, such as anxiety and depression after discharge support for my family members to adjust during my inpatient stay support for my family members to adjust after discharge education around psychological effects of spinal injury during my inpatient stay education around psychological effects of spinal injury after discharge education around chronic pain during my inpatient stay education around chronic pain after discharge
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teaching coping techniques such as relaxation or mindfulness during my inpatient stay teaching coping techniques such as relaxation or mindfulness after discharge offering support groups to share my experiences with others during my inpatient stay offering support groups to share my experiences with others after discharge offering support groups for family members and carers during my inpatient stay offering support groups for family members and carers after discharge other, please specify: none of the above, neither me or my my family needed psychological support during my
inpatient stay none of the above, neither me or my my family needed psychological support after
discharge
6. Any other comments?
Thank you for taking part! Your answers will help us to improve the Spinal Injuries RehabilitationService.
Survey 2 designed for ex-service users who had access to clinical psychology
Demographics:Gender: …… Age: ………. How long have you been on the ward: ………………
How long since you have been discharged: …………How long has been since your injury/illness: ………..
1. Please rate the outcome of seeing Rebecca, Nigel or any other clinical psychologistsworking on the ward.
4= Very helpful3 = Fairly helpful2 = Neither helpful or unhelpful1 = Not very helpful0 = Not at all helpful
2. What has been good about seeing a clinical psychologist?3. What was less good about seeing a clinical psychologist?4. What could be improved?5. How important it is to have psychological support as a part of YRSIC?
0 = Not Important at all1 = Of little importance2 = Of average importance3 = Very important5 = Absolutely essential
6. Why do you think that is?7. What is missing from available services that could make a difference?8. Can you select forms of psychological support that you personally would be interested in
if they were available to you? Select as many options as you wish.
support with adjustment during my inpatient stay support with adjustment after discharge
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support with emotions, such as anxiety and depression during my inpatient stay support with emotions, such as anxiety and depression after discharge support for my family members to adjust during my inpatient stay support for my family members to adjust after discharge education around psychological effects of spinal injury during my inpatient stay education around psychological effects of spinal injury after discharge education around chronic pain during my inpatient stay education around chronic pain after discharge teaching coping techniques such as relaxation or mindfulness during my inpatient stay teaching coping techniques such as relaxation or mindfulness after discharge offering support groups to share my experiences with others during my inpatient stay offering support groups to share my experiences with others after discharge offering support groups for family members and carers during my inpatient stay offering support groups for family members and carers after discharge other, please specify: none of the above, neither me or my my family needed psychological support during my
inpatient stay none of the above, neither me or my my family needed psychological support after
discharge
9. Any other comments?
Thank you for taking part! Your answers will help us to improve the Spinal Injuries RehabilitationService.
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Appendix 3 – Sample thematic mapShowing six main themes that emerged in analysis of question 1. Survey1
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Appendix 4 – Poster presentation of results
Clinical Psychology at a Regional Spinal Injury Centre:Patients’ perspective
Service Evaluation conducted by Alex Puchala, Psychologist in Clinical TrainingCommissioned by Dr Nigel Wainwright, Principal Clinical Psychologist and Dr Rebecca Ellis, Clinical Psychologist,The Mid Yorkshire Hospitals NHS Trust
Main reasons why ex-patients would not consider psychology support:• Receiving support from family, friends and other members of staff: “Didn’t feel
the need to speak to one. I have an excellent support network of friends and
family”• Not being ready at the time: “I wasn’t ready to talk about anything at the time”• Not considering their spinal injury as requiring psychological support: “[It] didn’t
affect me mentally”Main reasons why ex-patients would consider seeing a psychologist:• Having someone to talk to: “[For] general discussion. Reassurance that my
feelings of apprehension were normal.”
• Feeling isolated at the time: “People didn’t think to communicate with mebecause they did not want to upset me but it made me feel a little isolated”
• Recognising the mental health aspect of their condition: “I was strugglingmassively (…), it might had also been picked up that I had PTSD and wasdeveloping anxiety”
Interestingly, despite 50% of respondents initially stating they did not feel theyneeded psychological support, 84.2% of the same sample rated having ClinicalPsychology as a part of YRSIC as either ‘very important’ or ‘absolutely essential’.
“Having a spinal cord injury changes, in a moment, all aspects of one's life forever.There is a lot to cope with all at once”
(4) ResultsIn total we received 60 responses (61% male, 31% female, 8% prefer not to say/not
specified). 65% of our respondents did not have access to clinical psychology whilst an
inpatient. When asked whether, in retrospect, seeing a clinical psychologist might have
been useful for them, there was an equal split in responses:
(1) Background
The Yorkshire Regional Spinal Injuries Centre (YRSIC) based at Pinderfields Hospital
in Wakefield is a 32 bed rehabilitation centre with a large catchment area. It treats
patients with traumatic and non-traumatic spinal cord injuries from Yorkshire,
Humberside and beyond. The centre is consultant led, and inpatient service users
receive multidisciplinary rehabilitation from the team, which includes: spinal surgeons,
doctors, nurses, physiotherapists, occupational therapists, and clinical psychologists.
Clinical Psychology was introduced to YRSIC as a dedicated resource in October 2015,
with the addition of 2 Clinical Psychologists (1.5 whole time equivalent) into the MDT.
International and national guidelines on best practices in spinal injury rehabilitation
recognise psychology as a vital part of the healthcare provision (WHO, 2013; NHS
England, 2013; DoH, 2005). It is now widely recognised that spinal injuries can result in
total disruption of the person's life and that optimal emotional adjustment is vital to
successful recovery and rehabilitation.
(2) Aims
Part One of our goal was to capture patients’ experiences, thoughts and expectations
of clinical psychology as a part of their spinal rehabilitation. In Part Two, we aimed to
describe the role and work undertaken by clinical psychologists working at YRSIC
since their introduction in October 2015.
(3) Method
A mixed-method design was used for this service evaluation. Qualitative data
collection and analysis through an online survey was used to evaluate Part One.
In order to analyse the survey data, a thematic analysis was used (Braun & Clarke,
2006), the results of which are themes that are used to describe the data.
A qualitative method of data collection based on Microsoft Excel was used to
evaluate Part Two, with descriptive statistics used to analyse the data. The survey
was hosted on the Bristol Online Survey system and a link to the survey was sent
through SPINE, a charity working on the ward, which holds a database of 800 email
addresses of ex-patients of YRSIC. The survey was live for two weeks in October
2017. Given that for most ex-patients of YRSIC Clinical Psychology was not
available, we had two versions of the survey: one for patients who did not have
access to psychology (65% of the survey sample) and one for more recent service
users, who did have access (35%).
19
19
yes
no
While you were admitted do you think that seeing a Clinical Psychologist might have been of anyhelp to you?
Ex%patients-who-did-not-have-access-to-psychology
(5) SummaryThere was a clear difference in the answers from ex-patients who did not have access to Clinical Psychology and those who did. The
first group seemed less aware of the role of Clinical Psychology or the potential benefits of psychological support, which may explain
why some respondents in this group suggested psychological support may not even be necessary. The second group however was
very positive about the service, and felt that more extensive service provision would be beneficial. A strong theme appeared regarding
a need for ongoing psychological support following discharge. Multiple respondents commented that they felt very well supported
during their inpatient stay, but that continuing support following discharge from the unit would be especially helpful (“...this is often
when reality sets in and you feel most vulnerable and ostracised”) . Participants also commented on the busy environment of the
spinal unit, and that physical rehabilitation took priority over psychological support, when ideally it should be treated as equally
important.
Main reasons why participants considered psychology as a ‘very important’ or‘absolutely essential’ part of spinal rehabilitation:• ‘Coming to terms’ and adjusting to change following their injury: “Because
after a huge life changing experience some people need a little help coming to
terms with this”• Being able to receive help and support: “Having support around mental well-
being is as important as having access to physical therapy”• Having space to express their emotions: “[having] help with negative mental
states, talking always helps”Only 10% of the overall sample rated psychology as ‘of little/average importance’or ‘not important at all’, reasons being:• Individual resilience/qualities: “I am a positive person”• Individual preference: “Not for me. Never considered anything in that field”• Prioritising physical side of rehab: “it seems the physical side takes priority”Interestingly, all of the respondents in this 10% cohort were from the group that
did not have access to psychological support during their admission.
1
2
3
18
14
6
13
Not important at all
Of little importance
Of average importance
Very important
Absolutely essential
How important it is to have psychological support as a part of spinal injuriesrehabilitation?
Ex-patients who did not have access to psychology Ex-patients who did have access to psychology
ReferencesBickenbach, J. (2013). International perspectives on spinal cord injury. Geneva: World Health Organization.Department of Health (2005). National Service Framework for Long Term Conditions. London: DH.Julier, J. (n.d.).Anatomical studies [Drawings]. Retrieved October 26, 2017, from http://www.jamesjulier.com/drawingsKortte KB et al. Positive psychological variables in the prediction of life satisfaction after spinal cord injury. Rehabilitation Psychology, 2010, 55:40-47. doi: http://dx.doi.org/10.1037/a0018624PMID:20175633NHS England (2013). NHS standard contract for spinal cord injuries (all ages). NHS England, Redditch. Retrieved from http://www.england.nhs.uk/wp- content/uploads/2013/06/d13-spinal-cord.pdfBraun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. doi:10.1191/1478088706qp063oa
“Coping with such a sudden and dramatic change in lifestyle is stressful and to go through this without mental support fromanyone would have left me very depressed, confused and angry”
