There were four themes in total. The first theme is entitled ‘respected but unique part of the team’ and was developed from both staff and patient data. The second theme is entitled, ‘facilitating understanding’ and was also developed from both staff and patient data. The third theme is entitled, ‘beliefs about job role’ and was developed from staff data only. The fourth theme, entitled ‘putting psychologists on a pedestal’ was developed from both staff and patient data. Perceived enablers to implementation and engagement, and associated outcomes are discussed across these themes and summarised in Fig. 1 (see supplementary material).
Respected but unique “part of the team”
This theme describes the role that psychologists had within the team from the perspectives of staff, patients and the psychologists’ themselves, and provides explanations of what might have influenced these perceptions.
Psychologists were regularly visible on wards engaging with patients and spending time in the nursing office which afforded them status as a member of the ward team. Psychologists regular physical presence coupled with their flexibility and persistence (adding meetings to diaries, reminding staff and re-booking when cancelled) had multiple benefits for ward staff including accessible consultation about how to respond to patients’ behaviours and opportunities for emotional support during an emotionally draining shift. The changeable nature of ward environments meant staff could not always attend scheduled meetings with the psychologist, but psychologists physical presence enabled staff to access support in vivo.
Things run over but if you’ve got a psychologist there and they’re around and they’re visible you can just say oh have you got two minutes to talk about this. Psychiatrist A.
Psychologists presence was also essential in providing opportunities to develop relationships with staff further enhancing integration within the team. Informal social interactions outside of meetings were especially important for this rapport building. Being around and willing to help with tasks outside the remit of the psychologist’s role afforded respect from nursing staff and led to beliefs that psychologists recognised the difficulties of the nurse’s job. Psychologists also recognised the importance of these relationships for the implementation of the intervention noting they needed to be an insider to facilitate change:
In order to influence culture you need to not be a threat and you need to have relationships with people. Psychologist A.
Developing relationships with psychiatrists also aided psychologists integration within the wider multidisciplinary team and led psychiatrists to encourage patients to engage in psychological assessment or intervention. This endorsement from psychiatrists who were senior team members indicated that the intervention was credible and should be prioritised.
It made a huge difference if you’ve got a psychiatrist endorsing it, who is considered someone who is considered, the lead clinician on the ward. I suppose that gives you a bit of kudos by association. Psychologist A.
The psychologists effort to embed themselves within staff teams acted as a mechanism for staff and patient engagement with the intervention. Yet, maintaining some independence from the team by virtue of being from a different professional group was also beneficial. On wards with significant staff conflict, or hierarchal cultures, members of the nursing team felt able to confide in psychologists about their concerns due to their perceived understanding of the ward environment and some degree of impartiality.
They are a team member but you’re not directly a team member, so it would be nice sometimes just to, offload to someone. Nursing Assistant A.
Psychologists perceived impartiality and independence from the nursing team coupled with their provision of a dedicated safe space also fostered patient engagement. These patients described previous negative experiences of care on acute wards leading to a mistrust of nursing staff on the team.
We were in a safe space and that’s what the psychologist has to create. A place, you know, someone to talk to that is third-party neutral. That’s important. Patient A.
Facilitating Understanding
This theme describes how both staff and patients perceived that the psychologist was able to improve their understanding of the patients needs and behaviours. In the case of patients, this theme represented improved self-understanding through therapy and in the case of staff this theme involved psychologists helping staff to formulate the reasons for patients behaviours.
Patients described how one-to-one sessions with psychologists facilitated greater understanding of how life experiences related to current emotions and behavioural patterns.
I understood why I feel the way I do and act the way I do, and when I was able to sort of express myself, then I could understand myself more. Patient D.
This experience differed from treatment prior to the intervention where patients described a process of “telling their story over and over to different people” [Patient B] without opportunities to understand the reasons for their distress or help in developing coping strategies.
Some patients were anxious about the idea of making themselves vulnerable within the context of therapy, particularly for those reporting prior negative experiences of counselling or therapy. However, through showing understanding, psychologists were able to put these anxieties to rest.
You feel like [the psychologist] is taking an interest in your particular situation and then, you can then work with them better. You feel they are trying to understand me, not just a condition. Patient J.
Staff also perceived that the intervention improved patients self-understanding and described associated reductions in self-harm, aggression, and negative affect.
What I’ve noticed is that patients feel much safer when they have interactions with the psychologist and the number of incidents decrease, and they feel like there’s somebody really listening and understanding. Psychiatrist B.
As well as enabling patients self-understanding, psychologists facilitated staff knowledge of patient needs through different forums. Staff reported that attending psychologist-led formulation sessions increased their understanding of the meaning, and motivations behind behaviours that typically attracted staff criticism (e.g. aggression, self-harm).
I have better understanding of why, if someone’s behaving- if someone displays challenging behaviour should I say it helps me to have a better understanding of where they’re coming from. Occupational Therapist B.
Patients also welcomed the psychologist sharing aspects of their formulation with staff to improve staff understanding of support needs.
[The psychologist] can go to members of staff and say, he struggles with this, struggles with that, so the members of staff on the ward are getting a better insight in how you’re dealing with, the certain situations, which is a massive thing cos some of staff won’t even know. Patient L.
These examples of knowledge sharing were described in terms of psychologists acting as a bridge between patients and staff, suggesting staff and patients previously felt disconnected despite being physically present on the wards together much of the time. Understanding the functions of patient behaviour also helped to enable compassion and empathy, which staff associated with an increased feeling of reward from their work.
If we’d had a service user that is continually displaying aggressive behaviour, some staff find it really difficult to deal with, and they start almost feeling burnt out, and then I think the formulations and the one-to-one sessions have really helped staff take a step back and think about actually this is what’s triggered this behaviour It’s kind of helped people sort of be more empathetic. Ward Manager A.
Some patients perceived that staff had become more compassionate and “less judgemental” [Patient C] as a result of the intervention. Others believed that care had not improved as levels of compassion were dependent on individual differences among staff suggesting little optimism about future changes in staff behaviour.
It was only like a couple of [staff] members that that would do their utmost to cheer you up and make sure you’re okay. But a vast majority of them would just like, you might as well not be there at all. Patient K.
Formulations were also shared with community or home treatment teams. As a result, some patients perceived that step-down services were better equipped to continue supporting recovery.
My care coordinator, she had a session with [psychologist], and they spoke about the formulation that we’d done so I don’t have to repeat myself again and sort of talk about a lot of things. Patient D.
However, some patients described feeling “disappoint[ed]” [Patient M] at not being able to continue engaging in the intervention after discharge, preventing them from maintaining the level of functioning developed. Although patients still perceived the ward-based intervention to be beneficial, some felt it should extend into the community.
I would have liked to continue it to be honest especially as an outpatient because whilst sessions with her with good, it was just, it would have been nice to have it followed up. Patient C.
Beliefs around job role
This theme describes how beliefs about the function of acute mental health care and the nurse’s role within it hindered nurses involvement in delivering therapy and engaging with sessions delivered by the psychologists. We also describe what factors helped to improve engagement and counter barriers associated with these beliefs.
Staff described how acute wards served to stabilise patients and reduce risk with an aim to discharge them as soon as possible. This perception of ward function, combined with staff beliefs that psychological therapy is lengthy, complex, and unsuitable for patients with schizophrenia, led some staff to believe that the intervention was at odds with ward aims.
How do you embed the psychology into the purpose of the ward? ‘Cos if that purpose is to be a really acute short stay ward that rapidly turns around people, has bed availability and all those kind of things, that doesn’t tend to lend to lengthy, more consistent interventions. Ward Manager B.
Narratives around the function of acute wards fed into beliefs that nursing staff’s primary role did not include providing psychological therapy. Staff typically depicted their key responsibilities to be medication administration, risk management and completing paperwork. These beliefs likely limited staff engagement in delivering nurse-led interventions as these were seen as “low priority” [Occupational Therapist C]. Although staff busyness with other duties was a significant barrier to intervention implementation, some staff did successfully deliver interventions. These individuals prioritised intervention delivery over other tasks.
Some staff described how formulation sessions provided a safe and non-judgemental space to challenge rhetoric around the limits of their job role. For these individuals engaging with psychologists led to perceptions that their responsibilities should include providing therapeutic support to patients. For some staff this change in belief encouraged engagement in intervention delivery.
I’m not just there to unlock doors and to give people food, it (formulation sessions) reminds me that, in our everyday interactions with patients on the ward there’s a therapeutic reason for nursing assistants to be here. Nursing Assistant C.
However, this prioritisation of the intervention was primarily enabled by ward managers buy-in which was felt to be instrumental in enabling staff to prioritise engaging in interventions over other activities.
The way that it was talked about within the team was maybe like this is a nice optional extra, but it’s not essential, whereas on the other ward the ward manager really kind of prioritised staff being able to spend time with me. Psychologist B.
Unlike other members of the multi-disciplinary team, nursing staff lacked control over their time, meaning that without ward manager support they were unable to dedicate time to the intervention.
(Nurses) turn up on shift and you’re told what you’re doing for each hour and psychological work isn’t part of that scheduling. Psychologist C.
As a result, in the absence of ward manager support, level 2 interventions were most successfully led by staff who were in control of their diaries and not expected to respond to incidents, such as assistant psychologists and occupational therapy staff (including recovery workers and activity co-ordinators).
Putting psychologists on a pedestal
This theme describes how patients perceived psychologists compared with nursing staff and what factors influenced these perceptions. It also describes psychologist’s perception that staff turned to psychological therapy as a solution for patients they found difficult as opposed to trying to problem solve together with the whole team.
Psychologists flexible schedule enabled protected time and space to develop therapeutic alliance with patients. This ability to give uninterrupted, quality time was highly valued, and enabled patient engagement. In contrast, nursing staff lacked opportunities to devote time to patients and had other priorities as a part of their role which acted as an obstacle to patients seeking support.
If something happens on the ward, and that nurse has to go. You might be allocated a time, but that necessarily might not happen. You can never get through a full meeting, without something happening on the ward, and then you’re more reluctant to speak to them. Patient M.
Perceptions that psychologists held a higher level of therapeutic training and expertise also motivated patients to engage with psychologist-led sessions.
It’s the knowledge and the understanding of one’s emotions or what they’re going through. I’m not saying the nurses aren’t understanding, but when someone’s trained in that speciality of being a psychologist, they just have more of an understanding. Patient M.
Conversely, beliefs nursing staff were “not very confident” [Patient N] in delivering psychological interventions reduced patients’ motivation to engage in nurse-led interventions. Nursing staff themselves also reported a lack of confidence, due partly to few opportunities to build experience and skill in intervention delivery.
That is one of the difficulties with all the interventions we do is that there is always the sense that you’re learning as you’re going, so-so the first few that you do, it’s almost like you’re not 100% clear what you’re trying to work through with someone. Sometimes that can be off-putting. Nurse A.
Psychologists felt ward environments were not conducive of staff building confidence and learning new skills, such as those required to deliver interventions.
I think you just stay in your comfort zone, when you’re just feeling like you’re spinning plates, or you feel a bit stressed out in a job, so I think, staff confidence has impacted on their delivery of the interventions. Psychologist A.
Perceptions that support provided by psychologists was superior meant patients did not always see the benefit of engaging in nurse-led interventions. This perception contributed to a dichotomy in patient’s perceptions of staff, with psychologist who had the luxury of managing their own diary and more training in therapies being put on a pedestal whilst nursing staff who had multiple competing demands and skill sets were described more critically.
Psychologists also perceived that ward staff had high expectations of their role. They described how staff would refer patients for therapy who were difficult to manage rather than seeking advice and engaging in intervention delivery to adapt their own practice. In this way, staff’s perception that psychologists filled a gap in treatment was in some ways at odds with one of the main aims of the intervention: to upskill staff to engage more therapeutically with patients.
I still think that’s why sometimes people will say oh will you see this person? Often the medic will sort of tickety tick that box that, they’re seeing our psychologist that’s great then they feel okay. Supervisor A.
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