George_&_Genis_2012 workshop paper

24 Clinical Psychology Forum 239 – November 2012

APPROXIMATELY 150,000 people inthe UK suffer a stroke each year(The Stroke Association, 2011). It is

the third most common cause of death,after heart disease and cancer (NationalAudit Office (NAO), 2011) and a signifi-cant cause of disability – recent data sug-gests that 450,000 people in the UK arecurrently severely disabled as a result ofstroke (NAO, 2011).

It has long been recognised that effec-tive stroke treatment requires a multi-disci-plinary team (MDT) approach (Gibbon &Little, 1995; National Clinical Guidelinefor Stroke (RCP), 2004). However, in 2007the National Stroke Strategy (DH) high-lighted an important but previously over-looked point; that the ability of services toachieve best practice is contingent uponhealthcare professionals being equippedwith specialist knowledge, skills and com-petencies in stroke.

Specifically, the National Stroke Strategy(DH, 2007) outlined the importance ofensuring that all MDT members are compe-tent in their roles and possess stroke expert-ise. It stressed two main points:1. that stroke survivors should receive care

from staff members with the knowledgeand skills to meet their needs, and

2. that commissioners and employersshould undertake a review of theirstaff teams and draw up a plan tosupport development and training,with a view to creating a stroke-skilledworkforce.

In the same year, the Scottish Execu-tive (2007) called for in-service training tobe made a priority for staff working withpatients affected by stroke. Others haveargued that the provision of educationand training should be seen as the corner-stone of effective stroke care (Craig &Smith, 2007).

A general definition of training is that itis ‘a process which is planned to facilitatelearning so that people can become moreeffective in carrying out aspects of theirwork’ (Bramley, 2003, p.4). Evidence sug-gests that educational programmes for nurs-ing staff can be effective in improvingknowledge and creating a more organisedapproach to stroke care (Booth et al., 2005;Dowswell et al., 1999). Unfortunately how-ever, the opportunities for healthcare pro-fessionals in the UK to undergo specialisttraining in stroke have traditionally beenquite limited (RCP, 2004). Indeed, educa-tion and training for nurses has beenreported as ‘minimal and largely ineffective’(Booth et al., 2005, p.46). Perhaps for thisreason, nurses working in stroke serviceshave reported themselves as lacking confi-dence in working with stroke survivors (Gib-bon & Little, 1995) and possessing fewspecialist capabilities in the area (Forbes &Fitzsimons, 1993).

The two-day workshop described in thisstudy was facilitated by four clinical psychol-ogists from Kent Clinical NeuropsychologyService. The topics included: cognitive diffi-culties following stroke, mood and adjust-

Evaluation of the effectiveness of a two-day workshop, entitled ‘NeuropsychologicalPerspectives on Stroke’Melanie George & Michelle Genis

The aim of this study was to evaluate a series of two day psychologist-led workshops developed formultidisciplinary team members who work with stroke survivors and their families. Results revealed asignificant increase in knowledge and confidence amongst participants post training.

Clinical Psychology Forum 239 – November 2012 25

Neuropsychological perspectives on stroke

ment, understanding challenging behav-iour, and falls-related psychological con-cerns. To the authors’ knowledge there hasbeen no study to date, which explores theeffectiveness of transferring psychology-spe-cific stroke knowledge and skills training toother professional groups.

MethodThe evaluation took place over a six monthperiod. All staff members who attended theworkshops were asked to complete evalua-tion questionnaires both immediately priorto and following the two-day training.

The pre- and post-training question-naires were designed specifically for thisproject. The pre-training questionnaire con-tained eight closed questions, rated on afive-point scale, which aimed to capture levelof knowledge and confidence in workingwith stroke survivors and their families. Fiveopen-ended questions explored reasons forattending the workshop and expectations.Items that elicited information about worksetting and role were also included.

The post-training questionnaire com-prised three sections: Section A repeatedscale items related to level of knowledge andconfidence. Section B comprised the Work-shop Evaluation Questionnaire (WEQ;Milne & Noone, 1996); a training satisfac-tion measure which contains items aboutperceived outcomes of training. Section Ccontained five open-ended questions, aimedat eliciting more detailed feedback.

SampleOverall, 53 MDT members attended threesets of training workshops. Of these, 50consented to participate in the study. Par-ticipants were representative of a variety ofdisciplines, including 18 occupationaltherapists (OTs), nine physiotherapists,seven nurses, six speech and languagetherapists (SALTs), six support workersand four dieticians.

The majority (28) of the participantsworked in community settings, whilst 13worked on in-patient units. Nine workedacross both settings. The mean length oftime in post was three years and four months

(SD = 40.94, range = 2 months to 14 years).On average, participants had spent five anda half years in their profession (SD = 65.62).

Attendance at previous training coursesThe majority of the participants (40 out of50) indicated that they had not received anyprevious training in cognition, psychologicaladjustment or behavioural difficulties associ-ated with stroke. Six, however, had attendedgeneric training on cognition, provided byan independent organisation, and a furtherfour had completed counselling courses.

ProcedureAt the start of each workshop, a brief presen-tation was given, providing an outline of thestudy and its aims. Copies of the pre-trainingquestionnaires, further information aboutthe study and consent forms were subse-quently distributed.

Upon completion of the workshop,participants completed the post-trainingquestionnaires. Additional time was incor-porated into the workshops, to allowample time for completion.

Data analysesThe statistical software package SPSS(v.15, 2006) was used to analyse dataobtained from scale-item responses. Non-parametric methods were used, due to therelatively small sample size and use ofunstandardised measures.

Data from open-ended questions wereanalysed using content analysis (Krippen-dorff, 2004). To assess inter-rater reliability(IRR), a second rater independently codedapproximately 50 percent of responses.This suggested good IRR for all 12 open-ended questions (Kappa coefficientsranged from 0.83 to 1.0, which were signif-icant at p < 0.05 level).

ResultsPre-training responsesParticipants were asked to describe difficul-ties that they had experienced in workingwith stroke survivors and their families. Themost frequent responses concernedpatients’ lack of insight and unrealistic


Melanie George & Michelle Genis

expectations about their progress (n = 11).Five other categories also emerged; theseare outlined in Table 1, along with examplesof responses.When asked to specify theaspects of their work that concerned themmost, 10 out of the 50 participants expressedconcerns about their own lack of knowledgeand confidence. One OT stated: ‘This is avery specialist area and I feel very under con-fident at times when having to answer ques-tions.’ Another remarked, ‘I sometimes feelout of my depth.’

What participants hoped to gain from theworkshopIn answer to a question about what they hopedto gain from participating in the workshop, 10out of 50 participants indicated that theyhoped to gain treatment strategies and tools touse in their clinical practice. Increased confi-dence and knowledge of psychological issuesin stroke were also mentioned, as was a desireto learn more about both the role of clinical(neruo)psychologists, referral procedures andpatients’ points of view.

Knowledge and confidenceA Spearman rho correlation revealed thatpre-training level of knowledge and confi-dence was not associated with length oftime worked in the clinical setting (rs= –0.22, p = 0.13). A non-parametricKruskal-Wallis H test, indicated that pre-training level of knowledge and confidencedid not differ significantly between staffmembers from different professional disci-plines (H(4) = 7.220, P = 0.125) with a meanrank of 7.63 for dieticians, 21.64 for OTs,24.14 for nurses, 26.72 for physiotherapistsand 26.75 for SALTs.

Participants’ pre-training responses toscale-item questions suggested a moderatelevel of self-reported knowledge and confi-dence in working with stroke survivors andtheir families (mean = 29.38, SD = 4.3).This increased when re-assessed followingthe training (mean = 33.66, SD = 3.37).Using an alpha of 0.05 (significance level),the Wilcoxon signed-rank test indicatedthat this difference was statistically signifi-cant (Z = –5.65, p < 0.01).

Table 1: Difficulties experienced in working with stroke survivors/their families

Category Number of respondents Example

Patients’ lack of insight/unrealistic expectations

11 When stroke survivors lack insight into theseverity of their condition and have unrealisticexpectations.

Staff members’ own lack ofknowledge/confidence

8 I battle with my lack of confidence at times.

My lack of confidence has an impact on my work.

Issues related to family/relatives 7 A lot of times it’s not just the patient, it’s thefamily situation that I find most challengingto work with.

Challenging behaviour 6 Working with patients who are sometimes angryor aggressive can be very challenging at times.

Mood and adjustment 6 I sometimes find it difficult working withpeople who are really struggling to come toterms emotionally.

Service-related issues 4 In the past it has been hard to accesspsychological support for our patients – thishas slightly improved.



Post-training responsesParticipants were asked to stipulate whetherthey were thinking about or approaching anyaspects of their work differently as a conse-quence of the training. Three categoriesemerged. These are presented in Table 2,along with examples of participants’ responses.

Enhancing attendees’ skills andcompetencies in strokeParticipants were asked how the training hadhelped them in their day to day practice. Overa fifth of the participants (13 out of 50) indi-cated that they had gained treatment strategiesand tools to use in their clinical practice. Exam-ples of responses are presented in Table 3.

A separate question asked participantshow they planned to apply what they hadlearnt. Again, 13 out of 50 indicated that theyplanned to use tools and strategies they hadgained. A further seven participants reportedthat they planned to disseminate the infor-mation to colleagues. One remarked: ‘I’dlike to address in meetings, plans to imple-ment the ideas.’ Five also planned to shareinformation with clients and their families.Comments included: ‘I will be sharing someof what I have learned about cognitivedeficits with clients’ families.’

DiscussionThe study evaluated a series of psychology-ledworkshops, aimed at delivering training toMDT members working within in-patient and

community stroke services. Prior to the train-ing, the participants encountered a range ofdifficulties during their work with stroke sur-vivors and their families. Consistent with pre-vious research (Gibbon & Little, 1995), a lackof knowledge and confidence were high-lighted as areas of particular concern.

One of the main aims of the project wasto determine whether the training would beassociated with improvements in partici-pants’ knowledge and confidence. Posi-tively, findings suggest that there weresignificant improvements. It is also encour-aging to note that when participants wereasked what they had gained from the work-shop, categories that emerged echoed thosethat were revealed prior to the training.

Expressly, prior to the training, partici-pants’ most frequent responses revealed adesire to learn more about strategies andtools to implement in clinical practice. Fol-lowing training, the majority of participantsfelt that they had been equipped with newtools and strategies. Participants alsoreported that their confidence in utilisingthese in their work had increased.

The findings have several implicationsfor both clinical practice and future strokeeducation. Firstly, it is encouraging to notethat following the training a number of par-ticipants appeared to be reconsideringexplanations they had previously held inrelation to patients’ challenging behaviour.Pre-training responses suggested that some

Table 2: Aspects of their work that participants were thinking about in a different way


Re-considering patients’challenging behaviour

7 Because of the training, I realise thatchallenging behaviour of stroke patients isbecause of deficits and processes, not only theperson’s personality.

Better understanding of patients’ point of view

6 It has given me greater insight into patients’views and how they perceive their problems.

Re-considering when to make referrals

5 I am thinking about how to address the topicscovered with individuals in greater depthrather than referring them to neuropsychologyright away.


Melanie George & Michelle Genis

may have inadvertently made fundamentalattribution errors, in which they over-valuedpersonality-based explanations for behav-iour, while undervaluing situational expla-nations (Hamilton, 1998).

Furthermore, the responses of some par-ticipants indicated that they intended to dis-seminate their new knowledge and skills tocolleagues. Over time, it would be feasible toexpect that an enhanced awareness of psy-chological factors amongst teams would, intime, translate into improvements in thesupport that is offered to stroke survivorsand their families. This is important, as pre-vious research has indicated that stroke sur-vivors are typically dissatisfied with thecontent and quality of information provided(O’Mahony et al., 1997) and that, in partic-ular, psychological aspects are poorlyaddressed (Doswell et al., 1999).

Lastly, the fact that prior work experiencewas not found to be associated with level ofknowledge and confidence, indicates thatroutine clinical practice does not go farenough in equipping staff with specialist skillsin relation to stroke. Moreover, it suggests that

formal training may be helpful for all teammembers, regardless of their experience.

In conclusion, the findings underscorethe fact that clinical psychologists have aseminal role to play in training activities. Inparticular, it lends weight to the recommen-dation made by the Management AdvisoryService’s (MAS, 1989) that the future of theprofession lies within a consultancy frame-work, whereby psychologists would beincreasingly involved in working with teammembers to enhance their knowledge.

AffiliationsMelanie George: Principal Clinical Neuropsy-chologist, East Kent Neurorehabilitation Unit,Kent & Canterbury Hospital.Michelle Genis: Trainee Clinical Psychologist,Salomons Campus, Canterbury ChristchuchUniversity.

AddressDr Melanie George, Principal Clinical Neu-ropsychologist, East Kent Neurorehabilita-tion Unit, Kent & Canterbury Hospital,Ethelbert Road, Canterbury, Kent CT1 3NG.

Table 3: Ways in which the training helped participants in their work roles


Given strategies/tools touse in clinical practice

13 It’s prepared me better to use standardised tools to helpinform the assessment process.

It’s given me practical treatment applications to use.

Increased knowledge of(neuro)psychologists role

7 I have a better understanding of how to refer the clientsI see to the neuropsychology service and which clientsmight benefit the most from their input.

Increased confidence 6 It has given me more knowledge, which has in turngiven me more confidence in working with clients.

Reinforced/reaffirmedexisting knowledge

5 I realised I knew more than I thought I did.

The training was a good refresher for what I knew.

Booth, J., Hillier, V.F., Waters, K.R., & Davidson, I.(2005). Effects of a stroke rehabilitation educa-tion programme for nurses. Journal of AdvancedNursing, 24, 46–49.

Bramley, P. (2003). Evaluating Training: From PersonalInsight to Organisational Performance (2nd ed.).Trowbridge: The Cromwell Press.

Department of Health (2007). National Stroke Strategy.Available from www.dh.gov.uk/en/Publication-sandstatistics/Publications/PublicationsGuid-ance/DH_081062.

Craig, L. & Smith, L.N. (2007). The interactionbetween policy and education using stroke as anexample. Nurse Education Today, 23, 22–24.

References



Dowswell, G., Forster, A., Young, J., Sheard, J.,Wright, P. & Bagley, P. (1999). The developmentof a collaborative stroke training programme fornurses. Journal of Clinical Nursing, 8, 743–752.

Forbes, E.J. & Fitzsimons, V. (1993). Education: Thekey for interdisciplinary collaboration. HolisticNursing Practice, 7, 1–10.

Gibbon, B., & Little, V. (1995). Improving strokecare through action research. Journal of ClinicalNursing, 4, 93–100.

Hamilton, D.L. (1998). Dispositional and attribu-tional inferences in person perception. In J.M.Darley & J. Cooper (Eds.) Attribution and SocialInteraction (pp. 9–114). Washington, DC: Ameri-can Psychological Association.

Krippendorff, K. (2004). Content Analysis: An Intro-duction to its Methodology. London: Sage.

Langhorne, P., Taylor, G., Murray, G., Dennis, M.,Anderson, C., Bautz-Holter, E. & Wolfe, C.(2005). Early supported discharge services forstroke patients: A meta-analysis of individualpatients data. Lancet, 365, 501–506.

Management Advisory Service (1989). Review of Clin-ical Psychology Services: Activities and Possible Mod-els. Cheltenham: Author.

Milne, D.L., & Noone, S. (1996). Teaching and Train-ing for Non-teachers. Leicester: BPS Books.

National Audit Office. (2011). Progress in ImprovingStroke Care: A Good Practice Guide. Retrieved 27June 2011 from http://bit.ly/eTDNFE

O’Mahoney, P., Rodgers, H., Thomson, R., Dobson,R. & James, O. (1997). Satisfaction with informa-tion received by stroke patients. Clinical Rehabili-tation, 11, 68–72.

Royal College of Physicians (2004). IntercollegiateStroke Working Party: National Clinical Guideline forStroke (2nd Ed.). Available from www.rcplon-don.ac.uk/pubs/books/stroke/stroke_guide-lines_2ed.pdf

Scottish Executive (2007). Co-ordinated, Integrated andFit for Purpose: A Delivery Framework for Adult Reha-bilitation in Chronic Conditions. Edinburgh:Author.

SPSS Inc. (2006). SPSS Base for Windows Users Guide(Rel. 15.0.1). Chicago IL: SPSS Inc.

The Stroke Association (2011). Facts About Stroke.Retrieved 17 July 2011 fromwww.stroke.org.uk/media_centre/facts_and_fig-ures/index.html

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George_&_Genis_2012 workshop paper