Assistant Psychologist to Health Care Assistant… within the same hour

During the peak of the pandemic, some secure inpatient services experienced difficulties with staffing levels. Nursing staff were often being required to shield and isolate whilst others needed to stay at home for childcare purposes, due to education providers being closed.

Our service – which provides psychiatric care for men and women with forensic histories who are experiencing mental health difficulties, as well as for individuals whose mental health problems and challenging behaviour require medium and low secure accommodation – reacted in two ways. Initially, Allied Health Professionals (AHP's) were redeployed to work solely as Health Care Assistants in order to safely staff the inpatient wards (reflected in Emily's account). As the situation progressed, psychology staff later worked within a dual role as both HCA and AP (reflected in Sophie's account). 

Emily's account 

The moment I found out I would be required to work full-time as a Health Care Assistant on the low and medium secure wards of my service, I felt great anxiety. Whilst trying to manage that apprehension, I needed to upskill myself quite quickly from a knowledge and physical safety perspective. This felt like cognitive overload, given that I was also adjusting to life in a pandemic on a personal level too.

One of the first things I needed to equip me for this role was to attend training. This taught me how to safely use physical intervention if needed, as well as how to conduct physical assessments such as blood pressure and pulse monitoring. As I travelled back from the day, I thought 'this is not the job I signed up for'. I was disappointed that my identity as an AP no longer felt visible. I questioned my ability to do the job. But in amongst feelings of uncertainty, I also had a sense of camaraderie – I wished to support my service during a time in which staffing levels were unsafe. 

My first day working as a HCA on a male rehabilitation ward involved observations, hourly care rounds and promoting social activities such as board games, quizzes and conversational interchange. Each time I was required to work on a different ward I felt like I had started a new job. I worked with both different staff and a different service user group, ranging from female services to male autism and rehabilitation wards. Furthermore, my shift pattern changed to align with that of the nursing team meaning I felt a little disconnected from my profession. It was difficult for my anxieties to be contained without my usual source of support around me. I realised that I was missing the informal chats with my team, which would often serve as a quick debrief or a way to share clinical knowledge. They had been a way to feel validated as a member of the psychology team whilst increasing my wellbeing through a sense of belonging.

During my time as a full-time HCA, I was more present on the wards and more likely to observe situations in which service users required physical intervention (due to the risk to themselves or others). The high level of emotional arousal I experienced as a result of this meant it could be difficult for me to concentrate upon the task at hand, such as providing creative activities for the service users. 

A further challenge of being based on the ward was having less time to reflect, away from the ward environment. It became easy to at times be 'reactive' to service user needs (i.e. say 'yes') when a more 'proactive' (i.e. negotiate) approach would have been more beneficial for them. 

Although there were immense challenges during my time as a full-time HCA, the experience also served as an opportunity to learn and develop as a clinician. I became more familiar with the challenges that nursing staff face day-to-day. By experiencing their stressors first-hand, I have found myself to be more compassionate whilst facilitating supervision with staff, and to more easily recognise signs of possible staff burnout. 

I was also able to draw upon a range of psychological skills within my role as a HCA, and was more readily on hand to provide support. For example, I recall a time that I offered suggestions to a service user to manage their increased anxiety at that time using the DBT skills framework. Instances such as this enabled therapeutic relationships to develop with both staff and service users, which has since made multi-disciplinary working more effective. 

Sophie's account

I was excited to start my job as an AP within a Forensic Service. This was my first NHS post, and felt completely different to my previous posts within charities and the private sector. Despite the pandemic, my professional life had finally begun! Then on the first day in my new post, I discovered that there had been mass reconstruction within the service with AHP's, Aspirant Nurses, and retired professionals working in the nursing numbers. 

For the first two weeks of my new role, I shadowed the psychology staff on the wards acting as HCA's. This allowed me to get to know the service users and nursing staff in an accelerated way, which would not have been possible if I was doing my intended contracted role. There was a consensus between the other new Assistant Psychologists that this was actually a beneficial way for us to start our role. During this time, I observed that the psychology team had brought psychologically informed ideas to work with service users in the form of group sessions such as DBT skills and cognitive stimulation exercises whilst working on the wards.

As someone who lived in a city that was in a full lockdown (Tier 3), I felt stressed due to my protective factors and stress relief strategies being restricted. Some of my colleagues were in cities with fewer restrictions (Tier 1 and Tier 2) and I saw them as more able to enjoy themselves outside of work. In retrospect, I really struggled with this. It was essential for me to use skills such as a mindful-meditation and nature walks to support my own mental health during the pandemic. I had previously recommended such ways of coping to clients, but not tried them myself.  

When 'Lockdown 3' came into effect in January 2021, there was a greater demand on staffing as aspirant nurses were no longer deployed on the wards. The entire psychology department was once again redeployed into the nursing numbers. We were informed that this was happening on a Wednesday afternoon at 4pm and was coming into effect the following morning. This was extremely anxiety provoking. I wondered, 'what will be expected of me?' 

This time, the team was required to work to our job plans whilst based on the wards in case we were needed for nursing duties. This was distressing in terms of time management, balancing a dual role, and created worries regarding therapeutic relationships merging into that of a more direct caregiver. I no longer felt like a therapist as I was engaging service users in games, facilitating 1:1 debriefs, taking service users on leave and making drinks. This was a fatiguing experience, feeling the constant fight and flight response. I reminded myself of the Robert Sapolsky book Why Zebra's Don't Get Ulcers and continued to experiment with new ways to de-stress. On the more unsettled days in which services users presented with more acuity in risk to self and/or others and I found myself employing mindful breathing exercises and body scans to help alleviate the stress I had experienced on shift. I was also encouraging patients post-incident to do the same. 

Although we were told we did not have to respond to incidents which would require physical intervention, it was personal choice as to whether you helped out or waited for more staff to respond when an incident occurred. The thought that rushed through my mind in this moment was 'I need to help the staff and keep the service users safe' whilst worrying 'will this destroy the therapeutic relationship?' Responding to physical intervention was a complex issue throughout the pandemic… there's a conflict in 'wearing both hats' as a therapist and someone to support the patient through physical intervention. 

There were several positives from working as a HCA in my service. There was a feeling of togetherness with all disciplines resulting in a closer multi-disciplinary understanding: occupational therapy, HCA, Nurses, clinical leads, ward managers, dietetics, and social work. The teams truly bonded throughout this experience and we were able to witness what each discipline brings to an individual's care. I have been able to better understand service user difficulties through spending more time witnessing first-hand what a day on the ward is like for them. I have been able to see the personalities of the service users shine through: something that is difficult to experience in a 1-hour therapy session. The dual job role allowed for a greater quality of therapeutic relationship to develop with patients, and seemed to improve possible barriers of mistrust or psychological 'disconnect' which deterred them enjoying treatment before the pandemic. 

I was also able to recognise additional clinical needs via observation. It allowed for neurological referrals that may not have been recognised previously. This is really what the job is all about – improving care, quality of life and making a difference. Developing both personally and professionally is central to that. By being a reflective practitioner I have seen that there has been a range of positives from being in the nursing numbers, and found myself literally 'practicing what you preach'.

For the future

Working within the service during the pandemic posed challenges, but also created many opportunities for development and reflection. 

Shadowing on the ward and working alongside the nursing staff allowed the development of strong relationships with the nursing team and the service users. Psychology staff are now more respected and involved within working relationships in the service. If new staff regularly had this shadowing opportunity, they could begin fostering relationships and more easily understand the role of nursing staff. If there's another event like Covid, staff would have a more comprehensive understanding of the service and already be skilled to manage the situation. 

For us, the importance of maintaining weekly supervision also came to the fore. Even if you're not offering psychological intervention at the time, it represents the opportunity to connect to the team and maintain a sense of identity and belonging.

-       Sophie Kearney (Higher Assistant Psychologist) [email protected]

-       Emily Ward (Higher Assistant Psychologist) [email protected]

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