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Assessing the Acceptability and Feasibility of the Role of a Psychological Wellbeing Assistant in Inpatient Neurorehabilitation

  • Northern Care Alliance NHS Foundation Trust
  • Northern Care Alliance

Abstract and Figures

Inpatient neurorehabilitation guidelines recommend comprehensive psychological care for service users to support their cognitive, behavioural, and emotional needs following a neurological diagnosis (BPS, 2017; NHS England, 2016). The Psychological Wellbeing Assistant (PWA) role was developed to meet Level 1 psychological needs, following Kneebone’s (2016) stepped model of psychological care. This study assessed the acceptability and feasibility of the PWA role in three inpatient neurorehabilitation wards. In addition, two PWAs recorded clinical contacts and clinical supervision, and confidence in clinical competencies was measured via questionnaire. The implications of the study are discussed.
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Inpatient neurorehabilitation guidelines recommend comprehensive
psychological care for service users to support their cognitive, behavioural,
and emotional needs following a neurological diagnosis (BPS, 2017; NHS
England, 2016). The Psychological Wellbeing Assistant (PWA) role was
developed to meet Level 1 psychological needs, following Kneebone’s
(2016) stepped model of psychological care. This study assessed
the acceptability and feasibility of the PWA role in three inpatient
neurorehabilitation wards. In addition, two PWAs recorded clinical contacts
and clinical supervision, and confidence in clinical competencies was
measured via questionnaire. The implications of the study are discussed.
Following a stroke, acquired brain injury (ABI) or
neurological illness, delivering psychological care
during inpatient neurorehabilitation is paramount,
particularly when considering cognitive, behavioural
and emotional diculties (NHS England, 2016, BSRM,
2014; BPS, 2017). Service users should therefore have
access to specialist assessment, formulation, and
intervention (BPS, 2017) (see Figure 1).
To meet good practice standards, inpatient
neurorehabilitation teams should allocate their time
matched to the complexity of the needs of service
users (Kneebone, 2016; BPS, 2017). However, BPS
(2017) guidelines only recommend providing specialist
psychological support, failing to address those who
require lower-level support. Therefore, the host
NHS trust developed a new role, the Psychological
Wellbeing Assistant (PWA), to meet the needs of those
who may fall into this category, providing practical
experience for aspiring clinical psychologists.
The implementation of the undergraduate placement
scheme and development of the PWA role and
responsibilities has been described by Methley
PSYPAG_1 21-DEC 21 17
et al. (2020) and was designed to, under clinical
supervision, provide additional person-centred
psychological care to service users that did not
require specialist support. The PWA role was
informed by the stepped model of psychological care
(Kneebone, 2016), which suggests individuals who
have suered a stroke have psychological needs
separated into four levels (see Figure 2).
The PWAs’ responsibilities targeted service
users’ Level 1 needs, including the delivery of
person-centred psychological interventions
such as art therapy, increasing connectedness
through providing company, engaging in activities
that were personally important to service
users, and behavioural activation (Martell et al.,
2001). These roles were deemed appropriate
for undergraduate psychology students under
clinical supervision, as little or no qualifications
are required (Kneebone, 2016). The PWA role also
involved supporting assistant psychologists (APs)
within the service by co-facilitating activities and
groups across the inpatient neurorehabilitation
wards. The PWAs were asked to see services
users after their supervisors had triaged inpatient
neuropsychology referrals.
For aspiring clinical psychologists, the PWA role could
enhance their knowledge and clinical skills, which is
advantageous due to the competitive nature of clinical
psychology. Undertaking a placement year can
increase employability after graduation (The Graduate
Market, 2019), and can lead to obtaining higher-paid
graduate jobs (Brooks & Youngson, 2016). It has also
been found that psychology students who complete
a placement year are awarded higher degree
classifications (Huws et al., 2006).
However, there are several practical and ethical
considerations for the implementation of the PWA,
including clinical supervision, clinician availability,
exposure to distressing experiences, and risk of
exploitation (Pitt & Teager, 2020; DCP & BPS,
2016; Snell & Ramsden, 2020; Sharp et al., 2013;
Messinger, 2004). Undergraduate students should
not, for example, provide psychological assessment
or formal therapy (BPS, 2010). It was ensured that
Figure 1: What contributes to good psychological care in inpatient services? From ‘Psychological best practice in
inpatient services for older people’ by The British Psychological Society (2017).
PSYPAG_1 21-DEC 2118
the responsibilities of the PWA were acceptable,
supervision was feasible, and that the role would be
beneficial to their professional development (Methley
et al., 2020; Pitt & Teager, 2020).
Due to the novel nature of the PWA role, its
feasibility and acceptability were not understood, so
we aimed to investigate the implementation of the
PWA role across three inpatient neurorehabilitation
wards. Using data collected from the two PWAs,
the feasibility of the PWA role in clinical settings
will be assessed by reviewing clinical contacts,
which is defined as the face-to-face contact
each PWA had with a client. Also, the feasibility
will be assessed through the hours of clinical
supervision received from either qualified clinical
psychologist, academic super vision from their
university, and peer supervision from APs in the
service. Consequently, the feasibility for clinical
psychologists to adequately supervise each PWA
will be addressed. To assess whether the PWA role
is acceptable for the PWAs, the present study used
a questionnaire developed by Methley et al. (2020)
to assess confidence in clinical competencies.
Case log data and supervision records were
collected throughout the placement and reviewed
retrospectively. PWAs confidence in clinical
competencies ratings were collected pre- and
Microsoft Excel was used to hold anonymised
case log data. Supervision data were held in
Microsoft Outlook diaries. Methley et al. (2020)
questionnaire was used to assess PWA confidence
in clinical competencies.
The study was registered with the Research and
Development team at the host Trust. The Health
Research Authority decision tool indicated that the
Figure 2: A revised model for stepped psychological care after stroke from ‘Stepped psychological care after stroke,’ by
Kneebone, I. I., 2016, Disability and Rehabilitation, 38 (18), 1836-1842. Copyright (2016) Taylor & Francis
PSYPAG_1 21-DEC 21 19
study did not constitute research, and therefore did
not need ethical approval. The PWAs recorded each
clinical contact between September 2018 and August
2019 and September 2019 to April 2020. Demographic
data collected included service user age, gender,
ethnicity, and diagnosis. Clinical contact data included
the number and duration of face-to-face individual
and group sessions. Finally, PWAs completed the
confidence in clinical competencies questionnaire pre-
and post-placement (Methley et al., 2020).
The feasibility of the PWA role was first assessed by
reviewing service user contacts. In total, the PWAs
saw 73 service users across their placement years.
Of the service users seen by the PWAs, 53.42 per
cent of service users (n = 39) had sustained an ABI,
and 46.58 per cent of ser vice users (n = 34) had
suered a stroke. Demographic data indicated that
41.10 per cent of service users were male (n = 30),
and 58.90 per cent were female (n = 43). Mean
service user age was 62.39 years (SD= 20.86, age
range= 17-96yrs). The ethnicity of service users
were: 89 per cent White British (n = 65), 2.74 per
cent African/African British (n = 2), 1.37 per cent
Caribbean (n = 1), 1.37 per cent Chinese (n = 1),
1.37 per cent Czech Republic (n = 1), 1.37 per cent
Asian (Persian) (n = 1) and 2.74 per cent Other Ethnic
Group (n = 2).
Descriptive statistics are reported in Table 1. In
total, the PWAs had 536 service user contacts with
an average of 7.34 contacts per ser vice user (SD
=7.67). The PWAs spent a total of 337.25 hours
engaging in service user contact, averaging at 4.52
hours per service user (SD=4.51). Consequently,
the PWAs completed a total of 64 group sessions,
totalling 85 hours.
Feasibility was also assessed by reviewing clinical,
academic, and peer supervision hours during the
placement years. Across both placement years, the
PWAs received 97 hours of clinical supervision from
qualified clinical psychologists, 18 hours of peer
supervision, and two hours of academic supervision
(see Table 2).
The acceptability of the PWA role was assessed
through PWAs confidence in clinical competencies
via completion of self-report measures pre-and
post-placement (Methley et al., 2020). The measure
included clinical competencies required to work
within a neurological rehabilitation clinical setting,
such as the ability to use supervision and the ability
to engage a client. Table 3 indicated that both
PWAs experienced increased confidence after
completing their placement in 10 of the 11 clinical
competencies. Ratings on the ‘Knowledge and
understanding of common mental health problems’
competency remained at ceiling, with both PWAs
rating their confidence as 5/5 pre- and post-
The findings suggest that implementing a PWA
role was feasible for increasing clinical contacts
on neurorehabilitation wards and for clinical
psychologists to adequately supervise in line with
BPS good practice standards (DCP & BPS, 2016).
PSYPAG_1 21-DEC 2120
Table 1: Descriptive statistics for clinical contacts and contact time and clinical supervision.
PWAs Clinical
Total 536 337.25 97
Mean 7.34 4.52 48.5
Standard deviation 7.67 4.51 9.19
Note. N=50 for PWA 1, N=23 for PWA 2.
Table 2: Descriptive statistics for clinical, academic and peer supervision received by each PWA.
PWAs Clinical
Total 97 18 2 117
Mean 48.5 9 1 58.5
Standard deviation 9.19 4.24 0 13.44
Note. N = 68 for PWA 1, N
= 49 for PWA 2.for PWA 2.
Table 3: Mean PWA confidence in clinical competencies ratings.
Clinical Compentency Confidence
Ability to make use of supervision 4 5
Understanding of psychological assessment 2.5 5
Ability to manage endings 2.5 5
Ability to manage emotional content of sessions 3 5
Ability to see from a client’s ‘world view’ 3.5 5
Ability to engage a client 3 5
Understanding models of therapy 3.5 4
Knowledge and understanding of working with people with social and
cultural differences
4 5
Knowledge and understanding of professional and ethical guidelines 3.5 5
Knowledge and understanding of neurological conditions and presentations 4 5
Kknowledge and understanding of common mental health problems 5 5
PSYPAG_1 21-DEC 21 21
Clinical competence ratings also indicated that
the role was acceptable for the professional
development of the PWAs. There was evidence of
a substantial number of clinical contacts (N = 536)
and total time spent with service users (337 hours)
when supported with formal clinical supervision (97
hours). The PWAs provided 5.52 clinical contacts,
or 3.47 hours of clinical contact, for every hour
of formal clinical supervision. PWAs, therefore,
increased clinical contact with ser vice users in
return for regular supervision. Whilst the PWAs
caseloads may not be equivalent to APs or clinical
psychologists, they fall in line with the PWAs’ zone
of proximal development and supervisory needs
(BPS, 2010; Pitt & Teager, 2020).
Further to this, the flexibility of their role meant that
they had appropriate time to prepare for sessions,
reflect on them, and meet with service users on
multiple occasions during the same day. Also, the
overall feasibility of the PWA role for clinical settings
was evident through the ability of the PWA to support
APs in preparing and delivering therapy groups on
the wards. Therefore, qualified clinicians or other
multi-disciplinary team members were not required,
thus reducing barriers to running these sessions.
Demographic data also suggested that the PWAs
were able to work with service users post-ABI and
post-stroke, and common diculties associated with
these groups were not a barrier (e.g. communication,
cognitive diculties). It was noted that 89.00 per
cent of the service users were White British (n = 65),
58.90 per cent were female (n = 43), and their mean
age was 62.39 years. The data could suggest that the
service users most often identified as having Level
1 psychological needs were white women in their
Competency ratings indicated that PWAs felt their
knowledge and skills in 10 of the 11 items improved,
with the largest increases noted in the ability to
engage a client, understanding psychological
assessment, and managing endings. From this, it is
reasonable to assume that the role met the needs of
the PWAs and may therefore be regarded as being
acceptable. However, it would be beneficial to gather
longitudinal data regarding the PWA role to evaluate
a larger sample.
Overall, the work undertaken by the PWAs helped
the inpatient neurorehabilitation wards meet
BPS (2017) good practice standards by oering
psychological support to service users with Level
1 psychological needs (Kneebone, 2016), thereby
enabling qualified clinical psychologists to see
service users with more complex needs. The
PWA role was feasible when services can meet
the developmental and supervisory needs of
the PWAs, considering the guidelines for clinical
work undertaken by undergraduate psychology
students (DCP & BPS, 2016; Pitt & Teager, 2020).
Supervision data suggested that PWAs were
provided with the correct amount of supervision
as suggested by the guidelines for appropriate
clinical supervision for undergraduate placements,
supplemented by peer and academic supervision
(BPS, 2010; DCP & BPS, 2016: Pitt & Teager, 2020).
Neither PWA included time taken writing clinical
notes emanating from sessions in the analysis,
which might also constitute clinical work. One
placement was curtailed due to the coronavirus
pandemic, and so only seven months of data were
collected for that PWA. Whilst contact data provided
a useful metric, as the PWAs’ competencies
increased, they also began to work with service
users with more complex presentations (Kneebone,
2016). Future studies may benefit from measuring
the complexity of the PWAs caseloads.
PSYPAG_1 21-DEC 2122
To further assess the acceptability, service users,
sta, and families could provide outcome data and
qualitative feedback for the PWA role. Additionally,
whilst the onus of this study was regarding clinical
duties, the nature of the role meant that PWAs
job plans included non-clinical duties. These
duties were: time to prepare, learn additional
skills (e.g. test administration), complete research
and service development work, attend pertinent
meetings, shadow other team members (e.g. awake
craniotomies, cognitive testing), and attend training
and teaching. Future research regarding the role
should attempt to evaluate the acceptability and
feasibility of the non-clinical roles the PWAs engaged
in, which may also serve to benefit the ser vice and
the individual.
This study demonstrated that a PWA role was
acceptable for each PWA by providing development
in their confidence in clinical competencies. The
PWA role was also feasible for sta to adequately
supervise and to overall support clinical settings.
The PWA role provided additional support for service
users in inpatient neurorehabilitation with Level 1
psychological needs (Kneebone, 2016), and the
time invested via supervision and development was
outweighed by the clinical contact data. Services
looking to utilise similar roles would benefit from
using the process outlined by Methley et al. (2020)
and contacting local universities to implement
undergraduate placements. Still, PWAs should be
provided with appropriate clinical supervision and
not be used to replace AP or qualified posts.
Research Assistant
Salford Royal NHS Foundation Trust, Salford Royal
Hospital, Stott Lane, M6 8HD.
Research Assistant
Salford Royal NHS Foundation Trust, Salford Royal
Hospital, Stott Lane, M6 8HD.
Consultant Clinical Neuropsychologist
Salford Royal NHS Foundation Trust, Salford Royal
Hospital, Stott Lane, M6 8HD.
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ResearchGate has not been able to resolve any citations for this publication.
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Purpose: Emotional difficulties are common after stroke and have an impact on rehabilitation outcome. It is a challenge to manage these problems effectively, particularly in times of resource stringency. One proposal for how to do this has arisen out of an approach to general mental health management: a system of 'stepped care'. Such a system directs intervention by considering level of need, thereby making the most efficient use of available resources. It is the purpose of this article to articulate a stepped psychological care approach for emotional problems after stroke. Method: Narrative review and elaboration of the model proposed by the Department of Health in England for the management of emotional problems after stroke. Results: A stepped care model for the management of emotional problems after stroke is presented in detail, including descriptions of specific interventions and guidance to inform the level of management. Conclusions: The stepped psychological care proposal for emotional problems after stroke requires evaluation but is potentially of use within comparable healthcare systems. Implications for Rehabilitation Emotional problems are common after stroke and effect rehabilitation outcomes. A stepped care approach to these problems offers the ability to cater to all according to need. Greater specification of the services at each step can be outlined. While recommended, such an approach requires evaluation to prove its efficacy.
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Additional guidance for clinical psychology training programmes: Guidelines on clinical supervision
  • Bps
BPs. (2010). Additional guidance for clinical psychology training programmes: Guidelines on clinical supervision [online PDF]. Retrieved from: %20on%20