Based on the data collected through the pre-training and post-training CARE measure surveys, the online therapeutic communication training program had a clinically significant impact on the nurses' effectiveness in therapeutic interactions with the patients in the facility. The patients within the facility rated their therapeutic interactions with the nursing staff significantly higher after the nurses completed the therapeutic communication training. The nurses' therapeutic skills seemed to improve across all ten therapeutic domains measured by the CARE measure survey, increasing from 'fair' to 'good' before training to 'good' to 'very good' after training. These results not only indicate the need for therapeutic communication training for mental health nurses, but show that an online training program is an effective method of training to improve therapeutic communication skills among nurses.
Sustainability
The online format of this training will ensure that the training program is sustainable for the facility. Originally, the training program was intended to be uploaded to the facility’s existing employee training portal for nurse completion. However, this was not possible at the time of project implementation due to a number of changes being made to the IT department within the organization. This is why, for the purpose of the project, a cloud-based presentation sharing platform was utilized instead. However, since the training program was successful in improving CARE measure scores, suggesting improved therapeutic skills among the nursing staff, the Director of Nursing within the facility intends to have the training uploaded to the facility's
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employee training portal. Once it is uploaded to this portal, the facility will be able to continue to utilize this training program indefinitely, with no cost to the facility outside of the already
existing cost of IT staff. Once the training program is uploaded to the employee training portal, it can also be easily made available to other staff within the facility, as well as staff across other facilities under the parent healthcare organization.
Strengths and limitations
The literature shows that effective therapeutic communication skills increase patient satisfaction and improve patient outcomes in the mental healthcare. The evidence strongly supports that mental health nurses should receive training on therapeutic communication skills, and incorporate these skills into their practice, in order to improve patient satisfaction and outcomes (Stickley & Freshwater, 2006; Street, Makoul, Arora, & Epstein, 2009). Evidence also supports that providing training to healthcare staff on therapeutic skills does in fact increase their knowledge on the effective use of therapeutic skills (Ancel, 2006; Bowles, Mackintosh, and Torn, 2001; Robinson, Hills, and Kelly, 2011; William, Abd-Hamid, and Perkhounkova, 2017; Hsu, Lee-Hsieh, Turton, and Cheng, 2014; Chang, Sheen, Chang, and Lee, 2008). This evidence, along with Hildegard Peplau's (1997) seminal Theory of Interpersonal Relations (the theoretical basis for therapeutic communication in nursing), provided strong support for the implementation of this project.
This project provided mental health nurses with therapeutic communication training in a facility that, like many others, has no existing training available. The training curriculum was consistent with the Dialectal Behavioral Therapy principles upon which the facility operates in providing care for patients. Training was provided in an e-learning format that was not only convenient for the nurses to complete, but also sustainable for the facility.
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In evaluating the success of the training program, both the nurses and the patients completed assessments evaluating the nurses' use of therapeutic skills in their interactions with patients before and after the training. This provided valuable insight into whether or not the training program may have actually improved the nurses' use of therapeutic skills, as well as whether or not the nurses' perceptions of their own skills matched those of the patients. Although there were significant increases in scores on the patient-completed CARE measure surveys after the training period, the nurses self-rated their skills significantly higher than the patients did on both the pre-training and post-training surveys. This indicates that, although the nurses' skills have improved, there still may be somewhat of a disconnect between how the nurses' view their effectiveness and how well the patients' needs are actually being met during therapeutic
encounters.
Six out of the eight full-time and part-time nurses at the facility completed the training program. None of the PRN nurses at the facility completed the training program. This was not surprising, as most of the PRN nurses work other jobs and work infrequently at this particular facility. Since the full-time and part-time nursing staff have much more frequent contact with the patients, the training program had a significant clinical impact despite only six of the nurses completing the program. The clinical impact of the training program may have been even greater if completion rates were higher.
Due to the length of the training period, different patients were present after the training program than were present prior to implementation of the training program. Therefore, the post- training CARE measure surveys were not completed by the same patients that completed the pre- training surveys. In theory, if the nurses' therapeutic communication skills improved as a result of the training program then their scores should have improved regardless of the patients
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completing the surveys, and therefore the results are still considered clinically significant.
However, it is important to note that the scores could have been influenced in part by the level of acuity of the patient population at the time of administration of the surveys.
Recommendations for the future
The literature provides evidence that effective therapeutic communication is associated with positive outcomes among mental health patients, including decreased anxiety, enhanced coping ability, improved self-care and emotional management skills, and increased adherence to treatment (Stickley & Freshwater, 2006; Street, Makoul, Arora, & Epstein, 2009). This evidence supports the implementation of therapeutic communication training among mental health nurses. The implementation of this online therapeutic communication training program for mental health nurses led to a clinically significant improvement in the use of therapeutic skills among the nurses at the project site. It is recommended that this training program be incorporated into the facility's required training courses for all nurses within the facility, in order to continue to develop and maintain proficiency in therapeutic communication skills among the nursing staff. In the future, proficiency in therapeutic communication skills among the nursing staff may be measured using a combination of the CARE measure survey, simulations in which the nursing staff must demonstrate the effective use of therapeutic communication techniques, and direct observation of the nurses' interactions with patients. This training program should also be considered for required training among other staff members who have regular interactions with patients, such as residential patient assistants. Although the training program led to clinically significant improvements in therapeutic communication among the nurses in this study, the results were only measured short-term, immediately after completion of the training. The long- term impact of this training should be evaluated by re-administering the CARE measure survey
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Since the literature indicates a general lack of therapeutic communication training for nurses in mental health facilities, this training should also be adapted to and implemented in other mental health facilities. The online nature of this training program will make it easy to disseminate to other facilities. The video demonstrations used in this training program were filmed using the project members as actors. Prior to future implementation of this training program across other facilities, the video demonstrations may be re-filmed using actual
performing artists to ensure the most impactful and accurate video demonstrations. The impact of the training across a wider array of facilities should be evaluated using the same CARE measure empathy survey, and the training program should continue to be evaluated and modified to best meet patient needs at whatever mental health facility it is being implemented in.
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APPENDIX A: SCRIPT FOR RECRUITMENT OF NURSE PARTICIPANTS For my doctoral project within the School of Nursing at the University of North Carolina at Chapel Hill, I have created a therapeutic communication training program for mental health nurses, which I will be implementing at the facility over the next couple months. Therapeutic communication is an essential part of mental health nursing, and good therapeutic
communication has been shown to increase satisfaction and improve outcomes for psychiatric patients. Patient outcomes associated with good therapeutic communication are decreased anxiety, enhanced coping ability, improved self-care and emotional management skills, and increased adherence to treatment. My research has shown a general lack of therapeutic communication training in psychiatric facilities, and our facility is no different. In attempts to improve therapeutic communication skills among our nurses, I will be implementing an online therapeutic communication training program. The program will be presented on HealthStream, and will consist of three different modules. Each module should take about 30 minutes to
complete. The modules will be released one at a time in consecutive order, and each module will be available for 10 days before the next is released. You will receive an email notification when each module is released. Please do your best to get each module completed in a timely manner. The modules will teach you the basics of therapeutic communication in mental healthcare, and will have video demonstrations of both effective and ineffective communication techniques. My hope is that you are able to apply some of these techniques in your interactions with patients, and that this training makes your interactions with patients easier and more effective. After all of the training modules have been completed, you will be sent a survey to complete. This will be a self- rating survey asking you to reflect back and rate your therapeutic communication skills prior to completing the training, and then rate your current skills after completing the training.
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Completion of the training and the survey are both completely voluntary and anonymous, but I hope to recruit as many nurses as possible to complete both. My intention is to improve the training methods for our staff and add to our nurses’ therapeutic skills, in order to improve patient care within our facility. I will address any questions or concerns at this point.
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APPENDIX B: SCRIPT FOR PATIENT RECRUITMENT TO COMPLETE INITIAL SURVEY
My name is Olivia Glance and, in addition to being a nurse at Carolina House, I am working on a Doctorate of Nursing Practice at the University of North Carolina at Chapel Hill. For my doctoral project, I am creating a therapeutic communication training program for mental health nurses. Over the next couple months, our nurses will be completing this therapeutic communication training. My goal is to improve our nurses’ therapeutic skills in their interactions with patients. In order to measure the success of the training program, I need your input as patients. I will be asking you to complete a survey rating your recent interactions with nursing staff, in order to get an understanding of their current effectiveness in providing therapeutic care. I will then ask you to complete the same survey after the nurses have completed the training program, in order to see if the nurses’ skills have improved. The survey is 10 questions and should take less than 5 minutes to complete. These surveys are voluntary and will be completely anonymous. The nursing staff will have no access to your survey responses. I will be the only individual at the facility with access to the surveys, and they will not impact your care negatively in any way. My hopes are to improve the training for nurses in the facility so that we can provide the best care possible for our patients, and I need your help to understand how we are doing.
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APPENDIX C: SCRIPT FOR PATIENT RECRUITMENT TO COMPLETE FOLLOW-UP SURVEY
A couple months ago, I asked all of the patients to complete a survey as a part of my doctoral project with the School of Nursing at UNC-Chapel Hill. This was a survey asking you to rate the helpfulness your recent interactions with nursing staff. The nurses have since
completed a therapeutic communication training program, and I am asking you to complete this survey again, so that I can determine how effective the training program was in improving their skills. As before, this survey is completely voluntary and anonymous. The nursing staff will have no access to these surveys, and they will not negatively impact your care in any way. It is solely intended to help me determine how to most effectively improve the skills of our nursing staff, in order to provide you with the best care possible.
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APPENDIX D: OUTLINE OF TRAINING CURRICULUM Module 1 – The Foundation of Therapeutic Communication
• “Humans thrive on relationships. Positive interactions are the essence of our happiness. Often positive interactions occur in very brief encounters, even with relative strangers, where people share a moment of connectedness. Connecting to others, in a positive way, is affirming. It allows us to feel like we belong to our community, and it decreases our sense of isolation. There is perhaps no more important time for people to feel connected to and supported by others as when they face serious illness or trauma.” (Raphael- Grimm, 2015)
• Therapeutic communication is defined as the use of verbal and non-verbal messages with the goal of developing trust and respect in the nurse-patient relationship and assisting patients to successfully meet physical and psychological needs (American Psychiatric Nurses Association, 2017).
• Studies have found that 85% of patients believe that strong therapeutic relationships, which include good communication and emotional support, are very important to successful medical treatment. (Raphael-Grimm, 2015)
• Patients have reported that good and helpful therapeutic communication with healthcare providers fostered feelings of hopefulness, and a sense that they were active participants in their own care. (Raphael-Grimm, 2015)
• Patients have reported that experiences involving poor and unhelpful communication with healthcare providers led to psychological distress and feeling dehumanized. (Raphael-Grimm, 2015)
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• Patient outcomes associated with effective therapeutic communication are decreased anxiety, enhanced coping ability, improved self-care and emotional management skills, and increased adherence to treatment. (Stickley & Freshwater, 2006; Street, Makoul, Arora, & Epstein, 2009)
• “Every encounter provides an opportunity for the patient to experience the healing power of our full attention, to feel valued, cared, for, respected, and understood.” (Raphael- Grimm, 2015)
• However, staff often get caught up in the culture of healthcare, which is time-pressured, procedure-driven, and productivity-focused. (Raphael-Grimm, 2015)
• Nurses often fall into the trap of believing their value to patients primarily rests in their medical knowledge and mastery of various skills and treatments. Although these are valuable, emotional intelligence and interpersonal skills are where the true power to heal lies. Mindfully developing empathy for the patient, and communicating an interest in, respect for, and desire to understand the patient, are essential to creating a healing encounter. (Raphael-Grimm, 2015)
• Elements that characterize therapeutic communication are (APNA, 2018):
• Developing an attitude of respect and dignity
• Being fully present
• Listening with the whole self
• Communicating hope
• Developing trust
Module 2 – Mindfulness in Therapeutic Communication
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o “Mindfulness is a state of awareness, or consciousness, that is fostered by the consistent and deliberate effort to take notice of what is occurring in one’s inner and outer worlds, with a capacity to be fully engaged in the present moment, rather than distracted, preoccupied with, or focused on the past or future. To be mindful is to be attuned to one’s internal climate and with that awareness, make more conscious decisions about how to respond to everyday events in the here and now. It enhances the capacity to take notice of the subtle shifts in our emotions and thoughts and consider how those emotions and thoughts might influence our attitudes and drive our behaviors.” (Raphael-Grimm, 2015)
o “When mindfulness shifts from an internal focus (ourselves) to an external focus (others), it fosters a capacity for openness that allows us to be more sensitive to others and to monitor how our own behavior is impacting them. It fosters a curiosity and a drive to understand the lived experience of others, and to offer thoughtful responses that meet the unique demands of those interpersonal situations.” (Raphael-Grimm, 2015).
o In mental healthcare, mindfulness cultivates the desire to understand the thoughts, feelings, and needs of patients. Practicing mindfulness allows us to be fully present in our interactions with patients, and also allows us to self-monitor so that we are able to respond effectively to patients to meet their needs.
o Mindfulness is taking a step back and examining our own underlying thoughts and emotions, and analyzing how these might affect our interactions with patients. This allows us to better prevent our own emotions from getting in the way of meeting our patients’ needs.
o Domains of mindfulness: • The Emotion Mind
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• Can be positive or negative.
• Ex. “I hate this situation. Why should I have to put up with this?”
• The emotion mind can be problematic when our emotions take over and drive our behaviors, causing us to act reactively.
§ The Body Mind
• This is our awareness of physical experiences.
• Ex. “I’m tired and hungry and haven’t had time to go to the bathroom in 4 hours.”
• If we are not mindful of what our bodies are telling us, these physical experiences can take over and interfere with our ability to focus.
§ The Reason Mind
• These are our rational, analytical, controlled thoughts.
• Ex. “Patients who are newly diagnosed may have a lot of concerns and questions, so it is important for me to make extra time for these patients to address their
concerns.”
• Ex. “I know I get irritable when I don’t get enough sleep, so I can understand why this patient with insomnia is irritable today.”
§ The Wise Mind
• The wise mind is where the emotion mind, body mind, and reason mind overlap.
• This is a place of mindfulness where we are able to evaluate and monitor our
emotions, motives, desires, and biases, in order to prevent them from influencing and sabotaging our interactions with patients.
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§ First step-back, take a deep breath, and look inward, focusing on one state of mind at a time.
§ Assess your emotional temperature, or Emotion Mind: