essential therapeutic communication for mental health
TRANSCRIPT
ESSENTIAL THERAPEUTIC COMMUNICATION TRAINING FOR MENTAL HEALTH NURSES: A PROGRAM EVALUATION
Olivia Glance
A Doctor of Nursing Practice project submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Nursing
Practice in the School of Nursing (Psychiatric-Mental Health Nursing Practice).
Chapel Hill 2019
Approved by:
Theresa Raphael-Grimm
Grace Hubbard
Juliana Galioto
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© 2019 Olivia Glance
ALL RIGHTS RESERVED
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ABSTRACT
Olivia Glance: Essential Therapeutic Communication Training for Mental Health Nurses: A Program Evaluation (Under the direction of Theresa Raphael-Grimm)
Therapeutic communication is an essential skill in psychiatric nursing, and has been
shown to result in improved outcomes for mental health patients. Such outcomes include
decreased anxiety, enhanced coping ability, improved emotional management skills, and
increased adherence to treatment. However, there is no evidence indicating that mental health
facilities commonly provide training in therapeutic communication to their nurses, and, without
adequate training, psychiatric nurses may not have the knowledge to implement these skills in
their interactions with patients. The purpose of this project was to create and implement an
online training program on therapeutic communication skills for mental health nurses, with the
goal of increasing the frequency and effectiveness with which nurses implement these skills in
their interactions with patients. For this project, an online therapeutic communication training
program was created and implemented among the nurses at a residential eating disorder
treatment facility over the course of a month. The Consultation and Relational Empathy (CARE)
measure, a validated provider empathy survey, was administered to the patients at the facility
prior to and after the training to determine the effectiveness of the training program on
improving the nurses' therapeutic communication skills. Differences in average patient ratings of
nursing staff on the pre- and post-training CARE measure survey questions were analyzed, and
patient ratings of nurses' therapeutic communication skills after the training program were found
to be significantly higher. These results indicated that completion of the training program was
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associated with clinically significant improvements in the nurses' therapeutic communication
skills. Since evidence has associated effective therapeutic communication with positive
outcomes among psychiatric patients, a clinically significant improvement in the nurses'
therapeutic communication skills following this training program indicates the potential value of
the program, as well as a clinical need to provide mental health nurses with therapeutic
communication training. The results also suggest the potential value in expanding this training
program to a wider community of mental health nurses.
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ACKNOWLEDGEMENTS
Thank you to Dr. Theresa Raphael-Grimm, who served as my DNP committee chair for
this project and was instrumental in the development of the therapeutic communication training
program used in this project. I am so thankful for your expertise in therapeutic communication
and your help in developing an effective training program.
Thank you to Dr. Grace Hubbard, who served as a DNP committee member and provided
guidance throughout the design of the project and writing of this DNP paper. Your experience
working on DNP projects made navigating the process manageable, and I am thankful for all of
your help in organizing and editing this paper.
Finally, thank you to Juliana Galioto, who served as a committee member and was the
Director of Nursing at the project site. Your support throughout the implementation of the
training program was so important to the success of my project, and I appreciate your constant
support and positivity throughout the project.
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TABLE OF CONTENTS
LIST OF FIGURES ................................................................................................................... ix
LIST OF ABBREVIATIONS AND SYMBOLS ......................................................................... x
CHAPTER 1: INTRODUCTION OF THE PROJECT ................................................................ 1
Problem statement ........................................................................................................... 1
Purpose of project ........................................................................................................... 1
Search strategy ................................................................................................................ 2
CHAPTER 2: REVIEW OF LITERATURE ............................................................................... 3
Therapeutic communication in mental health nursing ...................................................... 3
Training programs for therapeutic communication .......................................................... 4
Resources to guide the development of a therapeutic communication curriculum ............ 8
Summary......................................................................................................................... 9
CHAPTER 3: CONCEPTUAL FRAMEWORK: THE ADDIE MODEL .................................. 11
CHAPTER 4: PROJECT DESIGN ........................................................................................... 13
CHAPTER 5: METHODS ........................................................................................................ 14
Setting and participants ................................................................................................. 14
Training development ................................................................................................... 15
Recruitment .................................................................................................................. 15
Resources and budget .................................................................................................... 16
Implementation barriers and solutions ........................................................................... 16
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Ethics and human subjects permissions ......................................................................... 17
CHAPTER 6: INTERVENTION .............................................................................................. 18
CHAPTER 7: DATA COLLECTION AND OUTCOMES ....................................................... 20
Data collection .............................................................................................................. 20
Data analysis and outcomes ........................................................................................... 22
CHAPTER 8: DISCUSSION .................................................................................................... 26
Implications for practice ................................................................................................ 26
Sustainability ................................................................................................................ 26
Strengths and limitations ............................................................................................... 27
Recommendations for the future .................................................................................... 29
APPENDIX A: SCRIPT FOR RECRUITMENT OF NURSE PARTICIPANTS ...................... 31
APPENDIX B: SCRIPT FOR PATIENT RECRUITMENT TO COMPLETE INITIAL SURVEY .................................................................................................................................. 33 APPENDIX C: SCRIPT FOR PATIENT RECRUITMENT TO COMPLETE FOLLOW-UP SURVEY .......................................................................................................... 34 APPENDIX D: OUTLINE OF TRAINING CURRICULUM.................................................... 35
APPENDIX E: EMAIL NOTIFICATION FOR MODULE RELEASE ..................................... 48
APPENDIX F: THE CARE MEASURE FOR PATIENT COMPLETION ................................ 49
APPENDIX G: INFORMED CONSENT FOR PATIENTS ...................................................... 51
APPENDIX H: THE CARE MEASURE ADAPTED FOR NURSE COMPLETION................ 53
APPENDIX I: INFORMED CONSENT FOR NURSES ........................................................... 57
APPENDIX J: PATIENT SURVEY RESULTS AND ANALYSIS .......................................... 59
APPENDIX K: NURSE SURVEY RESULTS AND ANALYSIS ............................................ 61
APPENDIX L: NURSING DEMOGRAPHICS ........................................................................ 62
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APPENDIX M: COMPARISON AND ANALYSIS OF PATIENT VERSUS NURSE SURVEY SCORES..................................................................................................... 63 REFERENCES ......................................................................................................................... 64
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LIST OF FIGURES
FIGURE 1 - Patient CARE measure survey results.......................................................................23
FIGURE 2 - Nurse CARE measure survey results........................................................................24
FIGURE 3 - Patient versus nurse CARE measure survey results..................................................25
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LIST OF ABBREVIATIONS AND SYMBOLS
ADDIE analysis, design, development, implementation, and evaluation
CARE consultation and relational empathy
CINAHL Cumulative Index of Nursing and Allied Health Literature
DNP Doctor of Nursing Practice
IT information technology
LPN Licensed Practical Nurse
PRN per diem
RN Registered Nurse
UNC University of North Carolina
= equal to
≥ greater than or equal to
< less than
≠ not equal to
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CHAPTER 1: INTRODUCTION OF THE PROJECT
Problem statement
Therapeutic communication is the cornerstone of psychiatric nursing, and has been
shown to result in increased patient satisfaction and improved outcomes for mental health
patients (Dziopa & Ahern, 2009; Priebe & Mccabe, 2008; Stickley & Freshwater, 2006; Street,
Makoul, Arora, & Epstein, 2009). Therapeutic communication is 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). 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). However, there is no evidence indicating that
mental health facilities routinely provide training on therapeutic communication to their nurses.
Without adequate training on therapeutic communication, psychiatric nurses may not have the
knowledge to implement these skills in their interactions with patients. This may lead to poorer
outcomes and reduced patient satisfaction among psychiatric patients. If mental health facilities
were to regularly provide their nurses with training on therapeutic communication skills, nurses
would be better able to utilize these skills more effectively in interactions with their patients.
Purpose of project
The purpose of this program evaluation was to create and implement an online training
program on therapeutic communication skills for mental health nurses. The goals of the project
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were to increase overall knowledge on therapeutic communication skills among mental health
nurses, as well as the frequency and effectiveness with which nurses implement these skills in
their interactions with mental health patients.
Search strategy
The literature search was conducted using CINAHL, PsychInfo, and Medline databases.
Results were limited to full-text available articles written in English, and duplicate articles were
eliminated. Results were limited to articles published after the year 2000; however, any relevant
seminal publications published prior to that date were considered for inclusion. Keyword
combinations included the following: nursing AND therapeutic communication AND
orientation; psychiatric nursing AND therapeutic communication AND training; mental health
AND nursing AND therapeutic communication; therapeutic communication AND patient
outcomes; ADDIE (analysis, design, development, implementation, evaluation) AND nursing;
online training AND nursing; ADDIE AND online training AND nursing; and theory AND
therapeutic communication. In total, 16 articles were identified as being relevant to this project.
One article discussed the theoretical basis of therapeutic communication in nursing, three articles
associated patient outcomes with therapeutic communication, four articles discussed previously
implemented training programs for therapeutic communication in the healthcare setting, six
articles discussed using the ADDIE model of instructional design in the healthcare setting, and
two articles discussed using the ADDIE model of instructional design to implement training
programs specifically for therapeutic communication.
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CHAPTER 2: REVIEW OF LITERATURE
Four aspects of the literature were reviewed: the theoretical basis for the use of
therapeutic communication in mental health nursing, the impact of therapeutic communication
on patient outcomes in the mental health nursing, evaluation of the effectiveness of therapeutic
communication training programs that have been implemented in the past, and identification of
appropriate resources to guide the development of a therapeutic communication curriculum.
Therapeutic communication in mental health nursing
The American Nurses Association (2014) identifies therapeutic communication as one of
the standards of psychiatric-mental health nursing practice, and states that mental health nurses
should continuously assess and seek to improve upon their therapeutic communication skills
(American Nurses Association, 2014). Hildegard Peplau’s (1997) seminal Theory of
Interpersonal Relations provides the theoretical basis for this standard of therapeutic
communication in mental health nursing, and supports the need to improve education on
therapeutic communication skills among mental health nurses. Peplau’s theory consists of three
foci: the nurse, the patient, and the relations between them. Peplau states that nurses must
constantly be aware of the intentions and messages they are communicating to patients, both
verbally and non-verbally, in order to evaluate the therapeutic usefulness of their messages in
client interactions. Peplau states that this is especially important in psychiatric nursing, because
these patients are particularly sensitive to others’ perceptions and reactions. According to
Peplau’s theory, therapeutic communication is essential in developing the nurse-patient
relationship, and in achieving positive patient outcomes (Peplau, 1997).
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Studies building on Peplau’s theory have correlated good therapeutic communication
skills with improved patient outcomes. Evidence supports that a positive therapeutic relationship
is associated with improved outcomes across a range of psychiatric diagnoses and treatment
settings (Priebe & Mccabe, 2008). Therapeutic communication has been associated with
decreased anxiety, enhanced coping ability, and improved adherence to treatment (Stickley &
Freshwater, 2006). It has also been associated with increased patient satisfaction, motivation, and
clinician-patient agreement, as well as improved self-care skills and emotional management
among patients (Street, Makoul, Arora, & Epstein, 2009).
Training programs for therapeutic communication
Six studies specifically aimed to implement a training program for therapeutic
communication in the healthcare setting. Types of training programs included both in-person
(Ancel, 2006; Bowles, Mackintosh, and Torn, 2001) and online trainings (Robinson, Hills, and
Kelly, 2011; William, Abd-Hamid, and Perkhounkova, 2017; Hsu, Lee-Hsieh, Turton, and
Cheng, 2014). In addition, one study implemented both in-person and online training programs,
in order to compare efficacy (Chang, Sheen, Chang, and Lee, 2008). These programs all focused
on providing training for nurses; however, one program also included other clinicians, such as
psychologists, social workers, and occupational therapists (Robinson, Hills, and Kelly, 2011).
The majority of programs were implemented internationally (Australia, Turkey, United
Kingdom, and Taiwan) (Hsu, Lee-Hsieh, Turton, and Cheng, 2014; Chang, Sheen, Chang, and
Lee, 2008; Robinson, Hills, and Kelly, 2011; Bowles, Mackintosh, and Torn, 2001; Ancel,
2006), and only one was implemented in the United States (William, Abd-Hamid, and
Perkhounkova, 2017).
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Two studies utilized in-person programs to provide therapeutic communication training.
The first of these programs was an in-service therapeutic communication training for nurses,
implemented with the goal of improving empathic skills (Ancel, 2006). This in-service was
performed for 263 nurses working on inpatient units at Hacettepe University Hospital in Turkey.
The training was performed over a five-day in-service, and the training was provided 13 times
(over 13 weeks) in order to ensure all of the nurses could complete the training. Training utilized
learner-centered methods of instruction and role playing to teach communication skills.
Empathic skills were measured pre- and post- training by the Scale of Empathic Communication
Skill B (ECS-B). The study found a statistically significant increase in ECS-B scores (p<0.05)
after the communication training (from 155.6 prior to training to 180.5 after training). Increases
in ECS-B scores were similar across nurses’ age, education level, work experience, and unit
(Ancel, 2006).
Another in-person therapeutic communication training program implemented training in
solution-focused brief therapy (SFBT), with the goal of improving communication skills among
nurses (Bowles, Mackintosh, and Torn, 2001). This program was implemented over four days to
16 registered nurses recruited from a variety of inpatient and community-based healthcare
settings in England. Communication skills were measured quantitatively using a pre- and post-
training 10- point Likert scale, which allowed participants to rank their communication skills in
various areas, and also qualitatively through a post-training focus group. The study found a
statistically significant increase in the quantitative measure of willingness to talk to troubled
patients from pre- to post-training (p<0.05). There were also increases in measures of
competency and confidence related to communication skills, although these increases were not
statistically significant. Furthermore, although only 10 nurses attended the focus group, the
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nurses that did attend reported consistently incorporating SFBT principles into their interactions
with patients (Bowles, Mackintosh, and Torn, 2001).
Three different studies utilized online training programs to provide therapeutic
communication training. Robinson, Hills, and Kelly (2011) developed and evaluated an online
education program for mental health clinicians working in a rural setting. This program included
training for therapeutic communication skills, as well as de-escalation techniques and assessment
skills. The program was delivered in an online format, and required four hours per week over 24
weeks. Information was presented through a number of online modules containing various
clinical scenarios, self-assessments, and group discussion forums. The program was completed
by 28 clinicians (nurses, psychologists, social workers, and occupational therapists) working in
rural mental health services in New South Wales, Australia. Outcomes were measured through
pre- versus post-training self-report questionnaires, using a seven-point Likert scale. Clinicians
were asked to rate their understanding of and confidence in their ability to perform particular
concepts or activities taught in the program. The program resulted in statistically significant
improvements (p<0.05) in the following domains: confidence in responding to common mental
health problems, knowledge about the role of different services, perceived safety of work, and
perceived self-efficacy in dealing with challenging behaviors.
William, Abd-Hamid, and Perkhounkova (2017) implemented an online communication
training program for nursing home staff, with the goal of improving therapeutic communication
skills. The online training program consisted of three one-hour sessions utilizing video
recordings to demonstrate effective and ineffective communication techniques. A sample of two
registered nurses, four certified nursing assistants, and three nursing students with current or past
experience working in a nursing home were recruited to complete the training program.
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Improvements in therapeutic communication skills were measured through two pre- versus post-
training evaluations. The first was a 13-item scenario-based assessment intended to test
participants’ applied knowledge about appropriate communication, and the second was a five-
point communication rating scale in which participants rated the effectiveness of staff-patient
communications demonstrated through a series of videos. Overall, the percentage of correct
responses on the scenario-based assessments increased 8.8% from pre- to post-training, and there
were statistically significant improvements in participants’ ability to accurately rate
communication appropriateness (p=0.005) and effectiveness (p=0.02) in the video examples.
Although this study utilized a small sample size (n=9), it demonstrated the effective use of an
online program to improve the ability to identify effective communication skills.
Hsu, Lee-Hsieh, Turton, and Cheng (2014) developed and implemented an online
training program on caring behaviors in inpatient nursing practice, with the goal of increasing the
frequency of caring behaviors. This program was implemented among 14 nurses working on an
inpatient obstetrics unit in a hospital in Taiwan. Training was provided online and consisted of
72 animated videos and five live-action videos based on actual patient and nurse experiences in
the hospital. Effectiveness of the training was measured through reflection quizzes taken at the
end of each online unit, as well as post-training focus group interviews. Analysis of the reflection
quizzes showed that all participants reported that they would perform better than the nurses in
the scenarios after completing the training, and nurses in the focus group reported making
changes in their behaviors and interactions with patients after training to improve upon their
caring behaviors. A Caring Behavior Measurement (CBM) scale was also used for nurses to self-
evaluate caring behaviors post-training, and the mean score was 3.58; however, since the CBM
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was not administered pre-training, the study could not show improvement in this score related to
the training.
Finally, Chang, Sheen, Chang, and Lee (2008) utilized both in-person and online training
programs to improve various nursing skills, including therapeutic communication skills, among
hospital nurses at a medical center in Taiwan. For this study, a traditional in-class program
(TICP), composed of five in-person classes each covering a different skill, was compared to an
e-learning program (ELP), consisting of five 30-minute online courses covering the same skills
as the TICP. Forty-two staff nurses in the hospital were randomly assigned to either the e-
learning intervention group (ELP) or the traditional-learning control group (TICP). Participants’
knowledge was measured in each training group through five 10-question multiple choice tests
administered at the end of each course based on the skills taught in that respective course, and
through video recordings of each participant performing a randomly selected nursing care skill.
Nurses in both training programs obtained passing knowledge scores (>70%), indicating that the
e-learning program and the traditional in-class program were both successful in improving
participants’ knowledge of nursing skills, including therapeutic communication skills. However,
although all participants achieved passing scores on communication skills in both programs, the
study did find a statistically significant difference in average scores between the e-learning
program and traditional in-class program (ELP=75.91%, TICP=89%, p=0.001).
Resources to guide the development of a therapeutic communication curriculum
A literature search was conducted to identify appropriate educational resources to guide
the development of a therapeutic communication training program. The two selected educational
resources were the core teaching strategies for therapeutic communication recommended by the
American Psychiatric Nurses Association (2018), and the communication strategies described in
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the book “The Art of Communication in Nursing and Healthcare: An Interdisciplinary
Approach” by Theresa Raphael-Grimm, PhD, CNS (2015).
The American Psychiatric Nurses Association (2018) recommends including the
following core components in a therapeutic communication training program: defining
therapeutic communication and the elements that characterize it, reviewing helpful and non-
helpful verbal communication techniques, and reviewing non-verbal communication techniques
and the use of space in the therapeutic encounter. Recommended program outcomes and teaching
strategies are outlined in Appendix A.
The second educational resource, "The Art of Communication in Nursing and
Healthcare" (Raphael-Grimm, 2015) guides clinicians in utilizing the principles of mindfulness
to develop effective therapeutic communication skills, which can be used even in difficult
situations and with challenging populations. The author, Dr. Raphael-Grimm, is an advanced
practice clinician in mental health, and has taught therapeutic communication skills to clinicians
for over 30 years. The specific contents of "The Art of Communication in Nursing and
Healthcare" (Raphael-Grimm, 2015) are outlined in Appendix B.
Summary
The reviewed literature provides evidence that effective therapeutic communication
improves outcomes for mental health patients, and supports training mental health nurses on
therapeutic communication skills. Previously implemented therapeutic communication training
programs found through the literature search were successful in improving knowledge of
therapeutic communication skills among nurses. However, few studies examined nurses'
effectiveness from the patient's perspective, making it difficult to determine whether the training
programs improved effective skill application rather than knowledge alone. Finally, the
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American Psychiatric Nurses Association's core therapeutic communication strategies (2018) and
“The Art of Communication in Nursing and Healthcare: An Interdisciplinary Approach” by Dr.
Theresa Raphael-Grimm (2015) were identified as appropriate educational resources to guide the
development of the training curriculum.
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CHAPTER 3: CONCEPTUAL FRAMEWORK: THE ADDIE MODEL
The ADDIE instructional design model was identified as an appropriate model to guide
the design, development, implementation, and evaluation of training programs in nursing. The
ADDIE model is a commonly used instructional design model for the development and
evaluation of educational and/or training interventions within organizations. The ADDIE model
was developed from instructional systems design, which was a post-World War II effort by the
United States armed forces to design and implement more effective training programs (Allen,
2006). Originally developed from behavioral learning theory principles, the ADDIE model has
been revised several times since its’ conception to better meet current instructional demands, and
to reflect the influences of technology in instructional design. The model’s current form draws
from concepts in both behavioral learning theory and cognitive learning theory, and also
incorporates system engineering, instructional technology, and quality improvement (Allen,
2006). The ADDIE model (analyze, design, develop, implement, evaluate) fits particularly well
as an instructional design model within the nursing profession because of how closely it aligns
with the nursing process (assess, diagnose, plan, implement, evaluate) (Yoder & Terhorst, 2012).
ADDIE is an acronym for the five phases in the model: analysis, design, development,
implementation, and evaluation. Analysis involves collecting information and assessing the
current issues and educational needs within an organization, as well as current knowledge and
skills among targeted learners. Analysis allows for identification of what education is actually
necessary. In the design phase, the program developer creates a plan of instruction and
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determines instructional objectives and methods. Design also involves determining what
instructional tools and media will be necessary to implement the instructional program. The
instructional materials to be used in the program are created during the development phase. Once
the instructional program is operational, it is then implemented among the targeted learners.
Evaluation occurs throughout the ADDIE process and includes assessment of whether learners
are meeting instructional objectives within the program, and learner evaluation of the
instructional methods and processes within the program (Allen, 2006).
The ADDIE model has been frequently utilized in the healthcare setting in staff training
and development, and has been shown to be effective in nursing continuing education initiatives.
Numerous studies have found that evidence-based training programs, developed for nurses using
the ADDIE model, consistently improve nursing knowledge and increase targeted desired
behaviors (Williams et. al, 2017; De Gagne et. al, 2015; Hsu et. al, 2014; Adams et. al, 2012;
Chang et. al, 2008). The ADDIE model has also been successfully implemented in the
development of web-based e-learning programs for both nurses and other health professionals
(Chang et. al, 2008; Weerasekera, 2013; Hsu et. al, 2014; De Gagne et. al, 2015; Williams et. al,
2017), and such programs have been determined to be equally effective as traditional in-person
training programs (Chang et. al, 2008).
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CHAPTER 4: PROJECT DESIGN
This project was a formative program evaluation of an online therapeutic communication
training program for mental health nurses. The intended program outcome was increased
frequency of application of effective therapeutic communication skills in the nurses' interactions
with patients. This outcome was measured quantitatively through a pretest-posttest patient-
completed survey, which allowed patients to rate their interactions with nursing staff across
several domains of therapeutic communication. Additional outcome data was collected through
nurse self-ratings on the same survey, administered in a retrospective pretest-posttest design.
This data was analyzed to determine if changes in the nurses' perceptions of their skills were
consistent with patient ratings of the nurses' skills.
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CHAPTER 5: METHODS
The therapeutic communication training program was presented in an online format,
consisting of three modules. The modules were intended to each take approximately 30 minutes
to complete, and were comprised of both didactic content and video demonstrations of effective
and ineffective therapeutic skills.
Setting and participants
The therapeutic communication training program was implemented among the
psychiatric nurses at a residential eating disorder treatment facility. The facility consists of two
separate houses, one of which has 16 beds for women patients, and the other of which has six
beds for both men and women patients. The facility offers individual, group, family, and
experiential therapies based upon the psychotherapeutic model of Dialectal Behavior Therapy.
At the time of this project, there were seven full-time nurses and one part-time nurse
working at the facility. This nursing staff included both RNs and LPNs who worked shifts at
both houses within the facility. There were also eight PRN nurses on the staff during this time,
who worked only occasional shifts within the facility. This setting was identified as an
appropriate site for this project because, similar to many psychiatric treatment facilities, it did not
have an existing therapeutic communication training program for its nurses. In addition, many of
the staff nurses came from varied nursing specialties, and had no training on therapeutic
communication skills specifically for mental health patients.
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Training development
The therapeutic communication training program was developed based upon the
American Psychiatric Nurses Association's (2018) core therapeutic communication strategies
and “The Art of Communication in Nursing and Healthcare: An Interdisciplinary Approach” by
Dr. Theresa Raphael-Grimm (2015), which were identified in the literature search as appropriate
educational resources for curriculum development in this project. “The Art of Communication in
Nursing and Healthcare” (Raphael-Grimm, 2015) was identified as a particularly appropriate
resource in the development of the training curriculum for this particular project because the
principles of mindfulness that the book is based upon are also a major component of Dialectal
Behavior Therapy, the psychotherapeutic model used at the project site. An outline of the
training curriculum is provided in Appendix D.
Recruitment
Nursing staff (RNs and LPNs) were recruited to complete the training program on a
voluntary basis. Recruitment took place through emails sent to all nursing staff (Appendix A).
The Director of Nursing at the facility was a major stakeholder in the project, and facilitated staff
completion of the training program by making note of training completion in annual staff
reviews, which are used in consideration for annual performance-based pay raises.
Patients were recruited to complete a survey to rate the nurses' therapeutic
communication skills before and after the training program. The project was explained to the
patients during their weekly community meeting time. This time is typically used to make
facility announcements and for patients to voice any requests and/or concerns to staff. Time
during this meeting was used to explain the project to the patients and to have the patients
complete the survey (Appendix B and C).
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Resources and budget
There was minimal to no cost associated with designing and developing the training
program, as the program was designed based upon existing educational resources, and it was not
necessary to hire any additional personnel to assist in the design and development. The only cost
involved in implementing the training was the fee to use the cloud-based presentation sharing
service chosen to make the training accessible to the nursing staff. The assessments used in data
collection for this project were available free-of-cost online; therefore, there was not any cost
associated with data collection and analysis.
Implementation barriers and solutions
The primary barrier to project implementation was expected to be achieving nurse buy-in
and recruiting nurses to actually complete the training program. Nurses were recruited to
complete the training program on a voluntary basis; therefore, the concern was that they may
have had little motivation to spend their time completing a non-mandatory training, or to make
considerable effort to incorporate the skills into their day-to-day practice. Several measures were
taken to facilitate nurse completion of the training program. First, key stakeholders within the
organization were utilized prior to implementation to show support for the project. Key
stakeholders included members of the leadership team within the facility, particularly the
Director of Nursing. The Director of Nursing was utilized leading up to implementation, as well
as throughout actual implementation of the program, to show support for the project and
encourage staff nurses to complete the training. Prior to implementation, the Director of Nursing
agreed to take staff completion of training into consideration in annual staff reviews, which are
used to determine eligibility for pay raises. This was intended to motivate nurses' completion of
the training. In addition, the nurses were provided clear information on the purpose of the
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project, and the training was explained in terms of how it would directly improve their
interactions with patients and could lead to better patient outcomes.
Ethics and human subjects permissions
Approval of this project was obtained from the Institutional Review Board at the
University of North Carolina at Chapel Hill on August 22, 2018.
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CHAPTER 6: INTERVENTION
The training modules were uploaded to a cloud-based presentation sharing website and
made available to the nursing staff on October 1, 2018. An online format was chosen for this
training program as the evidence supports training programs for nurses presented in an e-learning
format have been successful in improving targeted behaviors (Chang et. al, 2008; Weerasekera,
2013; Hsu et. al, 2014; De Gagne et. al, 2015; Williams et. al, 2017), and online programs can be
equally effective as in-person training (Chang et. al, 2008). The online format also allowed
participants to complete the training on their own time from any location, which was expected to
facilitate higher completion rates.
The three training modules were released consecutively, one at a time. The nurses
received an email, sent to their work and personal email addresses, to notify them each time a
module was made available (Appendix E). The participating nurses had approximately 10 days
to complete the first module before the second was released, and then another 10 days to
complete the second before the third was released. The nurses had access to this training both at
the facility and remotely from any internet browser, and were asked to complete all of three of
the training modules by November 10, 2018. Emails were sent every three to four days during
the training period as a reminder to the nurses to complete the training modules. An additional
email was sent to nursing staff by the Director of Nursing at the facility to encourage completion
of the training and to inform the nursing staff that she would make note of training completion,
and completion would reflect positively in annual staff reviews.
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At the end of the training period, six out of the eight full and part-time nurses
successfully completed all three of the training modules. None of the PRN nursing staff
completed the training, which was not surprising as many of these staff members work shifts at
the facility infrequently and were not interacting regularly with the patients at the facility during
this time.
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CHAPTER 7: DATA COLLECTION AND OUTCOMES
Data collection
Effectiveness of the therapeutic communication training program in changing nursing
practice was evaluated using the consultation and relational empathy (CARE) measure, a
validated empathy assessment tool (Mercer, Maxwell, Heaney, & Watt, 2004). The CARE
measure is a 10-question survey that allows patients to rate their experience with providers in ten
domains of the therapeutic relationship: 1) making you feel at ease, 2) allowing you to tell your
story, 3) really listening, 4) being interested in you as a whole person, 5) fully understanding
your concerns, 6) showing care and compassion, 7) being positive, 8) explaining things clearly,
9) helping you take control, and 10) making a plan of action with you. Patient responses are
scored on a 5-point Likert scale, from 1 being poor to 5 being excellent. The CARE measure has
established face and content validity, and a high internal reliability (Cronbach’s alpha = 0.93). It
also has high correlation with other established validated empathy measures, the Reynolds
Empathy Measure (REM) (r=0.85) and the Barrett-Lennard Empathy Subscale (BLESS) (r=0.84)
(Mercer, Maxwell, Heaney, & Watt, 2004).
The CARE measure (Appendix F) was administered among the patients at the project site
in a pretest-posttest design. Patients were asked to complete the CARE measure based upon their
recent interactions with the nurses at the facility. The CARE measure was presented to the
patients during their weekly community meeting at the facility. The patients completed the
CARE measure anonymously once prior to the nurses’ therapeutic communication training, and
again one month after the nurses’ training, to assess if average CARE measure scores improved
21
after the therapeutic communication training. A patient consent form for data collection
(Appendix G) was presented attached to the front of the survey. The consent was presented each
time the patients were asked to take the survey, in order to ensure consent was acquired from
patients that were admitted after the initial survey data was collected. A total of 11 patients
completed the CARE measure survey prior to the nurses' training, and 19 patients completed the
survey after the training period. This reflected a 100% completion rate among the patients
present during each survey. Due to the length of the training period, none of the same patients
that completed the initial survey were still present at the time the post-training survey was
administered. Results from the pre- and post-training patient-completed CARE measures can be
found in Table 1.
The CARE measure was also adapted for the participating nurses to be completed after
the therapeutic communication training in a retrospective pretest-posttest design (Appendix H).
The nurses were asked to rate their own skills across the ten domains of the therapeutic
relationship identified in the CARE measure. One month after the end of the training period, the
participating nurses were asked to retrospectively rate their skills prior to the training program,
and then to also rate their skills after having completed the training program. The CARE measure
survey for the nurses was uploaded onto an online survey hosting website, and a link was
emailed to the nurses to access and complete the survey anonymously. A consent form for data
collection was presented prior to the survey questions (Appendix I). Of the six nurses that
completed the training program, five of them also completed the CARE measure survey. Data
from the completed nurse surveys is presented in Table 2. The nurses’ self-rating scores were
compared to the patient CARE measure ratings collected prior to and after the training, in order
to see if the nurses’ perceptions of their skills correlate with patient perceptions.
22
Patient surveys were anonymous and contained no identifiable data about the patients.
All patient consents and surveys were kept in a locked file cabinet, in a locked office, and were
shredded upon completion of data analysis. Nurse surveys were anonymous, but did collect
demographic data of age, years of nursing experience, and level of education (Appendix L). All
study data collected from the patient and nurse surveys were kept on the principal investigator’s
password-protected computer.
Data analysis and outcomes
CARE measure scores were analyzed to identify increases in the perceived effective
application of therapeutic communication skills by the nursing staff after completion of the
training program. The primary measure of improvement in therapeutic communication skills was
an increase in mean patient-reported CARE measure scores after the training program. Mean
patient-reported CARE measure scores were calculated for each of the ten domains of the
therapeutic relationship on the pre- and post-training surveys (Appendix J). Mean scores on
every CARE measure question increased after the training period (Figure 1). Prior to the nurses'
training, the patients rated the nursing staff fair to good across the ten therapeutic domains. After
the nurses' training, the patients rated the nursing staff good to very good across the ten
therapeutic domains. An unpaired t-test was performed for each of the ten CARE measure
questions to determine if the increases in mean scores after training completion were statistically
significant. Analysis showed that the increase in mean scores on 8 out of 10 of the CARE
measure questions were statistically significant at p<0.05 (Appendix J). Overall mean scores
across the ten questions on the CARE measure were also calculated for the pre-training survey
and the post-training survey. The mean score on the patient-completed CARE measure survey
prior to the training period was 2.724 (indicative of a 'fair' rating for the nursing staff) and the
23
mean score after the training period was 3.738 (indicative of a 'good' rating for the nursing staff).
This increase in mean score after training was also evaluated using an unpaired t-test analysis,
and was determined to be statistically significant (t = -5.225, p = 0.000).
Figure 1: Patient CARE Measure Survey Results
Five out of the six nurses that completed the training program also completed the nurse
self-rating CARE measure survey. Out of these five nurses, one was an LPN, three were RNs,
and one preferred not to say. These nurses were aged between 30 and 69 years old with nursing
experience ranging from 16 years to over 25 years. Although all of these nurses had 16+ years of
nursing experience, half of them had 10 or less years of experience in mental healthcare, with
two nurses having less than five years of experience in mental health (Appendix J). Analysis was
performed for the mean nurse self-rating CARE measure scores to determine if changes seen in
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Question 10
Question 9
Question 8
Question 7
Question 6
Question 5
Question 4
Question 3
Question 2
Question 1
Pre-training Post-training
24
the nurses' perceptions of their competence in applying therapeutic skills after completing the
training program were clinically significant (Appendix K). The mean score on the nurse self-
rating CARE measure surveys increased from 3.96 (good) on the pre-training survey to 4.12
(very good) on the post-training survey, indicating the program led to clinically significant
improvements in the nurse self-rating CARE measure scores (Figure 2).
Figure 2: Nurse CARE Measure Survey Results
Finally, mean CARE measure scores after versus before training completion were
compared between the patient completed surveys and the nurse self-rating surveys. Overall, the
nurses rated themselves higher across all CARE measure survey questions both before and after
the training (Figure 3). An unpaired t-test was performed to determine if there was a significant
difference between the nurses' self-rating scores and the patients' scoring of the nursing staff. A
statistically significant difference was found between the patients' scoring and the nurses' scoring
3.85 3.9 3.95 4 4.05 4.1 4.15
Post-training
Pre-training
25
on both the pre-training (t = -5.923, p = 0.000) and post-training (t = -2.990, p = 0.008) surveys
(Appendix M).
Figure 3: Patient versus Nurse CARE Measure Survey Results
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Post-training
Pre-training
Patients Nurses
26
CHAPTER 8: DISCUSSION
Implications for practice
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
27
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.
28
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
29
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
30
periodically over time.
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.
32
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.
34
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.
35
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)
36
• 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
o It is important to practice mindfulness in our therapeutic interactions with patients.
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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
• This is where emotional thinking dominates.
38
• 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.
o The Mindfulness Process through the Patient Interaction
39
§ 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:
• What emotions am I experiencing in this situation?
o Ex. anger, anxiety, disgust, resentment
• How intense are these emotions?
• What thoughts am I experiencing related to these emotions?
o Ex. “Stop asking so many questions, I’ve got work to do.”
o Ex. “I’m so annoyed with how often this patient gets upset and needs support. I
don’t want to deal with them anymore.”
§ Assess your physical sensations, or Body Mind:
• Are you tired, hungry, or in pain?
• Is your pulse elevated?
• Is your stomach in knots?
• Is your jaw tense?
• Does your head feel full?
• What is your facial expression?
• How might these physical sensations influence how you interact with the patient?
§ Assess your capacity to reason (Reason Mind):
• Can you think clearly and objectively in this moment?
• What do you need to consider to shift your focus back to the patient?
• What facts can you draw from that would make sense of the situation with the
patient?
40
• What information do you have about the patient that could help make sense of the
situation?
• What is the patient likely thinking and feeling right now?
• What questions do you need to ask the patient that would help you better understand
the situation?
§ Enter a place of wisdom (Wise Mind):
• How could your current emotions interfere with caring for this patient?
• How much of your reactivity is coming from your own biases or assumptions?
• How can you challenge your biases or assumptions?
• What do you need to do to self-regulate and meet your own needs (ex. deep
breathing, eating, slowing down and doing one thing at a time)
• Given your current state of mine (emotionally, physically, and logically), what
makes sense for you to do first in this situation?
• If you were in the patient’s situation, what might you need from your nurse? How
can you best provide that for them?
• Videos demonstrations of mindfulness:
o Scenario 1 – A nurse is overwhelmed with physician orders and charting and a
patient comes to the nurse complaining that she doesn’t want to go to group, none of
the other patients like her, and she doesn’t think anything is going to help her. The
nurse is visibly annoyed with the patient and is short and dismissive, telling the
patient she has to go to group and sending her away.
o Scenario 2 – In the same scenario, the nurse takes a moment to practice
mindfulness. The video shows the nurse having an internal dialogue with herself.
41
She recognizes that she is feeling stressed with the amount of work she has to do.
She also recognizes she is tired and hungry, since she hasn’t had time to eat lunch
yet. She realizes these things have nothing to do with the patient, but could make her
more irritable and less empathetic with the patient. She thinks about what she knows
about the patient and recognizes that the patient has only been in treatment two days
and could be struggling to adapt to the environment. She also remembers that the
night shift nurse told her the patient was struggling to sleep in a new place, and was
up a lot throughout the night. The nurse recognizes that people often get irritable and
more emotional when they don’t get enough sleep, and also recognizes that the first
few days in treatment can be scary and difficult, and the patient may need more
emotional support during this time. The nurse decides to take a break from working
to listen to the patient for a few minutes.
Module 3 – Non-verbal and Verbal Communication Skills in the Therapeutic Interaction
• Listening
§ “Listening isn’t just an absence of talk, where we merely stand by silently until the
patient finishes speaking so that we can jump in and tend to the next question on our
checklist. It means fully, deeply, and attentively attending to patients’ efforts to
deliver their thoughts and ideas. We are listening not for information alone, but for
understanding. We are attempting to get a sense of what it is like for this patient to
experience his or her illness within the context of this patient’s life circumstances.
To attentively listen requires that we be fully present in the here and now, focused on
the patient and only the patient, and able to put other concerns aside, at least for a
moment.” (Raphael-Grimm, 2015)
42
§ In order to actively listen, we need to temporarily turn off and tune out all
distractions. Be mindful of anything that may distract you from listening to the
patient.
§ In order for a patient to feel as if they are being heard, they have to be deeply, fully,
and thoughtfully listened to. Fully listening to a patient makes them feel valued and
respected, and they are more likely to be open and honest with you.
• Non-verbal Communication
§ It is important to be mindful of how you are communicating non-verbally to patients
during your interactions. Your body language can communicate to a patient that you
are fully attentive, interested in them, and value what they have to say. Conversely, it
can also communicate that you are distracted or uninterested, regardless of what you
are saying to them verbally.
• SOLER (APNA, 2018):
§ Sit squarely facing the client (unless ethnic/cultural background of client
discourages direct eye contact).
§ Observe an open posture.
§ Lean forward toward the client.
§ Establish eye contact (unless ethnic/cultural background of client discourages
direct eye contact).
§ Relax
• Video demonstrations:
§ Scenario 1 – A nurse is performing an admission assessment with a patient at
the nursing station. The nurse is asking the patient questions and responding
43
to what the patient is saying but she is turned towards the computer and not
looking at the patient. The patient looks uncomfortable and anxious, and is
guarded in talking to the nurse.
§ Scenario 2 – Patient is talking to the nurse and she is facing the client, with an
open, relaxed posture and good eye contact. The nurse is turned away from
the computer monitor. The patient appears comfortable and relaxed, and
answers the nurses questions open and honestly.
• Verbal Communication
44
45
46
47
(Raphael-Grimm, 2015) Video Demonstrations:
• Scenario 1 – An eating disorder patient is talking to the nurse about her anxiety
related to food and meals, and the nurse responds in nontherapeutic ways described
previously in the module. The patient gets visibly more upset and frustrated in
response to the nurse, and storms away, stating “You just don’t understand what I’m
going through. No one understands.”
• Scenario 2 – An eating disorder patient is talking to the nurse about her anxiety
related to food and meals, and the nurse responds using therapeutic communication
techniques described previously in the module. The patient is able to calm down and
thanks the nurse for listening to her and understanding what she is struggling with.
48
APPENDIX E: EMAIL NOTIFICATION FOR MODULE RELEASE
You are receiving this notification because Module ___(insert module number)___ of
Essential Therapeutic Communication Training for Mental Health Nurses has been released for
your completion. Please complete this module within the next 10 days, prior to the next module
being released.
Please access the training module using the following link: [Insert link to access module]
49
APPENDIX F: THE CARE MEASURE FOR PATIENT COMPLETION
Please think about your recent interactions with the nursing staff. Please tick one box for each statement and answer every statement.
How were the nurses at ... Poor Fair Good Very Excellent Does Good Not Apply 1. Making you feel at ease... (being friendly and warm towards you, treating you with respect; not cold or abrupt)
2. Letting you tell your “story”... (giving you time to fully describe your illness inyour own words; not interrupting or diverting you)
3. Really listening... (paying close attention to what you were sayings; not looking at the notes or computer as you were talking)
4. Being interested in you as a whole person... (asking/knowing relevant details about your life,your situation; not treating you as “just a number”)
5. Fully understanding your concerns... (communicating that he/she had accurately understood your concerns; not overlooking or dismissing anything)
6. Showing care and compassion... (seeming genuinely concerned, connecting with you on a human level; not being indifferent or “detached”)
7. Being Positive... (having a positive approach and a positive attitude;being honest but not negative about your problems)
50
8. Explaining things clearly... (fully answering your questions, explaining clearly, giving you adequate information; not being vague)
9. Helping you to take control... (exploring with you what you can do to improve your health yourself; encouraging rather than “lecturing” you)
10. Making a plan of action with you ... (discussing the options, involving you in decisions asmuch as you want to be involved; not ignoring your views)
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APPENDIX G: INFORMED CONSENT FOR PATIENTS
INFORMED CONSENT FOR ANONYMOUS SURVEY
You are invited to participate in a program evaluation titled “Essential Therapeutic Communication Training for Mental Health Nurses: A Program Evaluation.” This program evaluation is being conducted by Olivia Glance for her doctoral project within the School of Nursing at the University of North Carolina at Chapel Hill. The purpose of this program evaluation is to determine the effectiveness of a program providing therapeutic communication skills training to mental health nurses. Participation in this program evaluation is entirely voluntary at all times. You can choose not to participate at any time. If you decide not to participate there will be no penalty or loss of benefits to which you are entitled, or any effect on your relationship with the investigator, or any other negative consequences. You are being asked to take part in this program evaluation because you are a patient at Carolina House and we would like to see how you would rate the helpfulness of the nursing staff in various aspects of your treatment. If you agree to participate, you will be asked to fill out the following survey rating various aspects of your recent interactions with nursing staff. The survey is 10-questions, and will ask you to rate your recent interactions with the nursing staff across ten categories: 1) making you feel at ease, 2) allowing you to tell your story, 3) really listening, 4) being interested in you as a whole person, 5) fully understanding your concerns, 6) showing care and compassion, 7) being positive, 8) explaining things clearly, 9) helping you take control, and 10) making a plan of action with you. The survey will take approximately 5 minutes to complete. The survey will be completed and returned today during this meeting. All of your responses to this survey will remain anonymous and cannot be linked to you in any way. No identifying information about you will be collected at any point. You are free to withdraw from this program evaluation at any time. However, once you submit your completed
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survey, there will be no way to withdraw your responses because the survey contains no identifying information. Completed surveys will be kept in paper format in a locked file cabinet in the principal investigator’s office. Data collected from completed surveys will be kept on the principal investigator’s laptop. Access to survey data will be password protected, and only the principal investigator and her project committee will have access to this data. There are no risks associated with completing this survey. Your responses are anonymous and the nursing staff at the facility will not have access to any of the completed surveys at any point. Your survey responses cannot negatively impact the quality of your care in any way. While you will not experience any direct benefits from participation, information collected in this program evaluation may benefit you or others in the future by helping us to improve the quality of nursing care provided in the facility. If you have any questions regarding the survey or this program evaluation in general, please contact the principal investigator, Olivia Glance, at 919-441-6663 or [email protected]. If you have any questions about your rights as a participant, please contact the IRB and Office of Human Research Ethics at the University of North Carolina At Chapel Hill at (919) 966-3113 or [email protected]. By completing and submitting this survey, you are indicating your consent to participate in this program evaluation.
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APPENDIX H: THE CARE MEASURE ADAPTED FOR NURSE COMPLETION
Please complete the following demographic information: Age: 18-29 30-39 40-49 50-59 60-69 70-79 80+ Years of nursing experience: < 5 5-10 11-15 16-20 21-25 > 25 Years of experience specifically in psychiatric nursing: < 5 5-10 11-15 16-20 21-25 > 25 Level of education: LPN RN – Associate’s Degree RN – Bachelor’s Degree MSN
Please think about your patient interactions BEFORE completing the training program.
Please tick one box for each statement and answer every statement.
How would you rate yourself BEFORE completing the training ... Poor Fair Good Very Excellent Does Good Not Apply 1. Making patients feel at ease... (being friendly and warm towards patients, treating them with respect; not cold or abrupt)
2. Letting patients tell their “story”... (giving them time to fully describe their illness intheir own words; not interrupting or diverting)
3. Really listening... (paying close attention to what patients were saying; not looking at the notes or computer as they were talking)
4. Being interested in the patient as a whole person... (asking/knowing relevant details about their life,their situation; not treating them as “just a number”)
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5. Fully understanding patient concerns... (communicating that you had accurately understoodtheir concerns; not overlooking or dismissing anything)
6. Showing care and compassion... (seeming genuinely concerned, connecting with patients on a human level; not being indifferent or “detached”)
7. Being Positive... (having a positive approach and a positive attitude;being honest but not negative about patients' problems)
8. Explaining things clearly... (fully answering patients' questions, explaining clearly, giving patients adequate information; not being vague)
9. Helping patients to take control... (exploring with patients what they can do to improve their health themselves; encouraging rather than “lecturing” patients)
10. Making a plan of action with patients ... (discussing the options, involving patients in decisions asmuch as they want to be involved; not ignoring patients' views)
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Please think about your recent patient interactions AFTER completing the training program.
Please tick one box for each statement and answer every statement.
How would you rate yourself AFTER completing the training... Poor Fair Good Very Excellent Does Good Not Apply 1. Making patients feel at ease... (being friendly and warm towards patients, treating them with respect; not cold or abrupt)
2. Letting patients tell their “story”... (giving them time to fully describe their illness intheir own words; not interrupting or diverting)
3. Really listening... (paying close attention to what patients were saying; not looking at the notes or computer as they were talking)
4. Being interested in the patient as a whole person... (asking/knowing relevant details about their life,their situation; not treating them as “just a number”)
5. Fully understanding patient concerns... (communicating that you had accurately understoodtheir concerns; not overlooking or dismissing anything)
6. Showing care and compassion... (seeming genuinely concerned, connecting with patients on a human level; not being indifferent or “detached”)
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7. Being Positive... (having a positive approach and a positive attitude;being honest but not negative about patients' problems)
8. Explaining things clearly... (fully answering patients' questions, explaining clearly, giving patients adequate information; not being vague)
9. Helping patients to take control... (exploring with patients what they can do to improve their health themselves; encouraging rather than “lecturing” patients)
10. Making a plan of action with patients ... (discussing the options, involving patients in decisions asmuch as they want to be involved; not ignoring patients' views)
57
APPENDIX I: INFORMED CONSENT FOR NURSES
INFORMED CONSENT FOR ANONYMOUS SURVEY
You are invited to participate in a program evaluation titled “Essential Therapeutic Communication Training for Mental Health Nurses: A Program Evaluation.” This program evaluation is being conducted by Olivia Glance for her doctoral project within the School of Nursing at the University of North Carolina at Chapel Hill. The purpose of this program evaluation is to determine the effectiveness of a program providing therapeutic communication skills training to mental health nurses. Participation in this program evaluation is entirely voluntary at all times. You can choose not to participate at any time. If you decide not to participate there will be no penalty or loss of benefits to which you are entitled, or any effect on your relationship with the investigator, or any other negative consequences. You are being asked to take part in this program evaluation because you are a nurse at Carolina House that completed the online therapeutic communication training. We would like to see how you would self-rate your therapeutic communication skills prior to completing the training versus after completing the training. If you agree to participate, you will be asked to fill out the following survey, which will ask you to self-rate your therapeutic communication skills before you completed the training, and to self-rate your skills now after you have completed the training. There are a total of 24-questions and the survey will take approximately 5-10 minutes to complete. All of your responses to this survey will remain anonymous and will not be linked to you in any way. The survey will not ask for your name; however, it will ask several demographic questions, including your age, years of experience, and level of education. You are not required to provide this information if you do not want to, and may leave the demographic section blank if you are not comfortable providing this information. You are free to withdraw from this program evaluation at any time. Data collected from completed surveys will be kept on the principal investigator’s laptop. Access
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to survey data will be password protected, and only the principal investigator and her project committee will have access to this data. There are no risks associated with completing this survey. Your responses are anonymous, and no one else at the facility will have access to any of your survey responses. Your responses will not negatively impact your job in any way. While you will not experience any direct benefits from participation, information collected in this program evaluation will be used to improve staff training methods, and to improve patient care. If you have any questions regarding the survey or this program evaluation in general, please contact the principal investigator, Olivia Glance, at 919-441-6663 or [email protected]. If you have any questions about your rights as a participant, please contact the IRB and Office of Human Research Ethics at the University of North Carolina At Chapel Hill at (919) 966-3113 or [email protected]. By completing and submitting this survey, you are indicating your consent to participate in this program evaluation.
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APPENDIX J: PATIENT SURVEY RESULTS AND ANALYSIS
Pre-training patient survey Question 1 2 3 4 5 6 7 8 9 10
4 2 2 2 3 3 3 4 1 2
4 3 3 4 4 5 4 5 3 3
3 2 3
2 3 3 3 1 1
3 2 3 2 3 4 3 3 1 2
2 2 1 1 2 1 2 1 2 1
3 1 1 1 1 3 3 2 2 1
5 3 3 2 3 4 4 3 3 4
1 1 1 1 2 2
2 3 2
1 1 1 1 1 1 2 1 1 1
5 4 4 3 4 5 5 4 3 3
5 5 5 5 5 5 5 5 5 5
Average score 3.273 2.364 2.456 2.2 2.727 3.273 3.4 3 2.273 2.273
Survey average 2.724
Post-training patient survey Question 1 2 3 4 5 6 7 8 9 10
4 5 4 4 4 4 5 3 3 2
3 3 2 3 3 3 3 3 2 2
5 4 4 5 4 5 5 4 2 3
5 4 5 5 4 3 3 4 1 2
3 3 2 3 1 2 3 1 3 3
4 3 5 5 4 4 5 5 5 5
4 3 4 2 4 4 4 3 3 2
4 2 4 5 4 5 5 4 4 3
5 5 5 5 4 5 5 4 5 3
4 4 3 3 3 3 3 2 2 2
2 3 3 5 3 4 4 3 2 3
5 5 3 4 4 3 4 5
4
5 5 5 5 5 5 5 4 5 5
5 4 5 5 3 4 5 3 3 4
2 4 5 4 3 4 3 4 4 3
4 5 4 4 3 4 3 3 2 2
4 3 3 3 3 4 4 4 2 2
5 5 5 5 5 5 5 5 5 5
4 3 2 4 4 5 5 2 5 3
Average score 4.053 3.842 3.842 4.158 3.579 4 4.158 3.474 3.222 3.053
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Survey average 3.738
T-test analysis
H0: µ1 ≥ µ2
HA: µ1 < µ2
Question 1 2 3 4 5 6 7 8 9 10 Mean T-value -
1.741 -3.591
-3.017
-4.458
-2.143
-1.689
-2.020
-1.037
-1.875
-1.741
-5.225
p-value 0.046 0.001 0.003 0.000 0.020 0.051 0.027 0.154 0.036
0.046 0.000
Statistically significant (p<0.05)
Yes Yes Yes Yes Yes No Yes No Yes Yes Yes
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APPENDIX K: NURSE SURVEY RESULTS AND ANALYSIS
Pre-training nurse survey Question 1 2 3 4 5 6 7 8 9 10
4 4 5 4 4 4 4 4 4 4
3 3 3 3 3 4 4 4 3 3
5 4 4 4 4 5 4 5 4 4
4 4 4 4 4 4 4 4 4 4
4 4 4 4 4 5 4 4 4 4
Average score 4 3.8 4 3.8 3.8 4.4 4 4.2 3.8 3.8
Survey average 3.96
Post-training nurse survey Question 1 2 3 4 5 6 7 8 9 10
4 4 4 4 4 4 4 4 4 4
4 4 4 4 4 4 4 4 4 4
5 4 5 4 4 5 5 5 4 5
4 4 4 4 4 4 4 4 4 4
4 4 4 4 4 4 4 4 4 4
Average score 4.2 4 4.2 4 4 4.2 4.2 4.2 4 4.2
Survey average 4.12
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APPENDIX L: NURSING DEMOGRAPHICS
Age
Nursing Staff
18-29 0 30-39 1 40-49 1 50-59 1 60-69 1 70-79 0 80+ 0
Prefer not to answer 1
Level of education
Nursing Staff
LPN 1 RN - Associate's degree 1 RN - Bachelor's degree 2
MSN 0 Prefer not to answer 1
Years of nursing experience
Nursing Staff
<5 0 5-10 0 11-15 0 16-20 2 21-25 2 >25 1
Prefer not to answer 0
Years of experience in mental health nursing
Nursing Staff
<5 2 5-10 1 11-15 0 16-20 1 21-25 0 >25 1
Prefer not to answer 0
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APPENDIX M: COMPARISON AND ANALYSIS OF PATIENT VERSUS NURSE SURVEY SCORES
Pre-training average scores Question 1 2 3 4 5 6 7 8 9 10 Mean
Patient surveys
3.273 2.364 2.455 2.2 3.723 3.273 3.4 3 2.273 2.273 2.824
Nurse surveys
4 3.8 4 3.8 3.8 4.4 4 4.2 3.8 3.8 3.96
T-test analysis for significance
H0: µ1 = µ2
HA: µ1 ≠ µ2
T-value
-5.925
p-value
0.000
Statistically significant? (p<0.05)
Yes
Post-training average scores Patient surveys
4.053 3.842 3.842 4.158 3.579 4 4.158 3.474 3.222 3.053 3.738
Nurse Surveys
4.2 4 4.2 4 4 4.2 4.2 4.2 4 4.2 4.12
T-test analysis for significance
H0: µ1 = µ2
HA: µ1 ≠ µ2
T-value
-2.990
p-value
0.008
Statistically significant? (p<0.05)
Yes
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