Therapeutic Relationship Skills Research Articles

The Role of Self-Determined Motivation and the Potential for Pre-registration Student Learning: A Comparative Study within a Mental Health Clinical Placement

Developing therapeutic relationship skills as well as clinical skill confidence is critical for nursing students. While the nursing literature has examined multiple factors that influence student learning, little is known about the role of student motivation in skill development in non-traditional placement settings. Although therapeutic skills and clinical confidence are vital across a variety of contexts, here we focus on its development in mental health settings. The present study aimed to investigate whether the motivational profiles of nursing students varied with the learning associated with developing (1) a therapeutic relationship in mental health and (2) mental health clinical confidence. We examined students’ self-determined motivation and skill development within an immersive, work-integrated learning experience. Undergraduate nursing students (n = 279) engaged in five-day mental health clinical placement, “Recovery Camp,” as part of their studies. Data were collected via the Work Task Motivation Scale, Therapeutic Relationship Scale and the Mental Health Clinical Confidence Scale. Students were ranked into either high (top-third), moderate (mid-third) or low (bottom-third) motivation-level groups. These groups were compared for differences in Therapeutic Relationship and Mental Health Clinical Confidence scores. Students higher in motivation reported significantly higher therapeutic relationship skills (Positive Collaboration, p < .001; Emotional Difficulties, p < .01). Increased student motivation was also associated with greater clinical confidence compared to each lower-ranked motivation group (p ≤ .05). Our findings show that student motivation plays a meaningful role in pre-registration learning. Non-traditional learning environments may be uniquely placed to influence student motivation and enhance learning outcomes.

The influence of a self-determination theory grounded clinical placement on nursing student's therapeutic relationship skills: A pre-test/post-test study.

For undergraduate nursing students, an integral mode of learning is their clinical placements. Learning within the clinical setting is influenced by factors such as the facilitators, peers, unit, or department the student is placed on. What is not known is the role of a social context that is grounded in Self-Determination Theory and how this influences the development of therapeutic relationship skills among undergraduate nursing students. The aim of this study was to examine the role of autonomy support in the professional learning of undergraduate nursing students. This study employed a two-group pre-test and post-test design, with undergraduate nursing students placed in either an autonomy-supportive group or a comparison group in an Australian context. Therapeutic relationship skills were assessed at the beginning and end of their compulsory mental health clinical placement. Participants were 210 (n = 210) Australian undergraduate nursing students. Using a tertile split, 140 students were placed into one of two groups based on their perception of autonomy support at the post-test time point. Pre- and post-test therapeutic relationship data were collected for both groups. A repeated measures analysis of variance was used to examine whether engagement in different clinical placements would illicit significant differences in therapeutic relationship skills. Undergraduate nursing students who were engaged in the autonomy-supportive setting had significantly higher scores associated with the therapeutic relationship subscales: Positive Collaboration and Positive Clinical Input. The importance of the social context is underscored, which is strongly influenced by the educational leader, typically referred to as a nurse facilitator.

An exploration of nursing students’ and clinical instructors’ perceptions of patient and parent involvement in the assessment of nursing students during pediatric clinical placements: A qualitative study

AimClinical instructors are typically the sole assessors of nursing students completing their pediatric clinical placement in Canadian children’s hospitals, as per their educational institution's assessment criteria and learning objectives. The purpose of this study was to explore nursing students’ and clinical instructors’ perceptions of and experiences with involving pediatric patients and parents in assessing nursing students during their pediatric clinical placement. DesignWe conducted a qualitative descriptive study. MethodsWe completed semi-structured interviews with fourth-year nursing students and pediatric clinical instructors from a University located in a city in central-eastern Canada. We used qualitative content analysis to analyze the data. ResultsWe found that students and instructors perceived patient and parent involvement in the assessment of nursing students' clinical practice as beneficial for patients, parents, students and instructors. Students and instructors believed patients and parents could contribute to assessing students’ communication and therapeutic relationship skills. However, we identified potential challenges including patients’ and parents’ lack of knowledge regarding nursing skills, as well as added stress for students and parents. ConclusionFuture studies should focus on ways of overcoming these challenges before implementing this novel assessment process.

A Preliminary Analysis of the Effects of Clicker Training and Verbal Instructions on the Acquisition of Relationship-Building Skills in Two Applied Behavior Analysis Practitioners.

Recent research has emphasized the need for training and competency beyond the standard technical skills acquired by applied behavior analysis (ABA) practitioners, including essential relationship-building and compassionate care skills (Taylor et al., 2019). Clicker training is a well-established behavior-analytic method for improving performance via immediate feedback in the form of an audible "click." The effectiveness of clicker training has not yet been evaluated as a technique for shaping complex clinical repertoires. This study evaluated the effects of verbal instructions, clicker training, and role-play on the acquisition of therapeutic relationship skills in ABA practitioners. Data were obtained as part of a training program conducted within an ABA agency, and the acquisition of target skills was evaluated using a multiple-baseline design across behaviors for two participants. During baseline, participants rarely demonstrated target skills. During training, the procedure resulted in increased engagement in all three target skills for both participants. Skill generalization with respect to untrained and novel scenarios was observed but at levels below mastery. Findings have potential implications for trainers and supervisors seeking efficient, nonintrusive, socially acceptable methods of improving practitioner performance.

Australian and Indian nursing students’ skills and attitudes surrounding mental illness: Preparing for a transnational nursing education collaboration

Cultural competence is a viewed as a necessary set of skills within nursing, and there is a need for student support in this area. This is particularly important in mental health care, with two skills considered crucial for providing quality care: therapeutic relationship skills and positive attitudes. With the objective of initiating an educational collaboration between two educational institutions, this study examined Australian and Indian undergraduate nursing student's perceived therapeutic relationship skills and stigma attitudes associated with mental illness. Participants were five hundred and fifty-five (n = 555) undergraduate nursing students from two different universities in Indian and Australia. The modified version of the Scale To Assess Therapeutic Relationship (STAR-C) and the Social Distance Scale (SDS) were both used to examine student's perceived therapeutic relationship skills and stigma attitudes. Australian nursing students indicated lower levels of stigma with lower levels of self-reported therapeutic relationships skills, as compared with the Indian nursing student cohort. However, Indian nursing students indicated higher levels of stigma with higher self-reported therapeutic relationship skills. The results of this study may reflect cultural differences and meanings attached to mental illness.

Evaluation of therapeutic relationship skills training for mental health professionals: the Therapeutic Relationship Enabling Programme (TREP).

This article was migrated. The article was marked as recommended. Background: A 3-day workshop in Taiwan, developed in accordance with Carl Rogers' person-centred theory, used an experiential-learning pedagogy and a helping learning technology mPath. This study aimed to evaluate the effectiveness of a short-term course for mental health professional students assessing to the acquisition of therapeutic relationship competencies. Objective:To evaluate the training effects and investigate any changes in the level of therapeutic relationship competence of the participants before, at the end and two weeks after the intervention. Methods:A sample of 59 mental health professional students from 7 medical schools studying in nursing, occupational therapy, medicine, clinical psychology and other specialities with the completion of psychiatry-relevant courses. 26 of 59 mental health professional students volunteered to form the experimental group, and the controls were recruited using the snowball sampling technique. All of them completed the Barrett-Lennard Relationship Inventory OS-40 three times. Mean values and statistical significance tests were computed to compare the results. Results:Within 3 days, the mental health professional students in the experimental group (N=26) completed the Therapeutic Relationship Enabling Programme (TREP) and showed a statistically significant level of change (Mean Difference= +9.5, p= 0.002), which was in contrast to the outcome of the control group (N=33, Mean Difference= +0.18, p= 0.683), in the therapeutic relationship competences. The effecting growth curve of therapeutic relationship competence in the experimental group continually inclined two weeks after the intervention (Mean Difference= +19.423, p= 0.000) while the control group reflected a decline in therapeutic relationship competence (Mean Difference= -0.515, p= 0.812). Conclusions: A person-centred-theory-based training workshop with the use of a specially designed technology enhanced Taiwanese mental health professional students' learning on therapeutic relationship competences. A further investigation into learning person-centred therapeutic relationship qualities in the workshop as an innovative pedagogy and learning approach for medical education would be recommended.

The Structure of Competence: Evaluating the Factor Structure of the Cognitive Therapy Rating Scale

The Cognitive Therapy Rating Scale (CTRS) is an observer-rated measure of cognitive behavioral therapy (CBT) treatment fidelity. Although widely used, the factor structure and psychometric properties of the CTRS are not well established. Evaluating the factorial validity of the CTRS may increase its utility for training and fidelity monitoring in clinical practice and research. The current study used multilevel exploratory factor analysis to examine the factor structure of the CTRS in a large sample of therapists (n = 413) and observations (n = 1,264) from community-based CBT training. Examination of model fit and factor loadings suggested that three within-therapist factors and one between-therapist factor provided adequate fit and the most parsimonious and interpretable factor structure. The three within-therapist factors included items related to (a) session structure, (b) CBT-specific skills and techniques, and (c) therapeutic relationship skills, although three items showed some evidence of cross-loading. All items showed moderate to high loadings on the single between-therapist factor. Results support continued use of the CTRS and suggest factors that may be a relevant focus for therapists, trainers, and researchers.

Adaption and validation of the Working Alliance Inventory for General Practice: qualitative review and cross-sectional surveys.

BackgroundRelational aspects of primary care are important, but we have no standard measure for assessment. The ‘working alliance’ incorporates elements of the therapeutic relationship, shared decision-making, goal setting and communication skills. The Working Alliance Inventory (short form) (WAI-SF) has been used in adult psychology, and a high score on the survey is associated with improved outcomes for clients.ObjectiveTo adapt the WAI-SF for use between GPs and patients and to test its concurrent validity with measures of shared decision-making and the doctor–patient relationship and discriminant validity with measures of social desirability.MethodsTwo rounds of online survey feedback from 55 GPs and 47 patients were used to adapt the WAI-SF—the WAI-GP. The tool was then completed by 142 patients in waiting rooms after seeing their GP and by 16 GPs at the end of their session. Concurrent validity with measures of shared decision-making and patient–doctor depth of relationship was determined using Spearman Rho correlations. Patients also completed two social desirability surveys, and discriminant validity with WAI-GP was assessed.ResultsFollowing feedback, the survey was re-worded to remove phrases that were perceived as judgmental or irrelevant. The patient measure of the WAI-GP was strongly correlated with Dyadic OPTION (rho = 0.705, P = 0.0001) and Patient–Doctor Depth of Relationship scale (rho = 0.591, P = 0.0001) and not with measures of social desirability.ConclusionThe psychometric properties of the WAI-GP support its use for measuring GP-patient alliance. Possibilities for use include assessing the influence of therapeutic alliance on the effectiveness of interventions.

Compassionate Care in Behavior Analytic Treatment: Can Outcomes be Enhanced by Attending to Relationships with Caregivers?

The practice of behavior analysis has become a booming industry with growth to over 30,000 Board Certified Behavior Analysts (BCBAs) who primarily work with children with autism and their families. Most of these BCBAs are relatively novice and have likely been trained in graduate programs that focus primarily on conceptual and technical skills. Successfully working with families of children with autism, however, requires critical interpersonal skills, as well as technical skills. As practitioners strive to respond efficiently and compassionately to distressed families of children with autism, technical skills must be balanced with fluency in relationship-building skills that strengthen the commitment to treatment. The current article provides an outline of important therapeutic relationship skills that should inform the repertoire of any practicing behavior analyst, strategies to cultivate and enhance those skills, and discussion of the potential effects of relationship variables on treatment outcomes.

Emotional Intelligence: An Opportunity for Occupational Therapy

ABSTRACTEmotional intelligence theory developed within the psychology and business fields and is described as an ability to monitor emotions and to use the information to guide thinking and problem solving. Emotional intelligence skills are needed by occupational therapy practitioners to support therapeutic use of self, promote client-centered care, and foster communication skills within the workplace. A scenario illustrates how emotional intelligence supports the therapeutic use of self during a clinical interaction. The Mayer Salovey Caruso Emotional Intelligence Test is introduced as a resource for occupational therapy practitioners to measure and develop therapeutic relationship skills based upon emotional intelligence research.

Care of patients in emergency department waiting rooms--an integrative review.

To conduct an integrative review of primary research examining patient care roles introduced into emergency department waiting rooms. Internationally, emergency departments are under pressure to meet increasing patient demand with limited resources. Several initiatives have been developed that incorporate a healthcare role in waiting rooms, to assess and initiate early interventions to decrease waiting times, detect patient deterioration and improve communication. The literature reporting these roles has not been systematically evaluated. Integrative review. Published English-language peer reviewed articles in CINAHL, Scopus, Medline and Web of Knowledge between 2003-2014. Identified literature was evaluated using an integrative review framework, incorporating methodological critique and narrative synthesis of findings. Six papers were included, with three waiting room roles identified internationally - clinical initiative nurse, Physician-Nurse Supplementary Assessment Team and clinical assistants. All roles varied in terms of definitions, scope, responsibilities and skill sets of individuals in the position. There was limited evidence that the roles decreased waiting times or improved patient care, especially during busy periods. Of note, staff members performing these roles require high-level therapeutic relationship and effective interpersonal skills with patients, family and staff. The role requires support from other staff, particularly during periods of high workload, for optimal functioning and effective patient care. Generalisations and practice recommendations are limited due to the lack of available literature. Further research is required to evaluate the impact emergency department waiting room roles have on patient outcomes and staff perspectives.

An investigation of factors that impact patients' subjective experience of nurse-led clinics: a qualitative systematic review.

To systematically review the qualitative evidence on factors that affect the experience of patients attending nurse-led clinics and compare with key elements of person-centred care. As the number of nurse-led clinics increases in response to health system needs, evaluation has focused on clinical outcomes and cost. Patient experiences are less researched and yet, they are an important influence on clinical outcomes and an indicator of person-centred care. A detailed review of existing research in this area is needed. A systematic review of primary, qualitative literature was conducted using the Joanna Briggs Institute methodology of meta-aggregation. Published research from 1990-2012 was located using CINAHL, PubMed, Medline and PsycINFO. Reference lists were searched and analysed. Two reviewers assessed the papers for methodological quality using instruments from the Joanna Briggs Institute to critically appraise, extract data and meta-aggregate findings. Eleven studies met all inclusion criteria. Three meta-synthesis statements were derived from 46 findings aggregated to nine categories. The key themes relating to establishment of a therapeutic relationship, effective communication, and clinical skills and collaboration mapped closely to the person-centred care framework. Concepts central to person-centred care proved to be factors impacting patients' subjective experience. Further research is warranted to meet the challenge to transform the key concepts of the person-centred care model into everyday nursing practice. Knowledge of patients' feelings and the importance of person-centred, individualised care may contribute to development of future training and re-training programs in basic nursing skills. This is significant in that it contributes to future positive patient experience.

Looking within: self-perceived professional strengths and limitations of psychotherapists in India

Practice as a psychotherapist can be both rewarding and challenging, generating a need for therapists to reflect on their professional strengths and vulnerabilities. As part of a larger international study of psychotherapists, information was gathered from 250 therapists in India using the Development of Psychotherapists Common Core Questionnaire (DPCCQ). One specific part of the DPCCQ asked for narrative answers to two questions: ‘What do you feel is your greatest strength as a therapist?’ and ‘What do you feel is your most problematic limitation as a therapist?’. Using the consensual qualitative research method, qualitative analysis of therapists' written responses identified several core themes. Three themes accounted for 82% of responses about therapists' perceived strengths: therapeutic relationship skills (32%), therapeutic professional expertise (28%), and therapist personal qualities and experiences (22%). Four themes accounted for therapists' views of their limitations: inadequate therapeutic competence (22%), professional stress and burnout (20%), inadequate professional knowledge and experience (19%) and therapist personal qualities and difficult experiences (19%). Themes relevant to the challenges and realities of therapeutic work in the Indian context also emerged. Implications of these narrative themes of therapist development are discussed.

Mapping the Characteristics of a 'Good' Play Therapist.

In this pilot study, concept mapping, a methodological approach combining qualitative and quantitative analytic strategies, was used to identify the therapist qualities, competencies, and skills necessary for effective play therapy outcomes as perceived by a sub-sample of 28 experienced play therapists who are members of the Association for Play Therapy (APT). The clusters associated with the therapeutic relationship and facilitative skills (e.g., empathy, warmth, and genuineness) were rated as the most essential skills to possess and also as the most difficult to develop. In contrast, the clusters associated with play therapy interventions and theories were rated as the least important skills to possess but as the easiest to acquire. The findings are discussed, with implications for therapeutic practice, research, and policy.

Interpersonal skills in behavioural psychotherapy: clinical psychology trainees' attitudes.

During a behaviour therapy training workshop, 15 postgraduate clinical psychology trainees were asked to assign 27 interpersonal therapeutic skills either to themselves and/or to the 'typical behaviour therapist'. The behaviour therapist's low ratings in therapeutic relationship skills is discussed, and the need for more research into the specific behavioural therapeutic relationship is emphasized.