Literature Review

Archives of Psychiatric Nursing 30 (2016) 722–728

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Implementation of a Recovery-Oriented Training Program for Psychiatric

Nurses in the Inpatient Setting: A Mixed-Methods Hospital Quality Improvement Study☆

Renee John R. Repique a,⁎, Peter M. Vernig a, John Lowe b, Julie A. Thompson c, Tracey L. Yap c a Friends Hospital, Philadelphia, PA b Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL c Duke University, School of Nursing, Durham, NC

a b s t r a c t

This mixed-methods hospital quality improvement (QI) study primarily aimed to reduce the use of mechanical restraints in a short-stay inpatient psychiatric setting by facilitating change in care delivery through recovery- oriented nursing practice. The implementation of an evidence-based education for psychiatric–mental health registered nurses (PMH-RNs) intended to improve their knowledge of, and attitudes toward, recovery-focused mental health treatment principles. Findings suggest that recovery-oriented training programs for PMH-RNs can be a potentially useful hospital strategy for restraint reduction. In this article, the authors report their findings using the SQUIRE 2.0 framework for publication of QI studies (Ogrinc et al., 2015).

© 2016 Elsevier Inc. All rights reserved.

PROBLEM DESCRIPTION

Since the President's New Freedom Commission on Mental Health (2003) published its groundbreaking report that envisioned a future when people with mental illness would recover, the concept of recovery has taken hold in the mental health field. Recovery is defined as a pro- cess of transformation through which individuals with mental illness are empowered to enhance their own health and wellbeing so they can live meaningful lives to the fullest extent possible (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). Al- though short-stay inpatient hospital care remains the only suitable level of care to treat and stabilize some individuals in an acute episode of mental health crisis, it can also present missed opportunities for sustained recovery (Glick, Sharfstein, & Schwartz, 2011). As such, it is imperative that psychiatric–mental health registered nurses (PMH- RNs) working in inpatient psychiatric settings have a basic understand- ing of how recovery principles are applied in practice. According to the latest national workforce survey, nearly half of PMH-RNs are employed in hospital settings across the United States (Budden, Zhong, Moulton, & Cimiotti, 2013); they make up the largest group of licensed mental health professionals in most mental healthcare organizations that pro- vide round-the-clock inpatient care (American Psychiatric Nurses Asso- ciation [APNA], 2014).

Despite a focus on reducing the use of restraints and seclusion in mental health settings, these interventions are still commonly used as

☆ Conflicts of interest: None. ⁎ Corresponding Author: Renee John R. Repique, Friends Hospital, 4641 Roosevelt Bou-

levard, Philadelphia, PA, 19124. E-mail address: [email protected] (R.J.R. Repique).

http://dx.doi.org/10.1016/j.apnu.2016.06.003 0883-9417/© 2016 Elsevier Inc. All rights reserved.

a last resort for managing aggressive or self-destructive behavior. In a systematic review of 49 studies, Beghi, Peroni, Gabola, Rosetti, and Cornaggia (2013) concluded that restraints are still widely used in acute psychiatric hospitals in many countries with an overall prevalence rate varying from 3.8 to 20%, despite myriad attempts to introduce other alternative interventions. More often than not, PMH-RNs are involved in directly managing patients' aggressive behaviors and supervising unli- censed mental health personnel in the inpatient settings during the im- plementation of mechanical restraint procedures. (Henceforth all references to restraints shall refer to mechanical restraints unless other- wise notEd.)

AVAILABLE KNOWLEDGE

Restraint use is a costly, largely preventable, high-risk, and coercive procedure used by healthcare personnel in acute psychiatric settings aimed at containing and controlling a person's maladaptive behaviors during a mental health crisis when there is imminent threat to the safe- ty of both patients and staff; however, it can also lead to negative out- comes for the organization, its workforce, and the persons being restrained (SAMHSA, 2011). According to Larsson et al. (2013), individ- uals with severe mental disorders have a high prevalence of significant trauma history, and growing evidence supports the notion that certain coercive and restrictive practices, such as restraint use, in acute care psychiatric settings are re-traumatizing to most individuals (Muskett, 2013). Restraint implementation and the ensuing patient monitoring activities are also resource-intensive procedures that require additional nursing staff time and can directly increase the hospital cost of care (Cromwell et al., 2005; Cromwell & Maier, 2006); the total cost of

Table 1 Focus Group Questions Based on the Three Elements of the PARIHS Framework.

PARISH elements

Question

Evidence Describe the clarity of the material and the strength of the evidence on mental health recovery principles presented in the training.

Context In your work setting, what are some of the environmental factors (e.g. leadership, culture) that influence the adoption and integration of recovery principles in your nursing practice?

Facilitation How would you describe the overall implementation process of the training program? In the future, what would help facilitate the implementation of the training program? And, what would you recommend in order to improve the implementation process?

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restraint use in an acute inpatient psychiatric unit is estimated at $1.4 million annually (Lebel & Goldstein, 2005). Yet its purported benefits remain unsubstantiated by solid research evidence (Scanlan, 2010; Steinert et al., 2010).

RATIONALE

Aforementioned psychiatric populations with a high incidence of trauma are often cared for in inpatient psychiatric settings; therefore, the importance of staff development and training programs which pro- mote emotionally supportive nurse–patient relationships and the inten- tional adoption of recovery-based approaches in acute inpatient mental health settings are essential to quality care delivery (Muskett, 2013). Prior studies have demonstrated that recovery-oriented training pro- grams for mental health care personnel could enhance their positive at- titudes toward a person's recovery from mental illness (Wilcryx, Croon, van den Broek, & van Nieuwenhuizen, 2012). Smith, Ashbridge, Davis, and Steinmetz (2015) have shown that recovery-oriented principles ap- plied in mental health practice and service delivery resulted in signifi- cant reductions in restraint use (from .37 to .08 episodes per 1000 patient days) and slight declines in patient-to-patient assaults. Work- force development and training programs for direct care mental health staff—including PMH-RNs—that incorporate trauma-informed care principles, concepts of recovery and wellness, and value systems that treat the individual with dignity and respect have been shown to be ef- fective and essential in providing treatment alternatives that result in sustainable restraint reduction in inpatient settings (Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2011; SAMHSA, 2006).

SPECIFIC AIMS

The primary aim of the present quality improvement (QI) study is to reduce the use of restraints in a short-stay inpatient psychiatric hospital setting by facilitating change in nursing care delivery. The intervention involved the implementation of an evidence-based didactic training for PMH-RNs aimed at improving nursing staff knowledge of, and atti- tudes toward, recovery-focused mental health treatment principles. Secondary aims of the QI study were to: 1) assess the knowledge, be- liefs, perceptions, and values of inpatient PMH-RNs regarding mental health recovery-based principles; and 2) evaluate the implementation process of the education intervention in an acute care psychiatric hospi- tal setting.

METHODS

Study Design

This hospital QI study used a mixed-methods design, featuring a pre–post survey and focus groups with a convenience sample of PMH- RNs from eight inpatient units across the hospital. PMH-RNs were asked to complete a survey to assess their knowledge of, and attitudes toward, various recovery-oriented concepts before and after the imple- mentation of a recovery-oriented education intervention. Effects of the training on nursing practice were measured by comparing restraint rates prior to and post-implementation of the education intervention. Focus groups were conducted to evaluate nursing staff's perceptions of the overall implementation process of the recovery-oriented educa- tion intervention. Focus groups were chosen because they can be an effective tool in program evaluation using feedback gathered from free-flowing exchange of participants' ideas and opinions during a group dialogue (Rennekamp & Nall). The Promoting Action on Research Implementation in Health Services (PARIHS), a multidimensional framework for the implementation of complex research-based evidence into clinical practice (Rycroft-Malone, 2004), was used to guide the focus group evaluation process. The PARIHS framework posits that suc- cessful implementation of innovations in clinical practice requires three

dimensions: clear and strong evidence, a context (or culture) that is re- ceptive to change, and an effective change facilitation process. Table 1 shows the open-ended questions for the focus group discussion that were carefully framed using the three aforementioned elements of the PARIHS framework.

Context

The setting for the study was a 192-bed private inpatient psychiatric hospital in a major metropolitan area in the Northeastern United States. At the time of the study, there were 87 PMH-RNs employed at the hos- pital and the average age was 43 years. As one of the nation's oldest psy- chiatric institutions, the hospital provides comprehensive acute inpatient and emergency psychiatric crisis services to adolescent, adults, and geriatric mental health patients, and operates one of five designated adult crisis response centers in the city that provide full-service psychi- atric evaluation and mental health crisis services. The hospital serves an ethnically and socio-economically diverse patient population. In 2015, 51% of hospital patients were Caucasians, 31% were African- Americans, 13% were Latinos, 1.6% were Asians, and 3.4% were from other ethnic origins. In the same year, the hospital's average patient's length of stay was 13.7 days. Despite hospital-wide staff development efforts directed to transform clinical practice and help promote recovery-oriented mental health care, the hospital's average restraint rate during the prior year was 2.91 episodes per 1000 patient days.

Measure

The Recovery Knowledge Inventory (RKI), an evidence-based 20-item survey instrument developed by Bedregal, O'Connell, and Davidson (2006), was used and it has been shown to be useful in assessing and evaluating the training needs of mental health staff who are expected to deliver recovery-oriented care in their practice settings. It has four theoretical domains: roles and responsibilities in the recovery process, non-linearity of the recovery process, the roles of self-definition and peers in recovery, and expectations regarding recovery. The RKI uses a 5-point Likert scale (ranging from 1 = strongly disagree to 5 = strongly agree) designed to measure mental health providers' knowl- edge, understanding, and attitudes toward the four aforementioned re- covery domains considered important in behavioral health care delivery. The questions contained in the RKI are framed in such a way that minimizes the effect of social bias and responses to items that did not follow the same direction: half of the positive responses to the items reflected a stronger recovery orientation, while the other half reflected a lower recovery orientation (Davidson, Tondora, Lawless, O'Connell, & Rowe, 2009, p. 211). Meehan and Glover (2009) reported good internal consistency for the aggregated RKI score (with α = .83), and the RKI's authors (Bedregal et al.) reported the subscales' internal consistency as α = .81, .70, .63, and .47 for the four scales, respectively. The empirical dimensions of the RKI extracted a good representation of the critical dimensions of the recovery model derived in the extant re- covery literature and the variance accounted for by these four

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components was 50% (Bedregal et al.). The primary author obtained permission to use the RKI instrument for this QI study (L. Bedregal, per- sonal communication, August 3, 2014).

Intervention

A training program developed by SAMHSA focused on the applica- tion of mental health recovery principles in acute care settings was used to help educate PMH-RNs and prepare them for recovery- oriented evidence-based nursing practice. The hour-long training program is available via archived online webinar resources as an intro- ductory program for all mental health professionals to promote recovery-oriented practices in acute care psychiatric settings (SAMHSA, 2010). Delivered by interdisciplinary experts in mental health recovery research and practice, the training program synthesizes the body of research in the field, which includes the following topics: (1) patient engagement models, (2) trauma systems theory, (3) restraint reduction strategies, (4) integration of peer-to-peer services in psychiatric treatment, and (5) outcomes of randomized trial of consumer-managed alternative mental health treatment programs.

The hospital's chief nursing officer and chief clinical and innovation officer (a clinical psychologist) served as executive sponsors for this QI study. Prior to its implementation, leadership rounding, unit staff meet- ings, email announcements, informational flyers and town hall meet- ings were used as methods to engage hospital PMH-RNs and encourage their voluntary participation. The hospital's clinical nurse specialist (a board-certified psychiatric–mental health nursing; PMH- CNS) served as project coordinator and helped oversee various phases of the implementation process.

The project was completed over a four-month period (see Fig. 1). Dur- ing pre-implementation (phase 1), baseline aggregated hospital restraint data for the first two quarters of 2015 were extracted from the hospital databank. Study implementation (phase 2) commenced in September 2015. During phase 2, the 60-minute SAMHSA training program was im- plemented as a series of continuing educational offerings. Four sessions of the same training program were offered via group webinars for all hospi- tal PMH-RNs across all shifts. This time period allowed for participation of PMH-RNs including those that might be away from the hospital. The trainings were held in the hospital's auditorium using a large projector screen with speakers. All the training sessions were facilitated by the hospital's PMH-CNS who provided a sign-in sheet to track attendance and participation. At the beginning of each training session, the hospital PMH-RNs were given a pre-test using the paper-and-pencil version of the RKI. The PMH-CNS proctored all the pre-test and training sessions over a three-week period. During the study evaluation (phase 3), which

• Extract baseline restraint data

Phase 1

Pre - implementation

• RKI Pre-test • SAMHSA Train Program

Pha

Impleme

Fig. 1. Study t

commenced in December 2015, the PMH-RNs who attended the training sessions were re-surveyed (post-test) by the PMH-CNS using the paper- and-pencil version of the RKI during a one-week period. An administra- tive assistant entered all RKI survey data collected into Duke University's Research Electronic Data Capture (REDCap™), a secure web-based appli- cation designed to support data capture for research studies (Harris et al., 2009). During phase 3, the PMH-CNS conducted two focus groups with PMH-RNs who participated in the trainings to evaluate the implementa- tion process of the training program.

Analysis

Quantitative To compare the nurses' pre- and post-intervention knowledge of

recovery-oriented practices, descriptive statistics were computed for the four dimensions of the RKI questionnaire and then compared pre and post using four separate independent two-sample t tests (one test for each of the four dimensions). To evaluate the effects of training on evidence-based recovery principles on the restraint practices of the hos- pital PMH-RNs, the hospital's aggregated restraint data between two quarters were compared before and after the implementation of the QI project using a line graph.

Qualitative To evaluate the overall implementation process of the training pro-

gram, two focus groups were conducted with a subset of the partici- pants who received the SAMHSA training program. The two focus groups consisted of four participants each. Participants were unit charge nurses recruited from day and evening shifts who voluntarily agreed to participate. Both groups were facilitated by the hospital's PMH-CNS following a set of guidelines for designing and conducting focus group interviews (Krueger, 2002). An administrative assistant attended both focus groups as a scribe and took field notes and with participant consent audio recorded responses. At the end of each session, the PMH-CNS debriefed with the scribe and reviewed and listened to the audio-recordings and validated accuracy of the notes. Since the same PMH-CNS facilitated both groups, discussion comments were aggregat- ed. The PMH-CNS met with study team members, and together, they transcribed and synthesized all focus group responses and analyzed them for recurring themes and content. Guba's four criteria of credibil- ity, dependability, confirmability, and transferability (Shenton, 2004) were used to assure rigor of the focus group process and ensure trustworthiness of findings (see Table 2). Fig. 2 illustrates the overall qualitative evaluation process and system of analysis.

ing

se 2

ntation • RKI Post-test • Focus groups • Compare restraint rates post-study to baseline

Phase 3

Evaluation

imeline.

Table 2 Strategies for Assuring Focus Group Rigor.

Criteria and related strategies

Credibility (1) Meetings with team members to review focus group questions and analysis procedures; (2) focus group data collection and analysis reviewed to detect biases

Dependability (1) Protocols for the focus group process; (2) standardized focus group questions using the elements of the PARIHS framework

Confirmability (1) Focus group findings reviewed by an external expert qualitative researcher; (2) comparison of focus group findings with other published studies on the implementation of recovery-oriented practices in inpatient psychiatric settings

Transferability (1) Purposive selection of focus group participants; (2) developed clear goals for the focus groups

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Ethical Considerations

The Duke University Health System's Institutional Review Board ap- proved this hospital QI study, which did not include the collection of in- dividual patient data. Quality measures used aggregated hospital data on restraint rates and no identifiable information was revealed for sur- vey participants. The PMH-CNS directly supervised the overall imple- mentation of the QI study in order to ensure that the PMH-RNs did not feel compelled to participate in the survey, training sessions, and focus groups and to allay any concerns about reprisal if they decided not to.

Aim: Evaluate the implementation process of the education intervention

Focus group protocols

Standardized questions based on PARIHS Framework

Question 2: Description of the Context

Question 3: Description of

the Facilitation

Question 1: Description of the Evidence

Main r esponse themes aggregated, synthesized, and analyzed

Verification of findings

Interpretation of results

Fig. 2. Systematic analysis process. Note. A schematic presentation of the qualitative pro- cess to evaluate the overall implementation of the recovery-oriented training program.

RESULTS

Quantitative

RKI Survey There were 42 individuals in the pre-intervention and 32 individuals

in the post-intervention group. Although data were intended to be matched for pre and post, the participants did not include identifiers on surveys, and thus groups had to be considered independent. Of note, everyone who took a post-test was also in the pre-test group. De- mographics were collected on the pre-intervention group, but not the post-intervention group. The average age was 43.03 years old (range = 24–76 years) and the majority were females (n = 34, 81.0%). Most participants reported being White (n = 25; 62.5%), follow- ed by Black (n = 11; 27.5%), and Asian (n = 2; 5.0%). Two participants (5.0%) reported being “more than one race.” Regarding education, the majority had a bachelor's degree (n = 22, 52.4%), with 13 (31.0%) reporting having an associate's degree, and 7 (16.7%) a master's degree. Years of nursing experience and years of psychiatric experience were collected from participants and revealed that 16 participants (38.1%) had over 10 years of nursing experience and 14 (35.9%) had 5–10 years of psychiatric nursing experience. Only 1 participant (2.4%) was ANCC certified in psychiatric nursing.

Internal consistency for the present sample was fair to good for the subscales of the RKI (roles and responsibilities in recovery, α = .81; non-linearity of the recovery process, α = .64; roles of self-definition and peer support, α = .62; expectations regarding recovery, α = .61). To examine participants' change in knowledge about recovery from pre to post intervention, a series of independent samples t tests were conducted on each of the four RKI domains and no significant difference between pre and post was found for RKI domain scores (all psN .05). Re- sults are displayed in Table 3.

Restraint rates During the pre-intervention phase (Q1 and Q2 of 2015), the average

hospital restraint rate was 1.48 episodes per 1000 patient days. During the intervention period (Q3), the average hospital quarterly restraint rate was 2.33 episodes per 1000 patient days. At the completion of the post-intervention phase (end of Q4), the average hospital restraint rate was 2.29 episodes per 1000 patient days. Aggregated hospital restraint rates per quarter displayed in Fig. 3 show a slight reduction in restraint rates three months after post-intervention (Q4 vs. Q3).

Qualitative

Responses gathered from focus group participants are grouped below according to the three dimensions of the PARIHS framework: ev- idence (question 1), context (question 2), and facilitation (question 3).

Question 1 Describe the clarity of the material and the strength of the evidence

on mental health recovery principles presented in the training.

Response. The focus group participants described the clarity and strength of the material presented in the training program as “good.” The recovery principles were presented well but participants felt that they were basic concepts that they already knew and the content of the material was nothing new for them. While the overall content of the presentation was good, the participants would have preferred a different recovery-oriented training program more tailored and applicable to their practice in their respective inpatient settings. The material presented was “not specific enough.” The participants would have liked to learn more regarding “specific examples” of how recovery principles are actually put into practice in an acute care psychi- atric hospital.

Table 3 Comparisons of Participants' RKI Domain Scores Between Pre- and Post-Intervention.

Time point

N M SD df t P d

Roles and responsibilities in recovery PRE 41 3.74 .72 71 −.95 .34 .19 POST 32 3.90 .64

Non-linearity of the recovery process PRE 41 2.49 .68 71 .63 .53 .11 POST 32 2.40 .57

Roles of self definition and peer support PRE 42 4.13 .54 71 −.93 .35 .17 POST 31 4.25 .51

Expectations regarding recovery PRE 42 3.40 .95 72 .33 .73 .08 POST 32 3.32 .98

726 R.J.R. Repique et al. / Archives of Psychiatric Nursing 30 (2016) 722–728

Question 2 In your work setting, what are some of the environmental factors

(e.g., leadership, culture) that influence the adoption and integration of recovery principles in your nursing practice?

Response. The focus group participants indicated that the treatment teams on their individual units and practice settings were doing a “de- cent job” with incorporating recovery principles. The participants ver- balized that getting direct feedback from the patients regarding their treatment on the units would motivate them to become more engaged and it would allow for more integration of recovery principles. The PMH-RNs indicated that they liked working with a peer support special- ist as part of the hospital staff because it has a positive influence on their nursing practice. The focus group participants indicated that “more hos- pital staff needs to buy in to the recovery principles” and it should start from the top with leadership.

Question 3 How would you describe the overall implementation process of the

training program? In the future, what would help facilitate the imple- mentation of the training program? And, what would you recommend in order to improve the implementation process?

Response. The focus group participants indicated that the overall imple- mentation process of the training program could have been improved. The participants would have preferred a training program delivered by a live presenter instead of a webinar format so it could have been more interactive. They also would have liked the opportunity to ask questions had there been a live presenter and experience that added el- ement of “human touch.” If the training program is delivered via a webinar in the future, they suggested supplementing the presentation by having a content expert on-site that knows the training material to respond to any questions or need for clarification. The participants

1.33

1.63

2.33 2.29

0

1

2

3

4

Q1 Q2 Q3 Q4

R at

e (p

er 1

,0 00

p at

ie nt

d ay

s)

Quarter

2015

Fig. 3. Hospital restraint rates. Note. A comparison of the hospital's quarterly restraint rates over a one-year period. In 2015, the QI study was implemented in three phases: phase 1 (pre-intervention) is Q1 and Q2; phase 2 (intervention) is Q3; and the end of Q4 is phase 3 (post-intervention/evaluation).

suggested that more clinical staff needs to be included in the training, especially the mental health technicians.

DISCUSSION

Summary and Interpretation

The hospital's restraint rate over the course of the study was consulted to see if any changes coincided with the training. As can be seen in Fig. 2, a slight reduction from the time period of the intervention (Q3 of 2015) to the time period following the intervention (Q4 of 2015) was observed; however, this small change cannot be attributed to the didactic training provided to PMH-RNs as part of this QI study. At the same time as the present QI study, several hospital-wide restraint– prevention initiatives were underway, which may have significantly confounded our results. Although there was no significant difference in the results from the pre and post RKI surveys, more education for hos- pital PMH-RNs on specific recovery domains is likely warranted and findings from the focus groups offered some valuable insights that could help improve the implementation of these recovery-oriented ed- ucation initiatives in the future.

Quantitative Findings The results revealed that the PMH-RNs had moderate to high knowl-

edge of recovery principles at baseline, and thus, a ceiling effect may have occurred for some subscales, wherein the opportunity to increase scores significantly was difficult based on the strong scores at baseline. The moderate to high scores in three dimensions of the RKI survey should be encouraging to the hospital's leadership because these scores showed that their ongoing organizational efforts to promote a recovery- oriented mental health workforce were incrementally gaining momen- tum. At the very least, there was an awareness of recovery principles among the hospital's frontline nursing staff as demonstrated by their RKI scores. According to McLoughlin and Fitzpatrick (2008), psychiatric nurses with more experience and those who had formal education on mental health recovery concepts and care principles rated their prac- tices higher on a recovery-oriented practice scale. Nearly 36% of PMH- RNs that participated in this study had at least five years of psychiatric nursing experience and 38.1% had over 10 years of nursing experience. It is our contention that prior knowledge of recovery-oriented princi- ples, either acquired experientially or through formal and informal trainings, might have contributed to the existing knowledge base of the PMH-RNs.

The high scores in the dimension Roles of Self Definition and Peer Support indicated that the PMH-RNs positively viewed their patients as individuals defined by their potential for recovery rather than by their mental illnesses. It is also worth noting that the peer specialist role was created at the hospital four years ago and this might have also contributed to the PMH-RNs valuing of peer support's active role in inpatient mental health treatment and recovery process. The moder- ately favorable scores in the dimension Roles and Responsibilities in Re- covery indicated that the PMH-RNs had a somewhat fair understanding of their professional roles vis-à-vis the patients' recovery process, al- though opportunities for improvement existed with regards to further role clarification. The moderate scores in the dimension Expectations Regarding Recovery indicated that the PMH-RNs expectations of their patients achieving recovery might be too high. This perhaps was subjec- tively influenced by the PMH-RNs' personal expectations regarding the recovery process. Conversely, the subscale Non-Linearity of the Recov- ery Process did not have high scores at pre or post suggesting that the PMH-RNs had less knowledge of the complex nature of the mental health recovery process. Not surprisingly, the emphasis of short-term inpatient treatment in the acute psychiatric setting is traditionally per- ceived as following a linear trajectory focused on symptom manage- ment and stabilization.

727R.J.R. Repique et al. / Archives of Psychiatric Nursing 30 (2016) 722–728

Focus Groups Findings suggest several opportunities for improvement in the over-

all implementation of the training program. Themes that emerged from the focus groups indicated that the PMH-RNs and various clinical staff had already been exposed to several recovery-focused education initia- tives at the hospital that were underway prior to implementation of the QI study. According to McLoughlin and Fitzpatrick (2008), staff educa- tion programs that are focused on mental health concepts and recovery principles could shift facilities toward recovery-oriented practices. We speculate that, although hospital education initiatives offered in the past were not specific to nursing staff per se, their tenets could still be applicable to nursing practice. Participants' feedback also revealed that the education intervention needed more specificity using real-world practice exemplars on how to apply recovery principles in the PMH- RNs' practice settings. Focus group participants further confirmed that an alternate format using a live presentation on recovery principles spe- cifically tailored to the hospital's setting would have been more effec- tive. To that end, for recovery principles to be effective in facilitating practice change, they must introduce new knowledge rather than just present a review of ideas and concepts. Thus, the slight decrease in hos- pital restraint rates post-intervention could be attributed to other con- founding factors instead of being a direct effect of the training intervention. Perhaps restraint use would have been more likely to de- crease if the recovery-oriented training program had been in person and had presented new information and actual practice-setting vignettes to the PMH-RNs.

Limitations

This study had several limitations. First, the size of the convenience sample did not represent the total number of PMH-RNs employed at the hospital limiting the generalizability of the findings. The partici- pants' high scores on the RKI may have indicated a selection effect, whereby the nursing staff who were already more knowledgeable and accepting of recovery principles were more likely to participate in the training. The high level of experience and training reported by the par- ticipants lends some support to this assumption. Additionally, 25% of the study participants who completed the pre-surveys did not complete the post-surveys due to a number of factors, including job attrition. An- other key limitation was the length of time between the pre and post in- tervention. Three weeks might not have been long enough for the PMH- RNs to internalize and integrate the information from the training pro- gram to facilitate practice change (i.e., restraint reduction). In their study, Wilcryx et al. (2012) noted improvements in recovery-oriented knowledge and attitudes among mental health workers after two edu- cational interventions over the course of 12 months. The format of the training program as a standalone webinar also limited the effectiveness of the education intervention.

CONCLUSION

Several key implications for practice were borne out of this study. First, and perhaps most important, the reduction and elimination of re- straint use in acute psychiatric settings requires visionary leaders who understand the integral role of PMH-RNs in these efforts. Much like the hospital leaders in this study, these visionary leaders are intentional in setting a clear agenda for organizational change through the use of preventative interventions at the system and individual unit levels. The implementation of recovery-oriented principles as an evidence- based restraint–reduction approach through staff education and train- ing is an iterative process. It requires enduring support and a high level of commitment from hospital leaders because it may take time and a series of educational initiatives before incremental improvements are embedded into clinical nursing practice and are sustained. As dem- onstrated in this study, the RKI can be an invaluable tool for future im- provement studies aimed to increase recovery-oriented knowledge

among hospital PMH-RNs because it can identify those key areas of recovery-oriented mental health care that they are less familiar with and, in turn, these findings can be used to develop more tailored recovery-oriented education interventions in the future.

Building upon the key findings and lessons learned, it is our aim to replicate this study using a series of tailored and setting-specific training programs that focus on certain recovery domains that the PMH-RNs at the hospital are less familiar with. We hope to administer evidence- based recovery-oriented nursing training programs that will provide more emphasis on two key areas: the PMH-RNs' expectations regarding recovery and their understanding of the complex non-linear nature of the recovery process. A more interactive in-person training format will be used with a live presenter who is an expert in recovery principles. To address the methodological limitations, we plan to replicate this study using a much larger sample size of PMH-RNs in the hospital and aim for a 12-month implementation period. These next steps are aligned with the hospital's ongoing commitment to restraint reduction and elimination; thus, we are optimistic that they can be easily under- taken with support from hospital's current leadership. Leadership en- gagement was a particular strength of this study given the direct support and involvement of the hospital's senior management. Accord- ing to Huckshorn (2004), demonstrated leadership commitment through executive sponsorship of hospital restraint reduction initiatives is a proven core evidence-based strategy for improving practice and fa- cilitating organizational culture change in mental health settings.

Today, there is a pressing need among PMH-RNs working in inpa- tient settings for evidence-based training/knowledge, attitudes/beliefs, and valuing and practice of recovery principles. Our findings with re- gard to the baseline scores on the RKI were encouraging as they show the mental health recovery movement continues to advance in psychi- atric hospitals. Nurses with formal education in recovery principles are more likely to be recovery-oriented in their practice than those who do not have formal education (McLoughlin & Fitzpatrick, 2008) and staff training programs are positively correlated with improvements in human resource outcomes and organizational performance (Tharenou, Saks, & Moore, 2007). Therefore, providing hospital PMH-RNs with for- mal evidence-based education and tailored training in contemporary mental health treatment using recovery principles is a prudent work- force investment and a critical patient-centered strategy toward restraint-use prevention in acute psychiatric hospitals.

Acknowledgment

The authors would like to thank Kathleen Walker, Maurice Washington, Sally Dylinski, and the nurses of Friends Hospital (Philadel- phia, PA, USA) for their participation in the implementation of the QI study and Sara D. Hauber for her editorial support in the preparation of the manuscript.

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