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Recovery-Oriented Care in a Psychiatric Health Setting
Section 1: Introduction
Background
Health care recovery efforts are vital in the last phase of case management
pursuing the full restoration of a patient’s normal health status. Health care recovery is
conceptualized as the patient connecting with health care professionals to positively
influence their care and recovery (Bennett, Breeze, & Neilson, 2014). Health care
professionals play a significant role in encouraging recovery by exhibiting optimistic
attitudes, applying operative interventions, and having the appropriate skills to support
patients on their recovery journey (Bennett et al., 2014). Therefore, recovery is essential
not only in the clinical cases but also in rehabilitative settings where nursing care focuses
on prolonging life. Nurses’ training in the field of patient recovery is an ongoing concern
being embraced by health care providers as the most important phase in efficiency of care
delivery. Contemporary nursing trainings provide education for the basics, which would
be experienced later in practice but failed to provide training in specialized nursing areas,
such as psychiatric nursing and how to conduct groups and provide recovery-oriented
care. Many of the useful and critical aspects of nursing care are learned through best
practices emanating from hands-on experiences and clinical research findings. These
sources provide valuable information, advising on the process in which recovery nursing
care should be approached for optimal health outcomes among patients in any setting or
conditions.
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Patients suffering from various disorders and diseases find recovery care to be an
integral part of health care delivery, which offers an opportunity to boost the individual’s
coping ability toward the illness. In addition to conditions and other cognitive, physical,
or developmental problems, health facilities with psychiatric patients are in urgent need
of recovery care. Mental health recovery has been acknowledged as the main objective
for patients with mental illness (Substance Abuse and Mental Health Services
Administration [SAMSHA], 2011). Recovery is an individualized journey that promotes
healing and assists individuals with restoring their ideal level of functioning. According
to Silverstein and Bellack (2008), recovery is defined as a reduction in mental health
symptoms that places the individual in widespread or limited remission from their
psychiatric illness. Although several definitions of recovery exist, the consensus is that
recovery helps patients with mental illness cultivate the necessary resources to manage
their illness efficiently. SAMSHA (2012) defined recovery from mental health and
substance use disorders “as a process of change through which individuals improve their
health and wellness, live a self-directed life, and strive to reach their full potential” (p. 3).
The SAMSHA definition has been widely accepted in the mental health field, used
extensively by the mental health advisory of Veterans Healthcare Administration (VHA),
and adopted in mental health facilities. SAMSHA (2012) included 10 essential
components that help guide recovery: self-directed, nonlinear, individualized, personal,
empowerment, holistic, strength-based, peer support, respect, responsibility, and hope.
These components have been accepted by the Veteran’s Healthcare Administration as the
core elements of recovery. Because recovery is multifaceted and unique to the individual,
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mental health professionals must have a clear understanding of recovery and the
interrelated role that psychoeducational groups play in the recovery process.
The benefits of mental health recovery-focused care drive the demand for
continuity of care and assist in restabilizing the patient by promoting positive coping
skills to help the patient reach his or her ultimate level of functioning. Despite the
important need for a phase of care delivery, many institutions, health facilities, and
rehabilitative care settings inadequately promote their potential in reaching top quality
care through the design and implementation of a proper recovery framework for their
patients (Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsch, 2012). The observed failure is
attributed to numerous factors. Some scholars report that the lack of commitment by the
policymakers at the institutional level led to inadequate resource allocation in investing in
recovery care, resulting in adverse health outcomes (Schlegel, Woermann, Shaha,
Rethans, & Vleuten, 2012). The efficiency of health institutions is also reduced. Other
scholars indicated that in instances in which recovery programs are initiated, human
resource limitations and inadequate approaches led to situations that hampered the full
realization of goals (Pupkiewicz, Kitson, & Perry, 2015).
Most approaches to recovery care leave out essential elements such as an
interdisciplinary composition of groups tackling implementation tasks of the program (A.
Cleary & Dowling, 2009). Diverse teams drawn from various disciplines in health care
apart from the nursing profession are effective in addressing the different logical
frameworks of recovery care. However, team management occurs in a setting of
psychiatric patients and other social development problems. Elements such as a positive
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attitude, a sense of ownership, and a feeling of possible achievement through shared goals
and targets of the team engaged in recovery programs are necessary for success.
According to Denham-Vaughan and Clark (2012), recovery-oriented care in mental health
includes the ability to orient the thinking and attitudes of each person involved to achieve
the optimal outputs from every individual.
The efficient evolution of the process of recovery is possible with proper
planning, good content, and suitable delivery methods for specific audiences and
subjects. Getting all the variables right provides a predisposition to the desired health
outcome at posttreatment, postdischarge, or as a part of managing chronic medical
conditions such as terminal illnesses (M. Cleary, Horsfall, O’Hara-Aarons, & Hunt,
2013). Nursing and other health care professionals have to be trained and mentored in the
delivery of the best proven practices in recovery-oriented nursing care in any setting.
However, such training is lacking in many medical facilities, especially in mental health
settings that have patients with psychiatric and addictive issues (M. Cleary et al., 2013).
The quality of care remains substandard despite adequate and proper staffing in clinical
treatment areas (Aebersold & Tschannen, 2013). There are underdeveloped skills and
abilities among nursing and other health care professionals who support posttreatment
and postdischarge patients.
The lack of adequate recovery-oriented care in many psychiatric health facilities
among psychiatric nurses is blamed partly on the reduced ability of patients to fully
regain their health status potential. Prepractice training of psychiatric nurses on
recoveryoriented practices may not include emerging best practices. New knowledge
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should be integrated into practice through on-the-job nurse training. Research indicated
that psychiatric nurses are given less consideration in terms of work and health equipment
than other health care professionals (Farley-Toombs, 2011). Consequential factors such as
security and improving the social and cognitive development of patients depend on the
implementation of recovery-based care. Among nurses and other health care workers in
psychiatric settings, emotional stability and coping skills are central to helping patients
recover properly (Farley-Toombs, 2011).
Focusing on nurses’ training in handling the recovery of patients with mental
health issues is important in improving the quality of care. Some of the applauded
approaches are group education, panel discussions, and task-oriented case scenarios
(Yuan, Williams, & Fang, 2012). Problem-based methods are preferred in nursing school
compared to theoretical approaches. Best practices are important in the achievement of
desired levels of expertise to promote recovery among patients.
Problem Statement
Psychiatric patient recovery is often slow and inefficient due to inappropriate
approaches used by psychiatric nurses in delivering recovery-oriented health services
(Farley-Toombs, 2011). A lengthy recovery period leads to low levels of patient
satisfaction (Department of Health, 2006). General quality of life deteriorates among the
affected patients. However, appropriate training in psychiatric nursing and other health
professions is effective in achieving the quality and efficiency needed in psychiatric
health units for optimal clinical outcomes (McKenna, Furness, Dhital, Park, & Connally,
2014). By conducting psychoeducational groups and providing recovery-oriented training
6
of nurses and other health care professionals in psychiatric health facilities, the treatment
disparity can be reduced.
Purpose
The purpose of this project was to develop and implement an educational
intervention for psychiatric nurses to provide recovery-oriented care and conduct
psychoeducational groups on an inpatient psychiatric unit. To accomplish this goal, I
assessed barriers and deficiencies among nurses to develop the educational intervention.
The Iowa model of evidence-based practice (Titler et al., 2001) guided the process of
implementation and evaluation of the practice change. The project included the following
objectives:
•assess the training needs of psychiatric nurses in the inpatient unit to devise
the most appropriate training content and approaches that would meet their
needs,
•evaluate the perceived barriers for effective recovery-oriented psychiatric
nursing care,
•determine strategies in addressing perceived barriers,
•educate psychiatric nurses on group dynamics and psychoeducational groups
in patient recovery, and
•evaluate the effectiveness of training on recovery-oriented nursing care for
psychiatric patients, considering the lessons learned, while advising future
training and nursing practice in mental patient recovery.
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Project Questions
The purpose of this project and its objectives were intricately linked to the issues
that the project addressed. The project’s questions formed the basis of the study and were
used to design the benchmarks of the program. Success depended on the level of
satisfaction with which the questions were answered. I conducted monitoring and
evaluation to meet the goals of the project. The project questions were as follows:
1. What are the perceived training needs of psychiatric nurses on an acute
inpatient psychiatric unit?
2. What are the perceived barriers to recovery-oriented psychiatric nursing care
on an acute inpatient psychiatric unit?
3. What strategies do nurses need to break the barriers of full and efficient
recovery-oriented psychiatric nursing practice?
4. Is recovery-oriented psychoeducational group training effective in increasing
the staff’s knowledge and confidence in conducting groups?
Evidence-Based Significance of the Project
Recovery-oriented patient care involves many factors. Most of these were not
explained to psychiatric nurses during their school-based training. Despite the inadequacy
of nursing curriculum on managing patient recovery in psychiatric care settings, the
ability to help psychiatric nurses manage patients’ recovery is crucial in improving the
quality and speed of recovery (Gale & Marshall-Lucette, 2012). Many health institutions
base their recovery efforts on patients (Pallaveshi, Zisman-Ilani, Roe, & Rudnick, 2013).
Health care providers encourage patients to be mentally and emotionally stable to cope
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with changes in their health status as they strive to return to normal health. However,
studies show that it is also vital for the psychiatric nursing fraternity involved in
psychiatric patient care to have a significant impact on the recovery process (Pallaveshi et
al., 2013). For example, effectively working in groups to manage outpatients or those in
rehabilitative facilities generated more positive health outcomes than in settings where
patients were left to strive alone on the way to recovery.
In cases in which health care practitioners are actively engaged in the patient
recovery process, health outcomes include higher quality of care and consumer
satisfaction. These two factors determine the sustainability of health systems through
increased productivity and operational efficiency (Cook et al., 2009). Other benefits of
health care provider-focused recovery plans are economic and social (Cook et al., 2009).
One of these is cost effectiveness. Quality health care delivered in psychiatric units
reduces the length of the patient’s stay, reducing the health care cost. A faster recovery
process also leads to a reduction in the level of stress or depression among patients
(Department of Health, 2006), thereby increasing the quality of life after recovery
(Pallaveshi et al., 2013). Group work, team management, and skill acquisition during
training programs promote cohesiveness at work, which encourages synergy of skills of
psychiatric nurses (Farley-Toombs, 2011). Psychiatric nurses should be able to utilize
themselves in a collaborative manner to promote therapeutic recovery.
Implications for Social Change in Practice
Increasing the quality of health care by increasing the rate of recovery among
psychiatric patients and patients with other social problems is a method of addressing the
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issue of disparity in health care and its associated risks (McKenna et al., 2014). In some
instances, the use of effective recovery in mental health patients leads to reduced
insecurity risks (Pallaveshi et al., 2013). Mental health patients who are subjected to
planned recovery processes are less likely to have violent incidents or misbehavior related
to their psychiatric conditions (Farley-Toombs, 2011). Recovery-oriented psychiatric
nursing care potentially impacts society by helping individuals with mental health
problems integrate back into their communities. The nursing profession is not unique in
creating a social impact through effective methodologies in practice. The ability to nurse
the patient both emotionally and clinically is vital to the success of nursing care. By using
emotional support to reduce the adverse health outcomes that impede the recovery of
mental health patients, recovery-oriented nursing care can reduce illness among the sick
(Alfaro-LeFevre, 2013).
Definitions of Terms
To ensure a clear understanding of words used in this project, key terms are
operationally defined. Some terms may be used differently in diverse settings or applied
separately in various academic disciplines.
Evidence-based practice (EBP): The use of sound elements of practice, which are
proven effective through hands-on experience or research (Fitzpatrick, 2007). Usually
EBP takes place at the workplace, as opposed to class-based training, as outlined by a
professional career training curriculum. Through the learned lessons, EBP is useful in
improving the quality of psychiatric nursing at the facility where the project is performed,
as it is a permanent practice skill among trained health providers (Fitzpatrick, 2007).
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Psychoeducational groups: A type of group that incorporates information on the
specific mental illness, treatment options, patient and family resources, coping skills, and
management strategies (Vreeland, 2012). Psychiatric nurses play a major role in
conducting these groups on a psychiatric unit. In a recovery-oriented environment, there
is a prominence on patient collaboration and a priority on promoting a partnership by
providing psychoeducational groups (Vreeland, 2012). Group dynamics include
occurrences and activities, both social and behavioral, affecting the general behavior of
the group in a certain way. Group dynamics can be effectively managed to reduce the
negative outcomes and amplify the positive outcomes, thereby leading to better team
efficiency. Group dynamics refers to the interactions among individuals conversating in a
group setting (Nazzaro & Strazzabosco, 2009). Group conflict, cooperation, and
neutrality are elements that shape the performance of any team.
Summary
The project may lead to changes in practice among psychiatric nurses and other
staff who are directly involved in the management of recovery of mental health patients.
Nurses working in teams or groups leads to better patient care than only one person
nursing the patient (Fitzpatrick, 2007). Nurses on duty attending to one patient and
agreeing on all aspects of care can yield better outcomes than those in disagreement.
Through group dynamics, team management, and teamwork, better health care decisions
for patients can be achieved compared to when this kind of cooperation is missing.
Culture in health care settings is reinforced by the use of proper teamwork in promoting
the well-being of patients. Moreover, the potential transferability of the recovery-oriented
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care project may influence best practices in other psychiatric units. The recovery model
includes a quality improvement framework to support competent nurses. On the surface
this may seem simple, but the process is quite complex.
Section 2: Background and Context
The process of psychiatric patient recovery is slow and hampered by inappropriate
approaches used by psychiatric nurses in delivering recovery-oriented health services
(Farley-Toombs, 2011). A lengthy recovery period leads to low levels of patient
satisfaction (Department of Health, 2006). The general quality of life deteriorates among
affected patients. Appropriate training in psychiatric nursing and other health care
professionals is effective in improving the quality and efficiency of patient recovery in
psychiatric health units for optimal clinical outcomes (McKenna et al., 2014). Through
psychoeducational groups and the provision of recovery-oriented training for psychiatric
nurses and other health care professionals, patient outcomes can be improved.
Project Purpose and Objectives
The goal of this project was to develop and implement an educational intervention
for psychiatric nurses on how to provide recovery-oriented care and conduct
psychoeducational groups on an inpatient psychiatric unit. To accomplish the goal, I
assessed barriers and deficiencies among nurses to develop the educational intervention.
The Iowa model of evidence-based practice (Titler et al., 2001) was used to guide the
process for implementing and evaluating the educational intervention. The project
included the following objectives:
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•assess the training needs of psychiatric nurses in the inpatient unit to devise
the most appropriate training content and approaches that would meet their
needs,
•evaluate the perceived barriers for effective recovery-oriented psychiatric
nursing care,
•determine strategies in addressing perceived barriers,
•educate psychiatric nurses on group dynamics and psychoeducational groups
in patient recovery, and
•evaluate the effectiveness of training on recovery-oriented nursing care for
psychiatric patients, considering the lessons learned, while advising future
training and nursing practice in mental patient recovery.
Project Questions
The purpose of this project and its objectives were intricately linked to the issues
that the project sought to address. The project questions form the basis of the project
inquiry and will help in designing the benchmarks of the program. Success will depend
on the level of satisfaction to which questions are answered. Also, monitoring and
evaluation was done accordingly to meet the goals of the project. The project questions
were as follows:
1. What are the perceived training needs of psychiatric nurses on an acute
inpatient psychiatric unit?
2. What are the perceived barriers to recovery-oriented psychiatric nursing care
on an acute inpatient psychiatric unit?
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3. What strategies do nurses need to break the barriers of full and efficient
recovery-oriented psychiatric nursing practice?
4. Is recovery-oriented psychoeducational group training effective in increasing
the staff’s knowledge and confidence in conducting groups?
Concepts, Models, and Theory
EBP is a collection of best practices in nursing based on credible forms of
evidence. Information on EBP is obtained through collecting evidence from primary
research studies, quality improvement initiatives, and expert panels, and applying this
knowledge in the clinical practice setting. This is useful for care delivery in psychiatric
nursing (Koivunen, Välimäki, & Hätönen, 2010). Although there is considerable literature
on best practices in psychiatric nursing care, this project focused on recoveryoriented
care. EBP for inpatient recovery-oriented care is passed down from one generation of
psychiatric nurses to another through on-the-job training as opposed to prepractice
education. Scholars agreed that although prepractice training integrates elements of EBP
into the curriculum, this approach is not as effective as on-the-job training, which is
immediately put into practice and evaluated for effectiveness (Stillwell, Fineout-
Overholt, Melnyk, & Williamson, 2010). Although approaches to nursing training on EBP
are informed by theoretical models on education and training, the content can vary
regarding the required skills and knowledge for a particular setting (Grove, Burns, &
Gray, 2013).
Theoretical frameworks are used to explain the approaches to recovery-oriented
care by advising implementers of such programs in achieving effectiveness among the
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beneficiaries. I used adult learning theory as the theoretical framework for the project
because this theory differentiates the learning needs of adults and how new information is
processed. Adult learning theory was developed by Knowles (1989) and originally
consisted of six assumptions regarding how adults learn and process new information.
These assumptions are based on andragogy, which is a learner-focused approach that
emphasizes operations and the significance of educational training instead of curriculum
(Knowles, 1989). Knowles further stated that due to life experiences, adults have more
preconceived notions about learning new initiatives, and they must perceive this need and
be ready to learn. Curran (2014) stated that health care organizations that fail to utilize
adult learning theory to guide educational development prevent the transfer of
knowledge, which can negatively impact patients. Adult learning theory is self-directed
and a shared learning experience (Knowles, 1989). Therefore, curricula should be
centered on interactive activities in which adult learners can actively participate and
acquire knowledge.
The implementation of recovery-oriented care by nurses requires that they
introduce, develop, and assess evidence-based practice (Doody & Doody, 2011). The
Iowa model (Tilter et al., 2001) provides a framework through which the approach is
holistically outlined. The model is superior to biomedical theories of practice, which are
inadequate in nursing settings especially as part of evidence-based care delivery. The
Iowa model includes seven important processes to be observed when implementing EBP,
and incorporates members of the organization, patients, health care systems, and other
stakeholders. Additionally, the Iowa model identifies triggers that determine the points of
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knowledge acquisition or problems to be solved. Shifting from risk management to
clinical problems is necessary for improving the practices for psychiatric care (Grove et
al., 2013). According to Grove et al. (2013), knowledge-focused triggers include EBP
elements, philosophies, procedures, and organizational policies. The Iowa model guides
implementation of patient recovery, thereby streamlining the process of quality
improvement in helping psychiatric patients to experience a fast and accurate recovery.
Relevance to Nursing Practice
Nursing education is a prerequisite for quality patient care, including the recovery
process. According to Denham-Vaughan and Clark (2012), psychiatric nursing stems
from proper education and training, which determine the achievable level of quality care
among psychiatric patients. I envisioned systems in which psychiatric nurses operate to
be vital in predicting the course of recovery for patients with mental health problems. The
main focus of this project was education and training of nursing personnel. Training plays
an important role in promoting the desired patient recovery outcome, especially for
psychiatric patients. Furthermore, EBP is effective in improving quality and efficiency in
health care delivery for psychiatric patients (Terry, 2015). Recovery-oriented care
depends on the level of training of psychiatric nurses on the best practices available for
specific types of patients.
Methodologies such as psychoeducational groups and knowledge of group
dynamics provided the best implementation framework for the project.
Psychoeducational groups help in facilitating the training of psychiatric nurses to promote
proper patient recovery. Researchers agreed that theoretical frameworks specific to
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nursing care settings are needed to improve the effectiveness of practices among nurses
(Stillwell et al., 2010). Through an interdisciplinary approach to patient care, recovery
can be optimized. The diverse disciplines can cooperate and channel efforts toward the
achievement of a shared goal of initiating and sustaining proper patient care to recovery.
This element of patient care differentiates recovery-oriented care from other types of
nursing care delivered to patients (Farley-Toombs, 2011).
Nursing training in recovery-oriented care needs a systematic approach and
continuous monitoring to be effective. It requires a comprehensive, logical framework
that includes the milestones, goals, and benchmarks for each process. It also requires the
inclusion of all possible parameters of nursing care, which can have a direct or indirect
influence on the elements of the logical framework (Lysaker & Buck, 2008). All activities
that affect the nursing schedule must be included and planned, placing every element in
its proper place and considering time and responsibility. The timing of task competition
and clear goals for each activity must be established before the onset of training.
Researchers agreed that there may be possible deviations between what is planned and
what is experienced in the process of executing the strategy (M. Cleary et al., 2013).
However, deviations may be mitigated through monitoring and evaluation, which lead to
a review of the blueprint for powerful impact on the subjects. Nurses in a psychiatric unit
who are to be trained in recovery-oriented care must be coordinated and assisted to
adhere to every aspect of the logical framework while going through a smooth and
efficient training process. Although the approach applies to nursing practice in any
setting, it is modifiable for use in recovery-oriented nursing care for psychiatric nurses.
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Psychiatric nurses understand the gaps in practice they are facing, which diminish
the efficacy of care delivery. Some may give suggestions on the best means of addressing
problems. Although full implementation of these suggestions are often not fully carried
out or successfully implemented in the workplace setting. However, the workplace
setting is not the only factor in recovery (Farley-Toombs, 2011). The atmosphere includes
the emotional readiness of the psychiatric nurses, as well as the skill sets owned in the
domain of care delivery. Nursing education and training provide an opportunity for
psychiatric nurses to improve their competencies in facing challenges in care delivery so
that patient satisfaction and quality of care can be enhanced. In recoveryoriented nursing,
nursing education and training should be an ongoing venture for continuous quality
improvement (McKenna et al., 2014). Optimal outputs are possible from psychiatric
nurses when new developments in their field are instilled in their practice. Recovery-
oriented care can help in achieving the goals of preventing patient relapse, improving the
pace of recovery, ensuring long-term well-being, and reducing the severity of unhealthy
conditions.
Local Background and Context
Patient care involves numerous factors. Most of these are not imparted to
psychiatric nurses at the time of their school-based training. Despite inadequacy in the
content of nursing curriculum on managing patient recovery, especially in psychiatric
care settings, the ability to help psychiatric nurses manage patients’ recovery is crucial in
improving the quality and speed of recovery (Gale & Marshall-Lucette, 2012). Many
health institutions base most of their recovery efforts on patients (Pallaveshi et al., 2013).
18
The health facilities allow patients to be mentally and emotionally stable and cope with
changes in their health status as they strive to return to normal health. However, studies
show that it is vital for nurses involved in psychiatric patient care to significantly impact
the recovery process (Pallaveshi et al., 2013). For instance, effectively working in groups
to manage outpatients or those in rehabilitative facilities generated more positive health
outcomes compared to settings in which patients were left to strive alone on the way to
recovery.
In cases in which health practitioners are actively engaged in the patient recovery
process, health outcomes include higher quality of care and consumer satisfaction. These
two factors determine the sustainability of health systems through increased productivity
and operational efficiency (Cook et al., 2009). Other benefits of health care
providerfocused recovery plans are economic, such as cost effectiveness, or social, such
as a reduction in the patient’s level of stress or depression (Department of Health, 2006).
Recovery-oriented care increases the quality of life after recovery (Pallaveshi et al.,
2013). Psychiatric nurses should be able to approach patients in a therapeutic manner that
encourages and promotes recovery.
The setting for this quality improvement (QI) project was a 26-bed inpatient
psychiatric unit. This unit provides mental health treatment for adults age 21 and older.
Primary admitting diagnoses include depression, bipolar, PTSD, and substance abuse.
Purposeful sampling, as described by Frankfort-Nachmias and Leon-Guerrero (2014),
involved the nursing staff members employed on this unit. Because of the project’s nature
(QI), written informed consent was not required. However, the full disclosure of the
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academic nature of the project was discussed with organizational leaders and project
participants. The institutional policies for vetting and conducting an academic capstone
project were followed. The local institutional review board (IRB) chair classified the
project as non-research operations activities on September 25, 2015 as per the facility’s
standard operating procedures. Walden IRB approved the project on May 27, 2016. The
approval number for this study is 05-27-16-0423452. Ethical considerations were fully
observed regarding confidentiality, privacy, and integrity of all participants. The above
measures were initiated with the consideration that psychoeducation is a requirement for
psychiatric patient recovery.
Psychoeducational groups provide a framework for achieving effective
recoveryoriented care in psychiatric patients. Colom (2011) cites three attributes of
psychoeducation groups in the implementation of efficient recovery-oriented psychiatric
care. The first attribute is an open relationship between the patient and the caregivers,
which facilitates support to psychiatric care in a proactive approach, rather than a reactive
approach. The person with a mental health condition benefits from the ability to open up
on self-care and improves in the capability to take personal decisions, an aspect which is
detrimental for the stability or increase in the speed of recovery. The second attribute of
the psychoeducation model in recovery care is an encouragement for teamwork. Working
in groups is essential in bringing out the best in different workspaces, including nursing.
Therefore, the psychoeducational group is based on the logic of teamwork in
recoveryoriented psychiatric care. Teamwork and open-door-policy come together in
affecting the third attribute of recipient-provider relationship which benefits the patient.
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The relationship sets up a sound social setting, in which the patient trusts the caregiver
and the providers deliver the best quality of service to the recipient (Phillips & Schade,
2012). In the mix, actual outputs are enhanced, as opposed to an environment of mistrust,
which is common in authoritarian patient-provider relations. The psychoeducation group
has become increasingly popular among psychiatric patient recovery programs.
The effectiveness of psychoeducational groups is highly influencing the patients.
However, the staff or provider of recovery-oriented care must have the knowledge and
skills to implement the methodology. According to Aho-Mustonen, Miettinen, Koivisto,
Timonen, and Räty (2008), the application of the psychoeducational group methodology
in psychiatric care settings not only helps long-term mental health patients to receive
better and faster treatment, but also the staff and severely ill patients benefit from the
additional skills and knowledge. Awareness of the illness, side effects, and coping
opportunities are highlighted, offering a collective approach to controlling the prognosis
of the disease. The attitude towards care is positively enhanced among the mental health
patients in the application of the psychoeducation groups, as is the methodology for
implementing recovery-oriented care. The ability of psychoeducational groups in
affecting the change necessary for patient recovery in psychiatric patients is explained by
Slade, Amering, Farkas, Hamilton, and O’Hagan (2014) as the mental transformation
among the staff and the patients, using the theory that human systems only transform
through cognitive development, learning, and training. According to Slade et al.,
changing the human system requires voluntary devotion, trust, and social harmony.
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Psychoeducation groups offer a concrete social setting that supports the positive mental
change in the trained staff member or the patient.
Recovery-oriented patient care instills capabilities of enhanced self-determination
and sense of responsibility. Nursing staff are responsible for providing the best
recoveryoriented care in order to achieve healthy outcomes (Decker, Peglow, & Samples,
2014). Attitudes of both the staff and the patient are positively changed to significantly
contribute towards recovery. Taking into consideration that psychoeducation is
personcentered, the same implementers of recovery care meet the welcoming efforts of
the patient and ensuing optimal health outcomes. As Bore, Hendricks, and Womack
(2013) discovered by using psychoeducational groups in schools, understanding the
context of the patient, such as lifestyle and culture, adds value to the enhancement of
positive health outcomes. The patients benefit from quality health care, as the provider
gains the skills and ability of effective care delivery. The use of psychoeducation groups
is patient recovery-oriented care. Recovery has a huge body of knowledge on the
capabilities of impacting positive health outcomes in the psychiatric setting upon both the
mental health patients and their caregivers.
Role of the DNP Student
As a Psychiatric Nurse Manager, DNP student, and advocate for mental health, I
play a significant role in ensuring that the highest quality of care is delivered to the
patients on the inpatient unit that I manage. In this role, I am responsible for staffing the
unit with competent and knowledgeable nursing staff, including nursing assistants and
registered nurses. This entails fostering a practice milieu that is conducive to learning and
22
securing resources for ongoing nursing staff development. Furthermore, I am responsible
for implementing best practices in mental health treatment and recovery-oriented care.
The motivation for this project comes from a commitment to the mission of the
VA, a commitment to our veterans, and a commitment to our nursing staff. Numerous
studies indicate that recovery-oriented care is a standard of quality care for mental health.
Therefore, producing an environmental milieu, structured to meet the multifaceted needs
of psychiatric patients, consists of establishing evidence informed recovery-oriented care.
Recovery-oriented care is often lacking on inpatient psychiatric units. The nursing staff I
work with appeared to lack fundamental confidence in delivering comprehensive
recovery-oriented care. The nursing staff verbalized several needs and barriers related to
recovery-oriented care, including lack of knowledge and confidence, precluding
recovery-oriented psychoeducational groups from being conducted. I embraced the
opportunity to utilize my doctoral education and training to create and engage staff in a
1hour educational session on recovery-oriented care, the goal of which was to increase
knowledge and the nurses’ level of confidence in conducting psychoeducational groups.
Because a formal project team approach was not utilized for this capstone, one
bias that I had to address was the potential conflict of having supervisory authority over
the nursing staff who participated in the learning needs and barriers assessment and the
subsequent training with evaluation. To address this issue, I relied on the facility’s ICARE
(integrity, commitment, advocacy, respect, and excellence) values to guide the open staff
discussions. I listened to all staff, respected their views, and developed the action plan
and training based on their input. I provided the staff with full project disclosure,
23
complied with the facility’s policies on conducting quality improvement projects, and
conducted the pre- and post-testing evaluation with no identifiers.
Summary
Recovery-oriented care has become a general guiding principle of many mental
health care organizations (McKenna et al., 2014). Recovery care restores patients to their
optimal level of functioning and promotes effective coping methods to manage crisis
situations. Although recovery is a standard of care, nurses may not be familiar with the
concepts and lack the competency and confidence in applying the recovery model in
practice. It is important for nurses to enhance their knowledge towards recovery-oriented
care approaches and improve their level of reliance and confidence. A systemic approach
to applying recovery-oriented frameworks is considered fundamental for the
improvement of services and to bridge the disparity gap to recovery for mental health
patients (Carpenter-Sing, Hipolito, & Whitely, 2012).
Recovery-oriented care views patients holistically, while promoting shared
decision making and social inclusion (Carpenter-Sing et al., 2012). A psychiatric
environment enriched with recovery-oriented care allows nurses to engage therapeutically
with patients and embolden shared decision making by encouraging patients to participate
in their care (Carpenter-Sing et al., 2012). Achieving such a milieu requires that nurses be
fully informed on the concepts of the recovery model. This QI project was conducted as a
first critical step towards developing a recovery milieu in one local setting. What follows
is a detailed description of the methods utilized to conduct the project.
24
Section 3: Collection and Analysis of Evidence
Recovery-oriented care is well recognized as an evidence-based approach to
enhance mental health and quality of life among those with mental illness or addiction.
The focus of recovery-oriented care is to engage patients in mental health or addiction
issues that put the person at the center of the care, rather than the diagnosis. Recovery
refers to the manner in which the person experiences and manages the mental illness or
addiction as they live in the community. Therefore, providing training to staff is essential
for increasing staff level of knowledge, confidence, and development on recoveryoriented
concepts (Le Boutillier et al., 2011).
There are multiple strategies incorporated in recovery-oriented care. One effective
strategy is nurse-led psychoeducational groups. Despite the recognized success of this
approach, many treatment programs have failed to implement high-quality,
comprehensive recovery programming for their patients (Fitzgerald et al., 2012). The
observed failure is attributed to numerous factors. The expressed lack of knowledge and
confidence among psychiatric nurses in planning and delivering psychoeducational
groups was identified as a modifiable barrier in implementing recovery programming
(McKenna et al., 2014). The purpose of the current project was to develop and implement
educational training for psychiatric nursing staff on recovery-oriented care, while also
focusing on how to conduct psychoeducational groups on an inpatient psychiatric unit. A
summary of the specific practice questions and the sources of evidence used to address
these issues is presented in the following section.
25
Practice-Focused Questions
The project was implemented within an inpatient psychiatric unit for adult
patients. Patients in this unit are primarily admitted for the treatment of anxiety and mood
disorders such as PTSD or substance abuse. Implementation of a comprehensive
recovery-oriented program was identified as a strategic goal of the local organization.
Based on internal organizational benchmarks, this unit identified a need to increase the
number and types of nurse-led psychoeducational groups offered to patients. Informal
discussions among nursing staff and nursing leaders suggested that a lack of knowledge
and confidence in providing psychoeducational groups was a concern. To address the
local problem and achieve the organizational strategic goals, the project was conducted to
answer the following four questions:
1. What are the perceived training needs of psychiatric nurses on an acute
inpatient psychiatric unit?
2. What are the perceived barriers to recovery-oriented psychiatric nursing care
on an acute inpatient psychiatric unit?
3. What strategies do nurses need to break the barriers of full and efficient
recovery-oriented psychiatric nursing practice?
4. Is recovery-oriented psychoeducational group training effective in increasing
the staff’s knowledge and confidence in conducting groups?
Sources of Evidence
Two primary sources of data (internal and external) were included in the capstone
project. Internal facility-level evidence was collected from the pre and post knowledge
26
and confidence test, along with the staff’s opinions, which were elicited to develop the
action plan. External evidence from published literature also guided the project.
Published research indicated that patient recovery-oriented care involves numerous
factors, most of which are not imparted to psychiatric nurses during school-based
training. Despite inadequacy in the content of nursing curriculum on managing patient
recovery, especially in psychiatric care settings, the ability to help psychiatric nurses
manage patients’ recovery is crucial in the quality and the speed of recovery (Gale &
Marshall-Lucette, 2012).
Many health institutions base their recovery efforts on patients (Pallaveshi et al.,
2013). The health facilities allow patients to be mentally and emotionally stable to cope
with changes in their health status as they strive to return to normal health. Nevertheless,
studies indicated that it is vital for psychiatric nurses involved in psychiatric patient care
to impact the recovery process (Pallaveshi et al., 2013). Working in groups to manage
outpatients or those in rehabilitative facilities resulted in more positive health outcomes
compared to settings in which patients were left to strive alone on the way to recovery.
Published Outcomes and Research
A systematic review (SR) is used to answer a specific clinical question based on a
thorough analysis and synthesis of the complete body of relevant research evidence. The
data included in an SR is based on preestablished inclusion criteria and follow a
welldefined, rigorous methodology. Although this project was guided by a narrative
review of the literature, the purpose and scope of the project did not warrant a formal
systematic review.
27
Archival and Operational Data
Although the scope of the project did not include a secondary analysis of archival
or prospective operational data, local benchmark information on the number of
psychoeducational groups was considered in designing the scope and focus of this
project. Based on benchmark analyses conducted by the staff (according to organizational
standards and procedures for collecting data, conducting benchmark analysis, and
communicating the outcomes to shared stakeholders), the local organization recognized
the need to increase the number and types of nurse-led psychoeducational groups.
Leaders and key organizational stakeholders worked closely in guiding this project and
were invested in the successful implementation of the project plan.
Evidence Generated From the Doctoral Project
The Iowa model of EBP (Titler et al., 2001) was used as a framework in
implementing this QI project. I followed the six steps outlined for piloting a change in
practice. These included selecting the targeted outcomes, collecting baseline data,
designing the intervention, implementing the intervention on the targeted unit, evaluating
processes and results, and modifying the intervention as required.
The setting for this QI project was a 26-bed inpatient psychiatric unit. This unit
provides mental health treatment for adults age 21 and older. Primary admitting diagnoses
include depression, bipolar, post-traumatic stress disorder (PTSD), and substance abuse.
Purposeful sampling approaches, as described by Frankfort-Nachmias and Leon-Guerrero
(2014), were used by inviting all of the nursing staff employed on the targeted unit to
participate in the open-ended staff discussions and formal educational training.
28
I used both qualitative and quantitative methods and procedures for the
evaluation. Qualitative methods include open-ended interviews/discussions to acquire
perceptions from participants regarding experiences. Open discussions with nursing staff
were used to identify learning needs and perceived barriers to implementation of
recovery-oriented care within the context of an acute inpatient psychiatric unit.
Discussions were conducted with the interdisciplinary team with the intent of gaining
insight into their thoughts on recovery-oriented care and barriers preventing
recoveryoriented care from being implemented. Following the qualitative approach, I
documented (through handwritten notes) the information obtained from these discussions
and examined the data for common themes (see Frankfort-Nachmias & Leon-Guerrero,
2014). This approach provided valuable information regarding the knowledge that the
nursing staff possess on conducting recovery-oriented groups and the barriers that these
nurses encounter. Engaging the nursing staff in these types of discussions allowed their
input and experience to be incorporated into an action plan for the unit, thereby
encouraging ownership and buy-in from the staff. A focused barrier-reduction
implementation action plan was developed based on the thoughts and beliefs presented in
these discussions.
Assessing and evaluating practices represent a key to quality psychiatric nursing
and help in developing interventions to promote a practice change. According to M.
Cleary et al. (2013), there is a need for education programs with an evaluation to address
the gaps in the knowledge of staff and ensure that clinical practices and philosophies are
recovery focused. As a second primary emphasis, I developed and implemented an
29
educational intervention aimed at improving the knowledge and confidence of nursing
staff in conducting psychoeducational groups. The educational intervention was delivered
in a face-to-face group session and covered key principles of recovery-oriented care and
psychoeducational groups. The instructional delivery strategies were based on
adultlearning principles and included didactic PowerPoint slides and guided group
discussion to achieve the objective of the teaching session. The educational intervention
was designed using the best available evidence on recovery-oriented psychoeducational
groups, as well as identified learning needs of the participants. The educational
intervention was delivered on site and included acceptable teaching strategies based on
adult learning principles.
According to Step 5 of the Iowa model of EBP, staff knowledge and confidence
were evaluated after their participation in the educational session. Baseline knowledge
and confidence data were collected before the implementation of the educational
intervention, using a Likert-type scale. A Likert-type pretest and posttest containing the
same 10 assessment questions was developed to evaluate the educational intervention
(five questions assessing knowledge and five questions assessing perceived confidence).
The following steps were implemented in the development of this test: Knowledge
questions were generated based on the content of the educational training, while
confidence questions were designed based on other confidence questions used in previous
local organizational training. Because the pretest/posttest was not a standardized tool
from the literature, information about its validity and reliability is not available. The
potential limitation and resulting bias from using such a tool is also recognized. However,
30
to help establish preliminary validity, I enlisted a nurse researcher, a nurse educator, and a
psychiatric clinical nurse specialist within the local organization to assess face validity.
Changes to the pretest/posttest first draft were made based on their comments and
expertise. Participants completed the pretest/posttest before and immediately after the
educational session.
Because this was a QI project, written informed consent was not required.
However, the academic nature of the project was discussed with organizational leaders
and project participants. The institutional policy for vetting and conducting an academic
capstone project was followed. The proposed QI project was submitted to the local
institutional review board (IRB) chair for a formal “non-research operations activities”
determination as required by standard operations and policies. Based on this review, the
project was deemed to meet the definition of quality improvement on September 25,
2015. The project was submitted to Walden IRB for review, and received final approval
on May 27, 2016 (IRB approval number 05-27-16-0423452).
Ethical considerations were fully observed regarding confidentiality, privacy, and
integrity of all participants. Participants’ pretests and posttests were labeled with a
deidentified code, and hard copies were stored in locked files according to the local
organization’s protocols. Electronic scores were recorded in an Excel file and stored in
SharePoint on a password-protected computer owned by the facility. The Excel data file
was transferred to SPSS 24 by a research nurse associated with the institution’s research
and development program. According to local policies, no data were removed from the
facility or stored on a personal computer. Furthermore, destruction of hard and electronic
31
data is in compliance with the local organization’s record-keeping policies. Open-ended
discussion notes were documented as per the organization’s standard process for keeping
minutes. Also, these notes were recorded without names to protect the participants’
identities.
Analysis and Synthesis
Internal data (evidence) specific to this project were collected using qualitative and
quantitative strategies as planned for each question. Open-ended staff discussions were
employed to collect information for Questions 1, 2, and 3. A pretest/posttest was used to
collect data for Question 4. Demographic information and experience level were
collected on the pretest questionnaire (Appendix A). The systems used to record, track,
organize and evaluate the data (internal evidence) were provided by the local
organization in which this project was conducted. All local policies and requirements for
collecting, storing, analyzing, and reporting on data and outcomes were followed.
Qualitative responses from the open-ended staff discussions were documented in
consonance with local policies for recording minutes.
Hard copies of the pretest/posttest responses were stored in a locked file cabinet in
a locked room pursuant to local policies. Item response data were transferred to an Excel
file by two individuals to ensure the quality of the database. Specifically, one person read
each response by question, while the other person recorded the responses in the Excel
database. A research nurse transferred the Excel file into the SPSS 24 statistical program.
A data dictionary was created for the purposes of coding and interpreting responses for
the SPSS data analysis. To ensure the data were transferred accurately, a random check of
32
items was conducted and it was found that all items were correctly coded and entered per
the data dictionary. Finally, a descriptive summary for each pretest/posttest item was
generated using SPSS 24. All data were consistent within the range of the coded
responses for each item; no erroneous data or outliers were identified.
Because the educational intervention was not classified as a mandated training per
local operating procedures, a requirement for all participants to complete the
pretest/posttest was not imposed. Nevertheless, all participants (24) completed the
pretest/posttest evaluation. To minimize missing information and data, participants were
asked to check their pretest and posttest for completion before turning them in. Even with
this prompt, there were a couple of items with missing information. Items with missing
data were included in the analysis.
This QI project incorporated both qualitative and quantitative analytic procedures
based on the focus of each project question. Further details linking project questions, data
collection strategies, and the evaluation plan are illustrated in Table 1.
Table 1
Project Analytic Plan and Procedures
Project question Data collection
strategies
Evaluation plan
1. What are the training
needs of psychiatric
nurses on an acute
psychiatric unit?
Open-ended discussion
with staff – qualitative.
Learning needs were identified
and shared with the local
leaders and the nursing staff.
Also, concurrence was elicited
from local leaders and nursing
staff.
2. What are the perceived
barriers to
recoveryoriented
psychiatric nursing care
on the acute psychiatric
Open-ended discussion
with staff – qualitative.
Common barriers were
identified and shared with the
local leaders and nursing staff.
Consensus was elicited from
33
unit? local leaders and nursing staff.
3. What are the perceived
strategies to implement in
order to address the
barriers to full and
efficient recoveryoriented
psychiatric nursing
practice?
Open-ended discussions
with staff – qualitative.
An action plan was
developed based on staff
input of perceived
training needs, barriers,
and strategies to address
barriers.
Common needs were
identified and shared with
local leaders and nursing staff.
Consensus was elicited from
local leaders and nursing staff.
The completion of an Action
Plan was evaluated by a
simple Yes / No completion
benchmark. The action plan
was shared with local leaders
and nursing staff.
4. Is the “RecoveryOriented
Psychoeducational
Group” training session
effective in increasing
nurses’ knowledge and
confidence in conducting
psychoeducation
groups?
Deliver face-to-face
training on group
dynamics and principles
of psychoeducation
groups.
Quantitative methods were
used to evaluate pretest and
posttest knowledge and
confidence.
A posttest score of 80% was
used as the benchmark goal,
as per the standard operating
procedures of the local
organization. The percentage
of participants that obtained
the 80% posttest benchmark
was calculated in SPSS 24.
Pretest/posttest change scores
were calculated. Ttest was
used to estimate differences
between pretest and posttest
scores. SPSS 24 was used to
generate change scores and to
conduct the t-test.
Summary
The aim of this project was to enhance recovery-oriented psychoeducational
group programming on an adult psychiatric inpatient unit. This was accomplished
through two key tactics. A practical action plan was developed for leaders and staff to
help address the perceived barriers and needs of local staff in implementing recovery care
and psychoeducational groups. A focused educational training on recovery care and
psychoeducational groups was implemented to increase the nursing staff’s knowledge and
34
confidence in providing rehabilitation care and psychoeducation groups. The findings and
recommendations of the project are presented in next section.
35
Section 4: Findings and Recommendations
Recovery-oriented care is an essential, evidence-based approach to enhance
mental wellness and quality of life among those with psychiatric disorders or dependency.
Kane (2015) indicated that recovery-oriented care promotes mutual respect and instills
hope, empowerment, and compassion, while focusing on the patient’s needs. The focal
point of recovery-oriented care is to engage patients in mental health and/or addiction
treatment modalities that place the individual at the heart of the illness rather than the
diagnosis. Recovery refers to how the person experiences and manages the mental disease
or addiction as he or she lives in the community. Developing an interpersonal relationship
is considered a patient-centered care aspect and is the foundation of providing recovery-
oriented care (Kane, 2015). Recovery-oriented care consists of several interrelated
approaches used by health practitioners to assist patients on their personal and
individualized recovery journey. One strategy is the inclusion of psychoeducational group
programming for patients on inpatient psychiatric mental health units. Despite the
recognized success of the recovery-oriented approach to care, comprehensive recovery-
oriented programming is lacking for many patients seeking mental health treatment
(Fitzgerald et al., 2012). Given this background, the specific aims for this project were
threefold: (a) to identify the perceived training needs and barriers to recovery-oriented
psychiatric nursing care, (b) to identify strategies to address these needs and barriers, and
(c) to develop and conduct an educational training on recoveryoriented psychoeducational
group programming for nursing staff on an inpatient psychiatric mental health unit. In this
36
section, I provide a summary of the specific practice questions and the sources of
evidence used to answer these questions.
Research evidence and best practice guidelines provide guidance and insight into
the multiple strategies incorporated in recovery-oriented care. One effective strategy is
nurse-led psychoeducational groups. Despite the recognized success of this approach,
many treatment programs fail to implement high-quality, comprehensive recovering
programming for their patients (Fitzgerald et al., 2012). This is attributed to numerous
modifiable factors. The expressed lack of knowledge and confidence among psychiatric
nurses in preparing and delivering psychoeducational groups is considered a modifiable
barrier in implementing recovery programming (McKenna et al., 2014).
This QI project was implemented in an inpatient psychiatric unit for adult
patients. Patients on this unit are primarily admitted for the treatment of mood disorders,
anxiety disorders including PTSD), and substance abuse. Most patients are diagnosed
with a dual psychiatric disorder, which necessitates recovery-oriented programming and
care. Implementation of a comprehensive recovery-oriented program was identified as a
strategic goal of the local organization. Based on evidence from internal organizational
benchmarks, this unit highlighted the need to increase the number and types of nurse-led
psychoeducational groups offered to patients, as patients voiced concerns about the lack
of teamwork and activity on the unit. Informal discussions among nursing staff and
nursing leaders indicated that lack of knowledge and confidence in providing
psychoeducational groups was a concern. To address this local problem and achieve the
organizational strategic goals, the project addressed the following four questions:
37
1. What are the perceived training needs of psychiatric nurses in acute
psychiatric units?
2. What are the perceived barriers to recovery-oriented psychiatric nursing care
on an acute inpatient psychiatric unit?
3. What strategies do nurses need to implement to break the barriers of full and
efficient recovery-oriented psychiatric nursing practice?
4. Is recovery-oriented psychoeducational group training effective in increasing
the staff’s knowledge and confidence in conducting groups?
Internal data (evidence) specific to this project were collected using qualitative
and quantitative strategies as planned for each question. Open-ended staff discussions
were used to answer Questions 1, 2, and 3. Question 4 was answered using a
questionnaire for data collection. Demographic information and perceived level of
experience were collected on the pretest questionnaire. The pretest and posttest contained
the same 10 assessment questions: Five questions assessed knowledge and five questions
assessed perceived confidence. To accurately match pretest and posttest responses, each
pretest/posttest paired set were numerically identified with matching numbers and paper
clipped together. To assist the participant in completing the correct test, the pretest was
printed on blue paper and the posttest was printed on white paper. Participants completed
the pretest (blue) questionnaire immediately prior to the educational training and turned it
in. Participants completed the posttest (white) immediately after the training and turned it
in. Participants were informed that the questionnaire responses would be anonymous, and
the numbering system was used for matching pretest and posttest scores. SPSS Version 24
38
was used to analyze the data related to the effectiveness of the educational session in
increasing knowledge and confidence in conducting recovery-oriented psychoeducation
groups (Question 4).
Findings and Implications
A total of 24 nursing staff members working on an acute inpatient psychiatric unit
participated in this QI project. Participants consisted of 8 men and 16 women, nine of
which were registered nurses (RNs) and 15 were nursing assistants (NAs). Most staff
(83.3%) reported that they had moderate to extensive experience working with
psychiatric patients. Although 50% indicated that they had moderate to extensive training
in recovery-oriented care, more than half (58.3%) reported that they had none to minimal
training in conducting psychoeducational groups. These findings were consistent with the
informal staff discussions on perceived training needs in conducting psychoeducational
groups. The reported levels of experience and training are presented in Table 2.
Table 2
Level of Experience and Training
Level of experience
working with
psychiatric patients
n (%)
Training in
recovery-oriented
care
n (%)
Training in
conducting
psychoeducational
groups n
(%)
Did not answer 1 (4.2) 1 (4.2) 0 (0)
None 0 (0) 2 (8.3) 2 (8.3)
Minimal 3 (12.5) 9 (37.5) 12 (50.)
Moderate 9 (37.5) 8 (33.3) 8 (33.3)
Extensive 11 (45.8) 4 (16.7) 2 (8.3)
39
Project Question 1 Findings: Perceived Training Needs
Results from the open-ended staff discussions revealed that most staff indicated
they had no formal training on how to conduct psychoeducational groups. They felt like
the organization was pushing them to perform groups without providing the appropriate
training. Although some staff voiced that they feared speaking in public during groups,
others stressed an overall lack of confidence in managing group dynamics. A few of the
staff expressed a lack of knowledge regarding group topics and the actual content to be
included during the groups. Finally, some staff voiced confusion over the various types of
psychoeducational groups. Several staff-led psychoeducational groups were observed and
noted to be poorly facilitated, further indicating that staff lacked knowledge and
confidence in managing the dynamics of the groups.
Project Question 2 Findings: Perceived Barriers
In addition to identifying a perceived lack of training and knowledge, staff voiced
frustration over, the numerous unit admissions and discharges, changes in patient acuity,
and the amount of documentation that made conducting groups a low priority. Staff
perceived these issues as barriers preventing them from conducting psychoeducational
groups and implementing recovery-oriented care.
Project Question 3 Findings: Strategies to Overcome Barriers
Staff asked for more education and learning opportunities related to recovery
programming and skill building in conducting psychoeducational groups. Staff also asked
for protected time to attend training sessions.
40
Project Question 4 Findings: Effectiveness of Recovery-Oriented Psychoeducational
Training
Per the standard operations procedures of the local organization, a posttest
knowledge score of 80% was used as the benchmark goal for the participants. The
knowledge test consisted of 8 questions with a possible total score of 0-8 points. A correct
response was scored as 1 point. The 80% benchmark was calculated as 6.4/8 correct
responses. Because scores were limited to whole numbers, a score of 7 (87.5%) was
required to meet the 80% benchmark for individual participants. As indicated in Table 3,
findings showed an increase in knowledge scores from pretest to posttest. Pretest scores
ranged from 3 to 8, with 10 (50%) participants meeting the 80% benchmark for passing.
Posttest scores ranged from 5 to 8, with 12 (58.3%) meeting the benchmark. Although the
number of individuals who reached the benchmark increased from pretest to posttest, 10
(41.7%) individuals did not reach the posttest benchmark set by the organization.
Table 3
Pretest and Posttest Knowledge
Knowledge Score
Pretest Posttest
Frequency % Frequency %
0 0 0 0 0
1 0 0 0 0
2 0 0 0 0
3 1 4.2 0 0
4 2 8.3 0 0
5 4 16.7 4 16.7
6 5 20.8 6 25.0
7 10 41.7 5 20.8
8 2 8.3 9 37.5
Total 24 100 24 100
41
As displayed in Table 4, the mean (average) score for knowledge increased on the
posttest immediately after participating in the educational session. The paired pretest and
posttest difference was statistically significant for knowledge at the .05 significance level
(Table 5). Additionally, a paired t test was conducted to compare pretest and posttest
confidence. As shown in Tables 4 and 5, there was a slight decrease in posttest confidence
scores, but this difference did not reach statistical significance. The confidence result was
not anticipated; however, on further reflection, the result makes sense as increasing
confidence is more likely achievable with tangible hands-on experience, which the
classroom setting did not provide.
Table 4
Descriptive Results for Knowledge and Confidence
Pretest Post test
Outcome N Mean SD Mean SD
Knowledge 24 6.125 1.296 6.792 1.141
Confidence 24 18.875 2.365 18.250 4.589
Table 5
Paired Sample t Test Results for Knowledge and Confidence
Paired differences
95% Confidence
Interval
Std. meanerror
t df (2-Sig.tailed)
Outcome Mean SD Lower Upper
Knowledge -.667 1.435 .293 -1.272 -.061 -2.277 23 .032*
Confidence .625 4.189 .855 -1.144 2.394 .731 23 .472
*Statistically significant at 0.05.
42
The recovery-oriented care project has substantial implications for positive social
change for individuals, communities, and institutions/systems. Project findings indicated
staff discomfort and lack of knowledge with recovery-oriented concepts. Findings also
confirmed staff reports, patients’ complaints, and the agency’s position that
recoveryoriented care is lacking on the inpatient psychiatric units. Educating staff and
providing ongoing training on recovery-oriented care and psychoeducational groups will
benefit patients, staff, and the agency. Vreeland (2012) stated that psychoeducational
groups help patients make behavioral changes that can contribute to improving
compliance with treatment. A team that is knowledgeable and competent in conducting
recovery-oriented psychoeducational groups is more likely to provide a safe and
structured patient-centered inpatient environment. The agency’s strategic goals of
providing the highest quality care are realized by improving patient outcomes and
decreasing recidivism rates.
Implementing recovery-oriented care has the potential to benefit the other two inpatient
units, while also improving the therapeutic relationships and the care that patients receive
on those units by providing an environment enriched by psychoeducation. According to
Vreeland, staff facilitating psychoeducational groups must possess the skills to guide the
team and provide a strong educational element. Having a competent staff is critical to
conducting psychoeducational groups and implementing recovery-oriented care.
43
Recommendations
For staff to achieve and sustain knowledge and confidence in recovery-oriented
care and conducting psychoeducational groups, a solid action plan for continued learning
is required. The recommendations are as follows:
1. Provide ongoing and mandated trainings for all nursing staff. Provide staff
with protected time to attend trainings.
2. In addition to immediate posttraining evaluations, incorporate longitudinal
program evaluations to inform sustained learning and confidence in
conducting recovery-oriented psychoeducational groups.
3. Implement future projects involving education for recovery-oriented care and
psychoeducational groups on all three inpatient psychiatric units.
4. Integrate classroom and experiential learning opportunities based on adult
learning theory.
These recommendations along with plans for dissemination will be shared with
the key stakeholders within the organization along with the Action Plan and Competency
Sheet (Appendices B and C).
Contributions of the Doctoral Project Team
While a formal project team was not utilized to conduct this capstone, key
stakeholders (including the service area Associate Chief Nurse, Clinical Nurse Specialist,
members of the psychiatric interdisciplinary team, and the Associate Chief Nurse for
Research) were fully engaged from the inception of the project. The cumulated
experience working with numerous key stakeholders with varying levels of buy-in was a
44
revelation for me. The organization attempted to implement recovery-oriented care in
2013, which was unsuccessful. Staff working on the acute inpatient psychiatric units had
limited knowledge of how recovery-oriented care relates to mental illness. The key
stakeholders collaborated throughout the early planning stages and the duration of this
project. Key stakeholders conducted a gap analysis and concluded that the absence of a
recovery model and lack of psychoeducational groups was an area for QI efforts. The
stakeholders were engaged from the very beginning by assisting, providing guidance, and
working in collaboration, to develop a solidified plan to help educate the staff on the
inpatient psychiatric unit. The next step was to share the outcomes with other
stakeholders and discuss expanding the project to the other inpatient units. Because this
project resulted in an increase in nursing staff knowledge, key stakeholders agreed to
extend the project to the other two psychiatric inpatient units. Furthermore, because
confidence overall did not have a significant improvement, experiential learning
opportunities will be built into the training for all three units. Future directions include
having nursing staff observe psychoeducational groups conducted by a psychologist
prior to conducting groups on their own. The nursing staff conducting the group will
receive honest and constructive feedback to help them improve their group facilitation
skills.
The team members were very helpful and identified the gap in practice and the
need to improve care delivered to psychiatric patients by implementing recovery-oriented
care. All members worked hard and fully participated in discussing the project’s
implementation. The group decided that future recovery-oriented training will utilize
45
adult learning principles and include experiential learning. A one-time training is not
sufficient for improving the nursing staff’s level of confidence in conducting
psychoeducational groups.
Strengths and Limitations of the Project
The main strength of the project was utilizing adult learning theory in designing
and delivering the educational training. The use of focused discussion using real life
situations to reinforce principles enabled the staff to self-direct the conversation and
openly discuss their concerns and fears while understanding the concept of
recoveryoriented care and psychoeducation groups. Staff commented that they felt
comfortable having the roundtable discussion. The atmosphere was conducive to learning
and the staff actively participated.
A limitation of the project was that the training was only offered to staff on one
inpatient psychiatric unit and not all staff members were able to participate. Protected
time was given to unit nursing staff to attend the training; however, 10 staff members
were on extended leave and were not able to participate in the educational session. Future
educational trainings focused on recovery-oriented care and psychoeducational groups
should be implemented with all nursing staff on all three inpatient psychiatric units using
the adult learning theory.
A second limitation was that the intervention was delivered as a single educational
session in a classroom setting. While the teaching approach was grounded in adult
learning principles and resulted in improved staff knowledge, it is recognized that
confidence is more likely to improve with experiential learning. Benner (1984) states that
46
there are five levels of skill acquisition that a nurse transitions through to achieve
expertise. All nurses begin as novices and gain expertise through clinical experience and
knowledge acquisition. Currently, a little over half (58.3%) of the nursing staff
selfidentify as having none to minimal experience (i.e., are novices) in conducting
psychoeducational groups. While not everyone reaches the expert level (Benner, 1984), it
is anticipated that the more groups staff facilitate, the more likely their skill level and
confidence will improve. Future education should include hands-on experiential training
in conducting psychoeducation groups.
A final limitation is the timing of the pretesting and posttesting. A stronger design
is to evaluate sustainability of learning and confidence over time. Given the scope of the
project, longitudinal data collection was not incorporated. Recovery programming is an
ongoing quality improvement initiative and linked to the organization’s strategic plan; as
such, learning opportunities (both in the classroom setting and hands on experience in
conducting groups) and longitudinal program evaluation are recommended and included
in the action plan developed as a part of this project.
47
Section 5: Dissemination Plan
The outcome of this recovery-oriented care training will be shared with the key
stakeholders within the institution. The key stakeholders will be informed that the nursing
staff members who received the training were able to score better on the knowledge
posttest. The results of this project proved useful in adding quality improvement evidence
to the field of nursing, especially on matters of recovery-oriented care in mental health.
Per stakeholder buy-in and commitment, the recommendations from this project will be
applied to all three inpatient mental health units in the organization to improve nurses’
training regarding recovery-oriented care of mentally ill patients. The findings and
recommendations from this study will be disseminated through additional internal facility
trainings, workshops, and seminars to provide ongoing education to train nurses on
recovery-oriented care and psychoeducational groups.
There are opportunities to share the results of this project to the local and national
community beyond facility level dissemination. I plan to submit an abstract to the Greater
Pittsburgh Nursing Research Conference held annually in the region’s area. Additionally,
I plan to share the findings at the national Veterans Administration (VA) level with the
VA Office of Nursing Services mental health clinical advisor.
Analysis of Self
Developing, implementing, and analyzing the results of this recovery-oriented
care project was a challenging process that has elevated my ability to implement an
evidence-based project to change practice and improve patient outcomes. I was a novice
starting out, unaware of the rigor of the process. However, as my knowledge expanded, I
48
gained a greater understanding of the importance of the institutional review board and the
cumbersome but necessary process for attaining approval. My passion for psychiatric
nursing and advocating for patients with mental health kept me motivated and engaged in
this project as I realized how beneficial this project would be for mental health patients
and staff. On the other hand, I was disappointed by my lack of knowledge of
recoveryoriented care and my failure in leading the staff toward recovery-oriented care
beforehand. My extensive research, my work with other disciplines, and my preceptor
helped strengthen my leadership and management skills. I am now able to recognize the
value of a recovery-oriented environment and the positive impact it has on the well-being
of psychiatric patients and staff. The knowledge and insight I have gained through this
experience have equipped me for my future role as a DNP nurse, my work as a lifelong
learner, and the responsibilities that come with that title, such as helping to change
clinical practice and implementing evidence-based projects to improve patient outcomes
and provide educational opportunities for staff.
Summary
Mental health patients face numerous daily challenges such as dealing with stigma
and other inadequacies as they strive to manage their mental illness. When confronted
with a mental health crisis, this vulnerable population requires quality care with a patient-
focused approach. This occurs through developing trusting partnerships with the staff to
help them obtain the necessary tools and resources to handle crisis situations and to assist
patients in returning to their optimal stage of performance.
49
Recovery-oriented care is a holistic approach that embraces several interrelated pieces
that create the foundation of patient-centered care. Psychoeducational groups are a major
component of recovery and are the driving force for educating psychiatric patients on a
variety of health and related social issues. According to Vreeland (2012),
psychoeducational groups decrease relapse and recidivism rates while improving
medication compliance and patient satisfaction by allowing shared decision-making.
Providing quality care for psychiatric patients requires a staff that is knowledgeable,
comfortable, and confident with conducting psychoeducational groups. Recoveryoriented
care and psychoeducational groups improve patients’ comprehension and level of
understanding regarding their mental illness (Vreeland, 2012). However, when staff
members lack knowledge and confidence in implementing recovery-oriented care, the
potential exists to negatively impact patients participating in noneffective groups. A lack
of knowledge and confidence among staff can be modified with proper training. Ongoing
training is the key for helping staff increase their level of confidence in conducting
psychoeducational groups with a vulnerable mental health population. This training
offered in this project proved to be a successful strategy in the ongoing goal for
implementing recovery-oriented care for the psychiatric patients in this facility.
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