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Effectiveness of Education Module on Therapeutic Communication

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Effectiveness of Education Module on Therapeutic Communication

Therapeutic Communication is crucial in mental health care as it enables nurses and

other staff to understand the needs of patients and plan how to improve their psychological

and emotional well-being. Still, some nurses experience difficulties in establishing a

therapeutic relationship, especially with patients presenting with moderate to severe mental

illnesses (Kyaw et al.,2019). The nurses either lack knowledge or competency in maintaining

a therapeutic nurse-patient relationship. Sharma & Gupta (2021) state that therapeutic

communication is the adopted communication structure in all areas of healthcare. This

implies that nurses and other staff should learn how to communicate effectively with patients

to help them achieve quality outcomes. Still, some nurses experience problems

communicating with patients due to a lack of adequate skills or being incompetent when

dealing with psychiatric patients. Cheraghi et al. (2021) state that educating nurses could help

improve how they communicate with patients. More research is needed to determine how

education can improve therapeutic communication. This literature synthesis paper will search

for evidence on the effectiveness of education modules in improving nurses' knowledge and

competencies in therapeutic communication.

Search Methodology

A literature search was performed using three electronic databases, PubMed,

CINAHL, and PsycINFO to identify studies that addressed how an education module on

therapeutic communication could improve nurses' knowledge and competencies. Inclusion

criteria involved articles published in the previous five years, published in English,

systematic reviews and RCTs, and articles that addressed education modules on therapeutic

communication. Search terms included “education module”, “nurses’ knowledge and

competence”, and “therapeutic communication”. The Boolean operator, “AND” was

incorporated in the search to specify results. For example, Education module “AND”

Therapeutic communication “AND” nurses’ knowledge and competence. The search resulted

in 5126 studies. 4987 studies were excluded remaining 139 studies. Abstracts of the

remaining studies were reviewed and 128 were removed since they did not apply

recommended methodologies. The remaining 11 articles were analyzed and six were

excluded, leaving five articles; Gutiérrez-Puertas et al. (2020), Kyaw et al. (2019), Li et al-

(2019), Talevski et al. (2020), Hartley et al. (2020). These studies are explained below.

Literature Review

Gutiérrez-Puertas et al. (2020) conducted a systematic review of RCTs between

September 2019 and January 2020 to determine the impact of educational interventions on

nursing students and mental health staff nurses who provided regular care to psychiatric

patients. The search was performed on PubMed, CINAHL, and Web of Science. Articles

published in English between 2000 to 2020 were included. RCTs and quasi-experimental

studies were given priority. The study population included mental health nurses and

undergraduate nursing students. Studies that focused on training participants about

therapeutic communication or patient-centered communication were selected. Objectively

measured or self-reported quantitative data about therapeutic communication were evaluated.

5,845 studies were retrieved from the search. 19 quantitative studies met the inclusion criteria

and were further included in the meta-analysis. An overall sample of 1295 participants

engaged in the included studies. Most studies were conducted in the mental health setting.

Eleven studies applied simulation as an intervention as a learning approach to promote

therapeutic communication. Standardized patients were used to enhancing learning in nine

studies, three studies applied role-playing, and five applied development courses to promote

therapeutic communication. More than half (n=11) of the studies that used simulation as an
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intervention reported improvement in patient-centered communication in the intervention

group compared to the control group.

Educating student nurses through simulation improved their competence in patient

communication since it provides realistic scenarios that enabled them to practice and evaluate

their skills in therapeutic communication. Participants also learn to interact with patients in

clinical settings, and this could help improve the quality of patient outcomes. The study has

strengths and limitations. Firstly, the systematic review enabled researchers to conduct a

broad search of studies that addressed communication between nurses and patients. Research

methods were systematically applied in the reviewed studies to improve the quality of

findings. A two-person analysis of the studies to include in the studies was done as well to

improve the reliability of findings. Some of the limitations that faced the study included the

elimination of studies not published in English. This might increase the level of bias by

ignoring other languages. Also, variability in the sample size, duration of studies, and

interventions affected the nature of the final results.

Li et al- (2019) conducted a systematic review and meta-analysis to investigate the

effectiveness of problem-based learning (PBL) in molding professional communication

competencies among nurses and nursing students. PBL was compared with the traditional

teaching and learning approach. A literature search was performed on PsycINFO, EMBASE,

PubMed, and MEDLINE. RCTs and quasi-experiments that involved nurses and nurse

students as participants were eligible for inclusion. Only students that applied PBL as a

primary intervention and evaluated communication as an outcome were selected. The search

resulted in 1388 abstracts. 1001 studies were excluded and 84 were chosen for full-text

review. 12 articles remained for a comprehensive review. Eleven studies showed PBL

improved communication skills among nurses and nursing students. The approach equipped

them with the necessary skills to develop a therapeutic relationship with patients and solve
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presenting health issues. Eleven studies also displayed no difference in outcomes between

PBL and traditional teaching methods. Only one study showed that PBL differs from the

traditional teaching method. These findings implied that PBL has no specific variations over

other education modules for improving communication skills.

A major strength of the study is that it involved a comprehensive review of the

literature to compare PBL and other education modules. Different databases were researched

resulting in many studies which were narrowed down based on the inclusion criteria. RCTs

were given priority during the selection and this improved the quality of evidence. Still, the

study had some limitations that affected the nature of the outcomes. For instance, there was a

lack of consistency in the length of intervention in different studies. Outcome indicators were

not consistent as well. The Sample size was also small to draw quality and accurate

outcomes. Finally, PBL intervention was too specific such that researchers could not identify

enough studies to explain its effectiveness.

Talevski et al. (2020) also undertook a systematic review based on PRISMA

guidelines. A literature search using EMBASE, CINAHL, MEDLINE, and Cochrane Central

was done. Eligibility criteria were applied whereby RCTs, nonrandomized trials, case-

control trials, and quasi-experiments were prioritized. All studies were supposed to have

teach-back intervention in either the control or intervention group. The study aimed to test the

effectiveness of 'the teach-back strategy in improving communication and its outcomes

between practitioners and patients. Quality assessment was done to determine if the studies

met the quality standards. The search resulted in 2,738 studies, of which 20 studies met the

inclusion criteria. Nine studies were RCTs, four pre-post studies, two controlled clinical, and

one before and after study. Teach-back intervention was implemented by different

practitioners, including nurses (n=9), PCPs (n=2), and pharmacists (n=1). Five studies

applied brochures and written content for teaching, four studies applied a less structured
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technique, and two studies applied the teach-back method during patient discharge. Findings

showed that the teach-back strategy was the most applied teaching method (n=8). Five studies

applied group education modules, three applied interactive role-playings, and one applied

online education modules.

Evaluative and iterative strategies were incorporated into four studies. Nurses

received weekly emails to remind them to apply a teach-back strategy when communicating

with patients. Nineteen studies showed positive outcomes following the implementation of

the teach-back intervention. Nurses and other practitioners were satisfied with the teach-back

approach and they viewed it as a simple approach that could harness positive communication

with patients. Nurses were trained to assess patient needs and reflect on the best-practice

communication techniques. This study showed that teaching practitioners about the teach-

back method improved how they interacted with patients, hence improving therapeutic

communication. The study has several strengths. It applied a strong and comprehensive

search approach which made researchers identify all the possible studies that addressed the

topic. Also, only studies that addressed the teach-back method were considered and this

improved specificity and quality findings. The study has limitations as well. Only published

articles were included and this increased potential for publication bias. Half of the articles did

not give a detailed description of how the intervention was implemented. This made it

difficult to relate the intervention with health outcomes and participants’ experiences.

Hartley et al. (2020) conducted a systematic review to identify interventions that

could improve the therapeutic alliance between nurses and patients. As the search was done

using Embase, MEDLINE, CINAHL, and PsycINFO. Eligibility criteria were applied

original, peer-reviewed, and articles written in English were included. Articles with an

intervention that aimed to improve therapeutic alliance between nurses and patients were

included. All studies were assessed for methodological quality before selection. A total of
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8,275 articles were retrieved and analyzed. Only eight met the inclusion criteria. The studies

applied different interventions, including staff training on psycho-social interventions,

psychological formulation, cognitive analytic model, consultancy model, structured ward

timetables, participatory action research, and broad-based collaborative care. Interventions

that targeted nurses’ attitudes, such as group-based programs and staff training improve staff

knowledge but did not improve the nurse-patient therapeutic alliance. The study showed that

other factors, other than nurses' knowledge of improving therapeutic alliance might affect

how they interact and communicate with patients.

The study had strengths and limitations which changed the outlook of findings. The

only strength is that it tested different interventions making it easier to compare and identify

different ways to promote the therapeutic alliance between nurses and patients. However,

several limitations make the study unreliable. For example, most of the studies applied weak

methodologies which affected the quality of findings. The number of selected articles was

also small such that it could not give realistic outcomes. Lastly, the study does not discuss a

specific intervention to promote nurses’ competency during therapeutic communication, such

as education modules.

Kyaw et al. (2019) performed a systematic review of RCTs and cluster RCTs to

investigate the effectiveness of education in improving communication skills among mental

health nurses. The research aimed to observe and analyze if digital education could help

mental health nurses develop quality communication skills in the future. A literature search

was performed based on PRISMA guidelines. Electronic databases used included MEDLINE,

Ovid, EBCSO, and Cochrane Central. Two reviewers were involved in data extraction.

Eligibility criteria were applied on RCTs that researched digital or blended education were

applied. Studies that compared digital education with other forms of learning were included

as well. Study participants were not excluded based on gender, age, or other
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sociodemographic factors. Assessment of the risk of bias was done using the Cochrane Risk

of Bias Tool. Data synthesis and analysis were done using SD and mean.

44,054 records were identified during the search whereby 43,287 were excluded since

they did not meet the eligibility criteria. Abstracts of the remaining articles were reviewed

and 28 of them were retrieved for further review. 12 articles were in the review, consisting of

2,101 participants. The remaining articles applied different modules of digital education such

as VP and online modules. Some studies applied traditional learning. The content of the

reviewed models also varied. They included cross-cultural communication, history-taking,

basic communication, ethical reasoning, and suicide risk management, among others.

Different tools were used to measure study outcomes, including Likert scales, OSCE, and

surveys. Four studies showed no significant statistical differences between digital education

and traditional learning in promoting communication skills among participants with patients.

Findings from one study favored online modules such as tutorials and virtual patient

simulation over traditional methods. One study found that medical students were more

satisfied with VP simulation compared to online-based video modules (P=.007). A complete

analysis of results implied that all education modules can improve communication skills

among mental health nurses and medical students.

One strength of the study is that it applied the systematic review and meta-analysis

approach which enhanced a comprehensive search of relevant studies with no limits

regarding the language or robust screening. The study also involved risk assessment of

retrieved studies which eliminated possible articles that could weaken the quality of evidence.

The study has limitations as well. Most of the retrieved studies were conducted in high-

income countries which might affect the applicability and transferability of the analyzed

evidence in low- and middle-income countries. Secondly, most studies focused on skill

outcomes with little emphasis on attitude, knowledge, and satisfaction.

Literature Synthesis

Gutiérrez-Puertas et al. (2020) and Kyaw et al. (2019) state that education modules

involving simulation, virtual patient simulation, role-playing, and digital or traditional

learning can improve skills and knowledge among mental health nurses and nursing students

as they communicate with patients in the clinical setting. Simulation provides nurses with

realistic scenarios that enabled them to practice and evaluate their skills in therapeutic

communication. Li et al- (2019) and Talevski et al. (2020) state that teaching nurses about

specific approaches that promote therapeutic communication can improve how to interact

with patients. For instance, nurses should be reminded to apply learned methods, such as

problem-based learning and teach-back methods, when communicating with patients until

they develop the habit. Finally, Hartley et al. (2020) state that while there are different ways

to promote a therapeutic relationship between nurses and patients, interventions that targeted

nurses’ attitudes, such as group-based programs and staff training improve staff knowledge.

The authors of the five studies acknowledge the importance of educating nurses in improving

nurses' knowledge and competence in therapeutic communication. Thus, the intervention

should be thoroughly reviewed so that it can be incorporated into staff training to improve the

nurse-patient relationship in mental health settings.

Article Level of Evidence

Studies’ Level of Evidence according to Melnyk Levels of Evidence

Author, year Level of Evidence

Gutiérrez-Puertas et al. (2020) Level 1- Systematic Review of RCTs

Kyaw et al. (2019) Level 1- Systematic Review of RCTs

Li et al. (2019) Level 1- Systematic Review of RCTs

Talevski et al. (2020) Level 1- Systematic Review of RCTs

Hartley et al. (2020) Level 5 – Systematic Review of

qualitative studies

Overall Conclusion

The synthesis of literature has shown that education modules can improve therapeutic

communication by improving nursing knowledge and competence. Mental health facilities

should assess how nurses and staff interact with patients so that they can implement

evidence-based education programs that would help equip them with the necessary

knowledge and skills to improve their competence. The reviewed studies have recommended

educating nurses on therapeutic communication to improve nurse-patient communication

skills among mental health patients. Further research can help identify different education

modules that can be effective and reliable.

Intervention

The literature review and synthesis have shown that education modules can improve

therapeutic communication among nurses and patients. Several education modules were

recommended in the studies, including virtual patient simulation, role-playing, online

learning, and traditional learning. Although two studies recommend simulation as the most

effective teaching approach, mental health facilities should identify their resources and select

the most applicable education module to implement to improve nurses' knowledge and

competencies in therapeutic communication.

References

Cheraghi, F., Hooshangian, M., Doosti-Irani, A., & Khalili, A. (2021). The effect of peer

support approach on communication skills of nursing students in the pediatric clinical

setting. Nurse Education in Practice, 52, 102984.

[Link]

Gutiérrez-Puertas, L., Márquez-Hernández, V. V., Gutiérrez-Puertas, V., Granados-Gámez,

G., & Aguilera-Manrique, G. (2020). Educational interventions for nursing students to

develop communication skills with patients: A systematic review. International

Journal of Environmental Research and Public Health, 17(7), 2241.

[Link]

Hartley, S., Raphael, J., Lovell, K., & Berry, K. (2020). Effective nurse-patient relationships

in mental health care: A systematic review of interventions to improve the therapeutic

alliance. International Journal of Nursing Studies, 102, 103490.

[Link]

Kyaw, B. M., Posadzki, P., Paddock, S., Car, J., Campbell, J., & Car, L. T. (2019).

Effectiveness of digital education on communication skills among mental health

nurses: systematic review and meta-analysis by the digital health education

collaboration. Journal of Medical Internet Research, 21(8), e12967.

[Link]

Li, Y., Wang, X., Zhu, X. R., Zhu, Y. X., & Sun, J. (2019). Effectiveness of problem-based

learning on the professional communication competencies of nursing students and

nurses: A systematic review. Nurse Education in Practice, 37, 45-55.

[Link]
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Sharma, N., & Gupta, V. (2021). Therapeutic Communication.

[Link]

Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-

back: A systematic review of implementation and impacts. PLoS One, 15(4),

e0231350. [Link]