Running head: IMPROVING THERAPEUTIC COMMUNICATION 1
Improving Therapeutic Communication in a Psychiatric Mental Health Clinic
Marshall Umoren
Arizona State University
IMPROVING THERAPEUTIC COMMUNICATION 2
Improving Therapeutic Communication
Abstract
Title: Improving Therapeutic Communication in a Psychiatric Mental Health Outpatient Clinic.
Authors: Marshall Umoren RN BSN, Psychiatric and Mental Health Nurse Practitioner-DNP
student, Ann Guthery, PhD, RN, PMHNP-BC.
Purpose: The purpose of this project is to demonstrate the benefits of therapeutic
communication in a mental health clinic with an outcome to increase patient satisfaction of their
care and improve patient-caregiver communication and relationship.
Background: The consequences of poor communication or non-therapeutic communication
cannot be overemphasized; these can include non-adherence to treatment plan, reduced treatment
compliance, higher psychological morbidity, dissatisfaction with care and poor patient-caregiver
relationship. Patients’ perception of how they are being treated affects how they respond to
treatment plans and medication regimens
Method: The project consisted of providing education on the principles of therapeutic
communication to healthcare workers in an outpatient psychiatric clinic. Follow up materials on
therapeutic communication principles were provided on a weekly basis for one month. A pre-
survey questionnaire was given to patients before intervention and a post-survey questionnaire
after intervention to determine patient satisfaction with care and degree of communication with
healthcare workers. The Short Assessment of Patient Satisfaction (SAPS) and the
Communication Assessment Tool-Team (CAT-T) were the instruments utilized in this project.
Finding: Patient satisfaction and communication with staff were statistically and significantly
improved after education on therapeutic communication was given to staff.
IMPROVING THERAPEUTIC COMMUNICATION 3
Conclusion: Education on therapeutic communication is an effective intervention tool in
improving patient’s satisfaction and communication with staff and health care team members in
a psychiatric outpatient clinic.
Keywords: therapeutic communication, non-therapeutic communication, patient
satisfaction, poor communication, principles of therapeutic communication, patient-caregiver
relationship
IMPROVING THERAPEUTIC COMMUNICATION 4
Improving Therapeutic Communication in a Psychiatric Mental Health Clinic
Effective communication and strong therapeutic relationships are critical to successful
mental health interventions (Doyle & Doherty, 2013). The purpose of this project was to
implement the principles of therapeutic communication (TC) in a mental health agency with an
outcome to improve patient satisfaction with care, and improve caregiver-patient relationship
through education provided to providers and healthcare workers.
Background and Significance
Communication in the field of mental health nursing is one of the most vital tools that
could be utilized to promote positive patient outcomes. A study conducted by Bhui et al. (2013)
established that black and minority ethnic groups who are receiving mental health specialist care
were more likely to be detained under the Mental Health Act, experience less use of effective
therapies and are more likely to be dissatisfied with their care. The researchers concluded that the
disengagement from services and poor satisfaction was as a result of lack of Therapeutic
Communication (TC). It is therefore imperative that for clients to receive premium care in the
mental health unit, caregivers must understand the rudiments involved in effective TC.
According to Thompson and McCabe (2012), TC is the foundational tool that establishes the
platform that promotes patient-caregiver relationship and creates a therapeutic alliance (TA) that
may determine the success of treatment. Patients’ perceptions of how they are being treated by
caregivers may also affect how they respond to treatment plans and medication regimens. Haron
and Tran (2007), conducted a study in a mental health hospital in Israel that amongst other things
considered important to patient, mental health clients desired to be respected by staff and not be
treated like just another psychiatric case.
IMPROVING THERAPEUTIC COMMUNICATION 5
Misdrahi, Verdoux, Lancon and Bayle (2009), stated that the style of communication
adopted by clinicians was also a determining factor in patient’s adherence to the treatment plan.
One of the greatest challenges in treating a mentally ill patient is the high rate of probability of
non-adherence. Approximately 50% of patients who suffer from diverse chronic diseases do not
take their medication as prescribed (Ahmed, Gandhi & Baruah, 2015). In their research, Ahmed
et al. (2015) suggested that the use of TC as an intervention may be used to better the outcome of
treatment for mental illness. The conscious use and application of TC is a specific intervention
that can improve adherence. When patients are not compliant with the treatment plan, the overall
negative outcome could be overwhelming. The consequences of poor communication or non-
therapeutic communication (NTC) cannot be overemphasized; these are seen with far reaching
costs including non-adherence to treatment plan, reduced treatment compliance, higher
psychological morbidity, incorrect or delayed diagnosis, patient’s dissatisfaction with care and
increased complaints (Jack et al., 2013).
According to Olfson et al. (2009), about one-fifth of adults in mental health treatment
dropped out before completing the recommended course of treatment, with 70% dropping out
after the first and second visits. This is an important statistic to consider as the foundation for TC
and therapeutic relationships can be laid in those early visits made by patients. In a randomized
control trial (RCT), Zarea, Maghsoudi, Dashtebozorgi, Hghighizadeh and Javadi (2014)
investigated the impact of Peplau’s Therapeutic Communication Model in patients suffering
from anxiety and depression. The Hospital Anxiety and Depression Scale (HADS) was used to
assess depression and anxiety before, and two and four months after the intervention. After seven
therapeutic communication sessions were held with the intervention group, the analyzed results
showed the mean anxiety and depression levels were lower in the intervention group after the TC
IMPROVING THERAPEUTIC COMMUNICATION 6
sessions were completed (p<0.01). Through education, providers and other caregivers can learn
the principles of TC and when applied can improve adherence to treatment plan. Cooper,
Martins and Wanda (2013) felt that part of the problem with lack of use of TC may be due to
inadequate training and preparation.
Patient Satisfaction and Improved Caregiver-Patient Relationship
Zendjidjian et al. (2014) found that amongst other determinants, stronger patient
satisfaction was firmly established when therapeutic alliance (TA) and TC were ingrained into
the day to day patient care routine. The authors concluded that therapeutic relationship (TR) was
the most important feature associated with a patient’s satisfaction and it is viewed as an
important indicator of the quality of care received in a psychiatric setting. Using the Rome
Opinion Questionnaire (ROQ), Paludetto, Camuccio, Cutrone, and Baldo (2015), acknowledged
that the satisfaction gained by patients during care should be routinely measured through the use
of short questionnaires.
The relationship of nurses and patients in a psychiatric inpatient unit was investigated by Seed,
Torkelson, and Alnatour (2010). The study revealed that nurses spent only 2.18 minutes per shift
educating patients on symptoms and almost two hours completing paper work. Due to lack of
quality and therapeutic time spent with patients, nurses were less satisfied with their jobs.
Internal Evidence and Problem Statement
The identified problem is ineffective and non-therapeutic communication, patient
dissatisfaction with care, non-adherence and non-compliance with care and incidences of
multiple missed appointments in an outpatient psychiatric clinic. Verbal interviews with some
patients revealed that they (patient) felt “insulted” or treated with “less respect” in the course of
their engagement in care with healthcare team. Some health care workers felt “sometimes a few
IMPROVING THERAPEUTIC COMMUNICATION 7
patients could be very difficult to deal with”. The resultant effect of this frosty relationship
between health care team and patients culminated in some patients refusing to show up for
appointments, opting out of therapeutic programs and activities, noncompliant with medication
regimen and in some instances requesting “to be changed to another facility”. It is therefore
important that the principles of TC should be one of the core educational cornerstones for mental
health caregivers so as to improve patient outcomes, improve communication between patient
and staff and increase patient-caregiver satisfaction. With the prevailing issue of lack of TC in
this particular mental health facility, this investigation has led to the relevant PICOT question:
“In a mental health care team working in an outpatient psychiatric clinic, how does education on
therapeutic communication compared to no education, affect patient satisfaction with treatment
plans and affect communication with healthcare team over a 3 month period”?
Search Strategy
In order to answer the aforementioned PICOT question, an extensive search of literature
was conducted within the following electronic databases: PubMed, Psychiatry Online, OvidMD,
Ovid Medline, Psych INFO, CINAHL and Cochrane. Key words used included; therapeutic
communication, patient satisfaction, seclusion and restraints, adherence and compliance, patient
outcomes, mental health and psychiatry, disruptive behavior management, poor communication,
non-therapeutic communication, patient dissatisfaction. The combination of “therapeutic
communication and mental health” yielded the most results.
In the Cochrane library database there were 22 trial results showing “therapeutic
communication” and 6823 results using the same combination for Psych Online. PubMed
provided 2828 results when “therapeutic communication and adherence” were combined. Ovid
provided just one result when “therapeutic communication and restraints” were combined. A
IMPROVING THERAPEUTIC COMMUNICATION 8
combination of therapeutic communication, patient satisfaction and mental health on CINAHL
produced 91 results. The articles selected in total was 10
Critical Appraisal and Synthesis
The level of evidence ranged from one to five, indicating strong to moderate strength of
the evidence. A few of the articles had instruments to measure patient satisfaction, staff
satisfaction, patient’s perception of provider’s knowledge in TC amongst other important
research markers. The studies were mainly descriptive with samples of narrowly defined
populations to illustrate the important relationship between TC and positive patient outcomes.
The level of statistical significance was high for a majority of the studies with a p value set at
<0.005. Intervention methods ranging from education on TC, cultural influence on
communication, self-assessment of TC knowledge and patient education on treatment options
were used in the studies. All the studies agreed that TC was an integral part of psychiatry and
nursing in general.
All of the studies included physicians, nurses and patients, while eight out of ten included
social workers and therapists. There was homogeneity in all of the studies reviewed, with TC as
an intervention and an integral part of patient care. Two of the studies used instruments that were
developed to specifically measure therapeutic relationships between caregiver and patients. A
modified version of the instrument (N-STAR) was used in one study and included other
parameters that were omitted in the original version of the instrument. One study used the Short
Assessment of Patient Satisfaction (SAPS) tool while another used the Communication
Assessment Tool-Team (CAT-T) tool.
A majority of the studies were conducted in the United States, one each in China,
Norway and Israel. All of the subjects were psychiatric patients, with only one study done
IMPROVING THERAPEUTIC COMMUNICATION 9
specifically with patients suffering from depression and schizophrenia. All the articles chosen for
inclusion included the subject of TC between caregivers and mental health patients. The
completion rate for all participants in the studies was greater than 90%, mostly due the
convenience of the sample population and the research methods. One study specifically included
the use of TC in nursing schools after determining that student nurses in psychiatry rotations
were not well versed in the principles and applications of TC. All the studies suggested educating
caregivers to improve their relationships with patients through the use of TC. The validity of the
data collected in all articles shows TC as a positive measure required in the treatment of mental
health disorders. Variables of interest were males and females between the ages of 32 years to 46
years for both patients and clinicians.
Evidence Based Practice Model/Conceptual Framework
Hildegard Peplau’s model of Therapeutic-Nurse Client Relationship/Interpersonal Theory
was the evidence based practice model and conceptual framework that guide this project. This
model is based on the conceptual framework of interpersonal relationship between caregivers
and clients. It is the first significant psychiatric nursing theory that views nursing as an
interpersonal and ongoing process, in which interventions and positive outcomes are the results
of nurse-client relationship (Peplau, 1991). This conceptual framework divides a therapeutic
nurse-client relationship into three phases: (1) introduction and orientation, (2) Working,
identification and exploitation and (3) Termination and resolution phase (Keltner, Schwecke &
Bostrom, 2007).
The first psychiatric interview of a client by the provider is considered very important,
the introduction and orientation phase should be used meticulously to create a trusting
environment that will be viewed as therapeutic by the client. The working, identification, and
IMPROVING THERAPEUTIC COMMUNICATION 10
exploitation phase allows the caregiver to clarify client expectations, implement treatment plans,
involve the client in decision making processes and evaluate outcomes of care. In the termination
phase, the progress made by clients will be reviewed while therapeutically disengaging from
relationships that were earlier established. The implementation of these concepts will help build
a therapeutic nurse-client relation that is fueled by TC.
Application of Evidence to Practice
The agency for Healthcare Research and Quality (AHRQ) Model of Knowledge Transfer
was used as the cornerstone for the application of evidence. The Steps of knowledge transfer in
the AHRQ model is divided into three groups: (1) knowledge creation and distillation, (2)
diffusion and dissemination, and (3) organizational adoption and implementation (Hughes,
2008). Knowledge creation and distillation is undertaking research with hopes that the findings
will be relevant with enough evidence for use in practice. Diffusion and dissemination involves
working with professional opinion leaders and health care organizations to disseminate
knowledge that can form the basis of action (e.g., facilitating the application of therapeutic
communication principles in an inpatient psychiatric unit). End user adoption, implementation,
and institutionalization are the last step of the knowledge transfer process.
In this project, knowledge creation involved gathering information on the usefulness of
TC and how its application will improve patient satisfaction and improve patient-health care
worker relationship. This knowledge will be diffused and disseminated to providers, managers
and other healthcare professionals to enhance the proposed change. The last step will involve
bringing organizations, teams, and individuals to adopt, implement and use the evidence-based
research findings and innovations in everyday practice. At the end of the project, stage three
IMPROVING THERAPEUTIC COMMUNICATION 11
should be fully implemented to bring about the desired change in the clinical site and
improvement in patient-caregiver relationship.
Conclusions about Evidence
It is evident that TC is an important aspect of patient care in psychiatry. Evidence from
the studies shows a correlation amongst patient satisfaction, adherence, reduced use of seclusion
and restraints, nurses’ job satisfaction and improved communication between staff and patients.
When there is therapeutic alliance, communication is much improved and care is patient centered
making recovery and wellness possible due to the likelihood of patients completing their
treatments. If TC is practiced, an alliance can be built between caregiver and patient that will
foster a stronger relationship, build trust and promote patient-centered care. Since the goal of
every provider is to see the improvement in health status of their patients, TC provides one of the
most viable tools to establish a good rapport, build a therapeutic relationship and gain the trust of
their patients
Project Method
Design
A quasi-experimental pre and post- test design using quantitative methods was used to
conduct this EBP project. A convenience sample was used as a sampling method for healthcare
members and patients participating in the study.
Recruitment and Participants
The administrator was approached by DNP student and project explained in detail. Flyers
advertising the project were printed and distributed to staff with a set date for the intervention to
be delivered. Potential participants (patients) were identified at the clinic site during daily
morning meetings held by staff and during appointment hours. The participants were given the
IMPROVING THERAPEUTIC COMMUNICATION 12
consent document at the time if interested in participating in the study. In addition, patients were
recruited to fill out a patient satisfaction survey and also patient’s perception of provider/
healthcare worker understanding of effective communication.
The recruitment was based on the following inclusion and exclusion criteria. Inclusion
criteria recommended for the training included the following: participants must be providers,
nurses, social workers, case managers, counselors, therapists, front desk or any staff that comes
in direct contact with patients working in the psychiatric/mental environment who speak English.
The inclusion criteria for patients participating in the project were: patients had to be 18 years or
older, patients that are able to read the consent form and questionnaires and those who were
receiving psychiatric treatment at the facility. The exclusion criteria included participants
suffering from Neuro-cognitive deficits and those that may not be able to sit for a period of up to
1hr. None of the recruits fell into this category and no one who consented to partake in this
project was excluded.
Practice Site/Setting
This practice setting was an outpatient clinic that offers psychiatric services, case management,
free transportation, interpreter services and health & wellness groups facilitated mostly by clinic
registered nurses. The facility seeks to view its relationship with patients as a partnership. The
facility is associated with the Maricopa Crisis Response Center for emergency cases, where
immediate help can be rendered to patient in danger of causing harm to themselves or others.
There are psychiatrists and nurse practitioners who serve as providers at this site. Support staff
includes case managers, social workers, nurses, therapists, activities director and coordinators.
IMPROVING THERAPEUTIC COMMUNICATION 13
The facility offers therapies such as cognitive behavioral therapy (CBT), trauma therapy,
dialectical behavioral therapy (DBT), individual therapy, group therapy and nutritional therapy.
Intervention/Procedure
Education on the principles of therapeutic communication was provided to the Healthcare
Team Members (HcTMs) for an hour with follow up materials termed “nuggets” provided
weekly for a month to update learning and maintain communication therapeutic skills. HcTMs
were reminded of the original lecture and advised that “nuggets” was a follow-up on the learning
process. Team meetings in the mornings were ideal to distribute “nuggets” with a brief summary
provided. HcTMs were also located on individual basis and handed the “nuggets” followed by a
brief explanation of the targeted section of the original lecture for clarity.
Organizational Culture
The organizations’ culture is hierarchal and the organization is well structured and
maintains a focus on efficiency, stability and promotes innovation and evidence based programs.
The organization encouraged the project and provided a letter of support from the chief medical
officer. Together with staff support, logistics and other resources were provided to assist with
project design and subsequent implementation.
Outcome Measures and Instruments
The outcomes measured in this project was patient satisfaction with care and patient’s
perception of provider/ healthcare worker understanding of effective communication after
completion of the educational intervention on therapeutic communication. The Short Assessment
of Patient Satisfaction (SAPS) was the instrument that was used to measure patient satisfaction
outcomes. It is a brief, valid and reliable instrument that can be used to assess patient satisfaction
with their treatment. The SAPS is a the product of scientific evaluation of a lists of patients
IMPROVING THERAPEUTIC COMMUNICATION 14
satisfaction surveys with only seven items eventually considered as having the best
measurement properties and the most comprehensive coverage of the domains of patient
satisfaction. Reliability is Cronbach’s alpha α = 0.85; it correlates highly with other measures of
patient satisfaction, and correlates well with other indicators of treatment outcomes (Hawthorne,
Sansoni, Hayes, Marosszeky & Sansoni, 2014). The validity and reliability were tested by
Hawthorne et al., (2014) in a hospital project sponsored by the Australian government. The
domains of patient satisfaction covered by SAPS include: treatment satisfaction, explanation of
treatment results, clinician care, participation in medical decision-making, respect by the
clinician, time with the clinician, and satisfaction with hospital/clinic care on a 5-point response
scale. SAPS scale has answers ranging from 0 to 4. Very dissatisfied, strongly disagree, none of
the time =0, Dissatisfied, some of the time=1, neither satisfied nor dissatisfied, about half the
time, not sure, neither satisfied nor satisfied=2, satisfied, agree, most of the time=3, very
satisfied, strongly agree, all of the time=4.
Patient perception of communication with the HcTMs was measured using an adaptation
of the Communication Assessment Tool (CAT), which is a previously validated instrument that
was made to assess communication across different specialties especially physicians (See
Appendix B). The CAT was adapted to include questions specific to the communication of
physicians otherwise all questions in the original CAT and CAT-T remained the same. It
contains 15 items on a 5-point response scale that evaluates the quality of communication (1 =
"poor," 5 = "excellent") between patient and HcTMs, with a Communication Assessment Tool
Cronbach’s alpha score of 0.98 (Mercer et al., 2008).
Data Collection
IMPROVING THERAPEUTIC COMMUNICATION 15
The project was approved by the Arizona State University Institutional Review Board (IRB).
After IRB approval, data collection began and data collection spanned over five weeks, with
actual collection done intermittently at least 2-3 times per week. Patients were met at the
outpatient psychiatric clinic and tool administered by Co-PI. A consent form and project
overview was given to would be participant. The pretest and posttest questionnaires consist of 7
questions from SAPS and 15 questions from CAT-T (a total of 22 questions) and administration
time was approximately 10 minutes per patient.
Data Analysis
Data analysis was conducted using SPSS® Version 23. The SPSS® version 23 statistical
package was used to analyze the data. Descriptive statistics were used to describe the sample and
outcome variables. The independent t-test was used to compare the mean scores of the SAP and
CAT-T of two independent groups (Cronk, 2014). The critical value was set at p<0.05.
Results
Patients (n=61) attending an outpatient psychiatric clinic completed the project; with 32
participants completing the pretest and 29 different patients completed the posttest. In the pretest,
23 (72%) participants were female, 9 (28%) were male whereas in the posttest, 15 (52%) were
male while 14 (48%) were female. The education of the patients completing the pretest and
posttest were similar. In the pretest, people with less than a high school education were 4 (6.3%),
15 (25%) had some college, 13 (21.9%) had college degrees and 29 (46.9%) had high school
diplomas. In the posttest, 23 people (37.9%) had high school diplomas, 21 (34.5%) had some
college,, 8 (13.8%) had college degrees and 8 (13.8%) had less than high school diplomas.
Lastly, the majority of the patients were Caucasians, followed by African American, Hispanics
and Asians in both pretest and posttest. (See Figures 1-3 in Appendix C).
IMPROVING THERAPEUTIC COMMUNICATION 16
An independent t-test comparing the mean scores of the pre and post- test groups on the
outcome variables. The mean score of the two groups on the SAPS (t (59) = -4.987, p <0.001)
was significantly different. The mean score of the two groups on the CAT_T scores of two
different groups were, also significantly different (t (59) = -2.31, p = 0.02). The average patient
satisfaction score was significantly different in the two groups. The mean of the post-test group
(M=3.43, SD=0.43) was significantly higher than the pre-test group (M = 2.7, SD=0.67). The
average communication score was significantly different in the two groups. The mean of post-
test group (M =4.19, SD= 0.72) was significantly higher than the pre-test group (M==3.7,
SD=0.94). Levene’s test give values p
saps
=0.065>0.05, and p
cat-t
p=0.142>0.05 for the SAPS and
CAT-T, respectively. Therefore; there are equal variances so the results are significant for both
outcome variables (See Tables 1& 2 in Appendix D).
Discussion
In comparing the results to the evidence, it shows that therapeutic communication is a
very useful technique in improving patient outcomes in psychiatric settings. Different authors all
agree that effective communication is a necessary tool that promotes patient outcomes.
According to Benedetti, 2011, “communication by clinicians has the power to turn diagnoses and
prognoses into parts of the treatment, to influence treatment effectiveness, and to modulate the
way in which patients cope with their conditions” (Benedetti 2011;
Strengths and Limitations
Random sampling of patient participants and ease of administration of the instruments are
major strengths. The small sample size of participants is one weakness. More so by not providing
the intervention group with the same pretest and posttest survey, one is not able to measure a
IMPROVING THERAPEUTIC COMMUNICATION 17
self-administered satisfaction scale and level of communication of the HcTMs. Conclusively,
this project can be easily replicated.
Recommendation
As seen from the demographic data, there is a significant difference between percentage
of males in pre and post samples. This could mean the difference in answers between males and
females in SAPS and CAT-T posttest and pretest questionnaires may depend on gender of
patients. Further research of this potential threat of results should be investigated. There was no
cost incurred in this project and its application in similar setting may be of benefits to patients
and HcTMs.
Conclusions
The significance of this project is the recognition of the role of therapeutic
communication in a psychiatric outpatient clinic. With overwhelming evidence supporting the
influence of HcTMs communication pattern on patient outcomes, education on the principles of
therapeutic communication will provide a foundation upon which patient-HcTMs relationship
can be built. A major outcome of this project is adoption of the lecture materials used during
intervention by the administration of this facility as part of its continuing education program. The
relevance of patient outcomes may be seen in reduced cancellations of appointments at the clinic,
reduced dissatisfaction rate with care and improved compliance. In healthcare delivery in
general, because patient satisfaction is improved, facility rating will also improve and this will
positively affect funding.
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References
Ahmed, N., Gandhi, S., & Baruah, A. (2015). Effectiveness of specific intervention on treatment
adherence of persons with mental illness: A pilot study. Indian Journal of Psychiatry, 57(4), 403.
doi:10.4103/0019-5545.171845
Benedetti, F., & ebrary., I. (2011;2010;). The patient's brain: The neuroscience behind the doctor-
patient relationship. New York, New York: Oxford University Press.
Bhui, K., McCabe, R., Weich, S., Singh, S., Johnson, M., & Szczepura, A. (2013). THERACOM: A
systematic review of the evidence base for interventions to improve therapeutic communications
between black and minority ethnic populations and staff in specialist mental health services.
Systematic Reviews, 2(1), 15-15. doi:10.1186/2046-4053-2-15
Box, G., Hunter, W., & Hunter, J. S. (2005). Statistics for Experimenters, p. 66–67.
Cooper, J. R., Martin, T., Fisher, W., Marks, J., & Harrington, M. (2013). Peer-to-peer teaching:
Improving communication techniques for students in an accelerated nursing program.
Nursing Education Perspectives, 34(5), 349.
Coyle, D., & Doherty, G. (2013). Supporting therapeutic relationships and communication about
mental health
Davies, M., Kermani, F., & ebrary, I. (2006;2012;). Patient compliance: Sweetening the pill.
Burlington, VT;Hampshire, Eng;: Gower.
Haron, Y., & Tran, D. (2014). Patients' perceptions of what makes a good doctor and nurse in an
israeli mental health hospital. Issues in Mental Health Nursing, 35(9), 672-679.
doi:10.3109/01612840.2014.897778
Hawthorne, G., Sansoni, J., Hayes, L., Marosszeky, N., & Sansoni, E. (2014). Measuring patient
satisfaction with health care treatment using the short assessment of patient satisfaction
IMPROVING THERAPEUTIC COMMUNICATION 20
measure delivered superior and robust satisfaction estimates. Journal of Clinical
Epidemiology, 67(5), 527-537. doi:10.1016/j.jclinepi.2013.12.010
Hughes, R., Agency for Healthcare Research and Quality, & United States. (2008). Patient safety
and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for
Healthcare Research and Quality
Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). Psychiatric nursing (5th ed.). St.
Louis: Mosby/Elsevier.
Mercer, L. M., Tanabe, P., Pang, P. S., Gisondi, M. A., Courtney, D. M., Engel, K. G., . . .
Makoul, G. (2008). Patient perspectives on communication with the medical team: Pilot
study using the communication assessment tool-team (CAT-T). Patient Education and
Counseling, 73(2), 220-223. doi:10.1016/j.pec.2008.07.003
Misdrahi, D., Verdoux, H., Lançon, C., & Bayle, F. (2009). The 4-point ordinal alliance self-
report: A self-report questionnaire for assessing therapeutic relationships in routine
mental health. Comprehensive Psychiatry, 50(2), 181-185.
doi:10.1016/j.comppsych.2008.06.010
Olfson, M., Mojtabai, R., Sampson, N. A., Hwang, I., Druss, B., Wang, P. S.. . Kessler, R. C.
(2009). Dropout from outpatient mental health care in the United States. Psychiatric
Services (Washington, D.C.), 60(7), 898-907. doi:10.1176/ps.2009.60.7.898
Paludetto, M., Camuccio, C. A., Cutrone, F., Cocchio, S., & Baldo, V. (2015). Can we have
routine measurement of patient satisfaction in acute psychiatric settings? A cross
sectional study. Archives of Psychiatric Nursing, 29(6), 447. Seed, M. S., Torkelson, D.
J., & Alnatour, R. (2010). The role of the inpatient psychiatric nurse and its effect on job
IMPROVING THERAPEUTIC COMMUNICATION 21
satisfaction. Issues in Mental Health Nursing, 31(3), 160-170.
doi:10.3109/01612840903168729
doi:10.1016/j.apnu.2015.07.006
Peplau, H. E., & ebrary, I. (1991;2004;). Interpersonal relations in nursing: A conceptual frame
of reference for psychodynamic nursing. New York: Springer.
Zarea, K., Maghsoudi, S., Dashtebozorgi, B., Hghighizadeh, M. H., & Javadi, M. (2014). The
impact of Peplau’s therapeutic communication model on anxiety and depression in
patients candidate for coronary artery bypass. Clinical Practice and Epidemiology in
Mental Health : CP & EMH, 10(1), 159-165. doi:10.2174/1745017901410010159
Zendjidjian, X. Y., Auquier, P., Lançon, C., Loundou, A., Parola, N., Faugère, M., & Boyer, L.
(2014). Determinants of patient satisfaction with hospital health care in psychiatry:
Results based on the SATISPSY-22 questionnaire. Patient Preference and Adherence, 8,
1457-1464. doi:10.2147/PPA.S67641
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Appendix A
The Short Assessment of Patient Satisfaction (SAPS)
(Please mark an “X” where applicable)
DEMOGRAPHICS:
AGE______
GENDER: MALE____ FEMALE____
EDUCATION: Less than high school______ High school______ some
college________, College degree_______ Graduate Degree______
Ethnicity: Caucasian________, African American/Black_________,
Asian______, Hispanic ________Pacific Islander_________,
Other______
Instructions: After reading each question, circle the answer that best describes you. The order
of the answers varies between the questions, so take a moment to read each
question carefully.
We know that sometimes answers may not describe you exactly, so please pick
the answer that most closely describes you.
When you have finished, please check that you have answered all questions.
1. How satisfied are you with the effect of your {treatment/care}?
___ Very dissatisfied =0
___ Dissatisfied=1
___ Neither satisfied nor dissatisfied=2
___ Satisfied=3
___ Very satisfied=4
2. How satisfied are you with the explanations the {doctor/other health
professional} has given you about the results of your {treatment/care}?
____Very dissatisfied=0
____Dissatisfied=1
____Neither satisfied nor dissatisfied=2
IMPROVING THERAPEUTIC COMMUNICATION 23
____Satisfied=3
____Very satisfied=4
The Short Assessment of Patient Satisfaction (SAPS)
Instructions: After reading each question, circle the answer that best describes you. The order
of the answers varies between the questions, so take a moment to read each
question carefully.
We know that sometimes answers may not describe you exactly, so please pick
the answer that most closely describes you.
When you have finished, please check that you have answered all questions.
3. The {doctor/other health professional} was very careful to check everything
when examining you.
____Strongly disagree=0
____Disagree=1
____Not sure=2
____Agree=3
____Strongly agree=4
4. How satisfied were you with the choices you had in decisions affecting your
health care?
____Very dissatisfied=0
____Dissatisfied=1
____Neither satisfied nor dissatisfied=2
____Satisfied=3
____Very satisfied=4
5. How much of the time did you feel respected by the {doctor/other health
professional}?
____ None of the time=0
IMPROVING THERAPEUTIC COMMUNICATION 24
____ Some of the time=1
____ About half the time=2
____ Most of the time=3
____ All of the time=4
The Short Assessment of Patient Satisfaction (SAPS)
Instructions: After reading each question, circle the answer that best describes you.
The order of the answers varies between the questions, so take a moment
to read each question carefully.
We know that sometimes answers may not describe you exactly, so
please pick the answer that most closely describes you.
When you have finished, please check that you have answered all
questions.
6. The time you had with the {doctor/other health professional} was too short.
____ Strongly disagree=0
____Disagree=1
____Not sure 2
____ Agree=3
____Strongly agree=4
7. Are you satisfied with the care you received in the {hospital/clinic}?
____Very dissatisfied=0
____Dissatisfied=1
____Neither satisfied nor dissatisfied=2
____Satisfied=3
____ Very satisfied=4
IMPROVING THERAPEUTIC COMMUNICATION 25
Appendix B
COMMUNICATION ASSESSMENT TOOL -TEAM (CAT-T)
Communication with patients is a very important part of quality medical care. We would
like to know how you feel about the way your medical team communicated with you.
Your answers are completely confidential, so please be as open and honest as you can.
Thank you very much.
Please use this scale to rate communication during this visit. Circle your answer for
each item below.
The medical team:
Poor
Fair
Good
Excellent
1. Greeted me in a way that made me feel
comfortable
1
2
3
5
2. Treated me with respect
1
2
3
5
3. Showed interest in my ideas about my health
1
2
3
5
4. Understood my main health concerns
1
2
3
5
5. Paid attention to me (looked at me, listened
carefully)
1
2
3
5
6. Let me talk without interruptions
1
2
3
5
7. Gave me as much information as I wanted.
1
2
3
5
8. Talked in terms I could understand
1
2
3
5
9. Checked to be sure I understood everything
1
2
3
5
10. Encouraged me to ask questions
1
2
3
5
11. Involved me in decisions as much as I wanted
1
2
3
5
12. Discussed next steps, including any follow-up
plans
1
2
3
5
13. Showed care and concern
1
2
3
5
14. Spent the right amount of time with me
1
2
3
5
The front-desk staff
Poor
Fair
Good
Excellent
IMPROVING THERAPEUTIC COMMUNICATION 26
The medical team:
Poor
Fair
Good
Excellent
15. Treated me with respect
1
2
3
5
IMPROVING THERAPEUTIC COMMUNICATION 27
Appendix C
Appendix C
Figure 1 Gender distribution in pre and post test
Figure 2
Education distributions in Pre and Post test
Figure 3
Ethnicity distribution in pre and post test
IMPROVING THERAPEUTIC COMMUNICATION 28
Appendix D
Table 1
Independent Samples Test
Levene's Test for
Equality of
Variances
t-test for Equality of Means
F
Sig.
t
df
Sig. (2-
tailed)
Mean
Difference
Std. Error
Difference
95% Confidence Interval
of the Difference
Lower
Upper
SAPS2
Equal variances
assumed
3.530
.065
-4.987
59
.000
-.72791
.146
-1.020
-.436
Equal variances
not assumed
-5.090
53.606
.000
-.72791
.143
-1.015
-.441
CAT-T
Equal variances
assumed
2.216
.142
-2.310
59
.024
-.49914
.216
-.931
-.067
Equal variances
not assumed
-2.341
57.333
.023
-.49914
.213
-.926
-.072
Table 2
Group Statistics
TESTSTAGE
N
Mean
Std. Deviation
Range (min, max)
SAPS
PreTest
32
2.7031
.66899
1.43
PostTest
29
3.4310
.43305
3.57
CAT-T
PreTest
32
3.6917
.94231
2.29
PostTest
29
4.1908
.71641
4.00
IMPROVING THERAPEUTIC COMMUNICATION 29