Leading change

The Professor of Mental Health Nursing at Kingston and St George’s, University of London, a group of registered mental health nurses (RMHNs) and academics worked in partnership with service users to develop a therapeutic engagement questionnaire (TEQ) that measures the impact of engagement on a service user’s recovery.

Where to look

NHS England guidance highlights the importance of supporting service users to become and remain actively involved in their care, treatment and support, and how this can lead to improved outcomes and experiences for service users as well as potentially yield efficiency savings for the system through more personalised commissioning. The aim is to support people to stay well and manage their own conditions better so they can lead healthy lives.

Walker (2014) identifies that therapeutic engagement is a fundamental aspect of mental health nursing, however tools to support effective engagement are limited. Specifically, tools which capture the impact of engagement on a person’s recovery aren’t widely available which could lead to unwarranted variation in practice as objective measures aren’t consistently applied.

The Nursing Professor saw an opportunity to develop and implement a tool to address this unwarranted variation whilst also improving engagement in recovery and measuring impact upon outcomes, experiences and use of resources.

What to change

Prior to the development of TEQ, a number of scales were available for use, for example the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989), and the Helping Alliance Scale (HAS; Priebe & Gruyters, 1993). These measure the quality of therapeutic engagement in research evaluating care of people with severe mental illness (McGuire-Snieckus et. al. 2007). Several service user post-session questionnaires exist such as the Helpful Aspects of Therapy (HAT; Llewlyn, 1988), which is a simple ‘client self-report’ tool developed to identify significant therapy events. While this tool is useful for identifying and assessing important therapeutic processes (McGuire-Snieckus et. al. 2007), it is a qualitative measure making reports difficult to quantify.

More recently, the ‘Scale to Assess the Therapeutic Relationship’ (STAR; McGuire-Snieckus et. al. 2007) was developed using psychometric theory of test construction to specifically assess the relationship between multidisciplinary clinicians and service users with mental illness but in community care settings.

The Nursing Professor identified that a therapeutic engagement tool was required because:

• Service users need to be actively involved in all decision-making processes about their care, treatment, health and well-being;
• Mental health nursing needs to make a visible difference to service user recovery;
• Mental health nurses need to demonstrate that their interactions reflect the values of the profession and service user views about the delivery and management of care and treatment;
• Acute care environments should provide optimal support and treatment for individuals, delivered with care and compassion.

How to change

Led by the Professor of Nursing, a working group of RMHUs and academics worked in partnership with service users to develop two questionnaires, one for RMHNs and one for service users. This working group included experts from Higher Education Institutes and NHS Foundation Trusts.

The questionnaires are based on available literature, data collected from individual interviews with service users and a workshop focusing on how to measure the contribution of mental health nurses to service user recovery. The thematic data analysis resulted in questionnaires that incorporate elements of the ‘6Cs’ of nursing, reflecting:

• Nursing needs to make a difference;
• Nursing behaviour reflecting the shared values in the delivery and management of care and treatment;
• Service users being informed and involved in and about real-time monitoring and improvement about their own health and well-being;
• Providing for basic human needs with care and compassion.

Using psychometric principles, a ‘Therapeutic Engagement Questionnaire’ (TEQ) was developed and authenticated across 26 NHS Mental Health Trusts in England to measure therapeutic engagement in adult acute inpatient healthcare settings in two contexts – general therapeutic environment and one-to-one interactions with service users. The TEQ was piloted on two wards in a London-based NHS Mental Health Trust.

Following validation of the TEQ the Professor of Mental Health Nursing at Kingston and St. George’s University of London in collaboration with South West London and St George’s Mental Health NHS Trust implemented the tool to address this unwarranted variation. The aim was to improve and measure impact locally as well as possibly nationally.

During the pilot, service users and their named registered mental health nurses completed the appropriate version of the TEQ independently at service user discharge. In addition, the nurses completed a reflective feedback log that involved responding to five questions about what helped and/or hindered their completion of the TEQ at service user discharge and how the TEQ should be used in an acute care environment; asking for the optimum conditions for use and administration of the TEQ.

Adding value

Better outcomes – The pilot of the tool has demonstrated its practical use in supporting staff to engage therapeutically with patients, with a view to delivering improved outcomes in their treatment and care. As the next phase of implementation progresses, building on lessons learned, pre- and post- implementation data will be collected to establish the impact on patient outcomes, before the tool is rolled out more widely into day-to-day service delivery.

Better experience – Feedback from service users and staff has been positive about the tool and its impact on practice. Examples include:

• “Simple to answer questions. Didn’t feel overwhelmed trying to answer the questions”;
• “It makes you think about the time on the ward and different aspects of your care”;
• “The questionnaire matches what I am experiencing. The tool will give a good idea of the quality of nursing care”.

Service users when surveyed expressed high satisfaction with the TEQ by rating their satisfaction as 4 or 5 out of 5, on a 5-point Likert scale (“Overall, how would you rate the TEQ?”), where 5 was the most satisfied.

Examples of staff feedback include:

• “Pinpoints our need to be respectful to clients”;
• “It made me look at my own practice”;
• “Good reflection of work ethic and performance”;
• “Clinically relevant questions”.

Better use of resources – The intention of using TEQ is that it provides more objective data on the nature and quality of nursing interactions with service users, encourage reflective practice and indicate any training needs. Similarly, it captures the qualities of the therapeutic environment indicating its strengths and limitations. This is intended to support meaningful interactions and care planning for service users so that they can access timely high-quality care.

Challenges and lessons learnt for implementation

Optimal conditions for successful implementation of this programme includes ensuring appropriate ‘buy-in’ and support from the Director of Nursing as well as use of clear and simplified written guidance on the implementation process.

Support on the ward using the new approach was instrumental in ensuring staff consistently applied the tool as well as fed back their findings.

Due to the success of the tool, more Trusts are adopting it as good practice and plans are now in place to support implementation on an international scale.

For more information contact

Mary Chambers
Professor of Mental Health Nursing
Kingston and St George’s, University of London
m.chambers@sgul.kingston.ac.uk