Solution-focused approach therapy for mental health nursing students Nicola Evans and Anne-Marie Evans
Key words: Solution-focused therapy ■ Mental health ■ Education ■ Skills acquisition
S
olution-focused brief therapy (De Shazer, 1985) is based on taking a solution-building, rather than a problem-solving, approach to individuals, couples or families wanting change in their lives. It encourages an exploration of the client’s current resources, in terms of their strengths, meaningful relationships and achievements, while also considering their future hopes and aspirations. The underpinning assumption of this model of therapeutic change is that the client presents as a motivated individual, wanting change and looking for a new direction. Working collaboratively in an equal relationship with the client, therefore, has the potential for the client to achieve a positive outcome. This approach is based on the person-centred idea that the client is the one who is best informed about their own life and able to draw on ‘exceptions’ from which possible solutions can emerge. As Quick (1998) suggests, where an aspect of a client’s world is functioning well for them, it makes sense to encourage them to continue with it.
Nicola Evans and Anne-Marie Evans are Lecturers in Mental Health Nursing at the School of Healthcare Science, Cardiff University, Wales Accepted for publication: October 2013
1222
Offering a solution-focused intervention generally involves between three and five sessions with an individual client, couple or family. There is value in offering frequent sessions, although the frequency and duration of sessions are negotiated between the practitioner and client. This approach can be offered as an individual intervention; as an adjunct to other therapeutic approaches; or as a preliminary therapeutic approach to engage the client in thinking about change. The overriding principle for the intervention is to do only as much as is required to enable the client to move on with their life. In colloquial language: ‘What’s the trouble? If it’s not broken, don’t fix it. If it works, do more of it. If it doesn’t work, stop doing it and do something different.’ Suggestions or interpretations of the client’s situation are only rarely offered and, if so, are tentatively framed. The focus of collaborative talk between the practitioner and the client is on the future, not the past, with the aim of achieving small changes that potentially have a big impact on the client’s life.
Using solution-focused approaches in practice There is evidence in the literature to suggest that solutionfocused approaches are used across a number of nursing specialties.Within mental health, solution-focused approaches are useful when doing mental health assessments (Ward, 2013); to promote service users’ engagement with services on in-patient facilities (Bowles et al, 2007); and as an optimistic approach to mental health promotion (Wand, 2011) and care generally (Ruddick, 2011). Coxon (2012) even suggests it is one of the core competencies that community mental health nurses should have. This approach is useful for nurses working with children in a number of settings. School nurses have used it both to address behavioural change for vulnerable families (Wakefield et al, 2010) and to tackle bullying by increasing children’s empathy with victims of bullying (Kvarme et al, 2008). Gupta and Woodman (2010) described a solution-focused approach was used to manage stress for a palliative nursing team who were caring for children with complex needs (Gupta and Woodman, 2010). There are also reports of solution-focused approaches to nursing work being effective in working with children with diabetes (Christie, 2008); in chronic care (Boscart, 2009); with people with learning disabilities (Smith, 2005); with asylum seekers (Freeman, 2007); and to help patients with long-term conditions self-manage (Smith et al, 2011). Aside from direct clinical work, Fowler (2011) suggested that self-affirming strategies and scaling questions
© 2013 MA Healthcare Ltd
Abstract
Solution-focused therapy is a model of therapy that builds on the client’s strengths, is future-focused and can be generally offered as a brief intervention. It can be used across multiple clinical settings and is not limited to being useful for clients accessing mental health services. Learning the underlying principles and developing a foundation level of skill in the approach was found to be achievable in an undergraduate nursing course, with students reporting an increase in their knowledge of the model and confidence in basic therapeutic skills in just one day of training. In this paper, we introduce the solution-focused approach in relation to nursing practice. We describe the template used for the training day offered to undergraduate mental health nurses. Students reported that this method of learning a therapeutic approach was helpful and increased both their knowledge and skill base.
Therapeutic approach when using solution-focused therapy
British Journal of Nursing, 2013, Vol 22, No 21
British Journal of Nursing.Downloaded from magonlinelibrary.com by 139.080.123.046 on July 19, 2015. For personal use only. No other uses without permission. . All rights reserved.
education were helpful in professional development activities for nursing staff wanting to improve their portfolios.
Review of the literature on training solution-focused approaches The literature was examined to establish what is already known about training nurses in solution-focused therapy skills. Ferraz and Wellman (2009) offered a helpful review of the literature, which concluded that solution-focused approaches are congruent with contemporary mental health nursing in particular, and can be safely incorporated into nursing practice without compromising other therapeutic interventions. In summary, these papers suggested that a range of techniques in solution-focused therapy can be acquired in a relatively brief period of time (Bowles et al, 2001; Hosany et al, 2007; Ferraz and Wellman, 2009) and that, once gained, these skills are incorporated quickly and effectively within the practitioner’s toolkit. The papers reported on the introduction and effect of solution-focused training for health staff. Four of these were training for nurses across specialties (Bowles et al, 2001; Hosany et al, 2007; Smith, 2010; Simm et al, 2011); the others for mental health workers (Ferraz and Wellman, 2009) and counselling students (Miller, 2010). The training programmes were short, ranging from a few days (Bowles, 2001; Ferraz and Wellman, 2009) to 6 months (Smith, 2010; Miller, 2010) and some included refresher training (Hosany et al, 2007; Simm et al, 2011) or clinical supervision afterwards to consolidate learning (Miller, 2010). Evaluations of the impact of these training programmes showed that students had begun to incorporate solution-focused approaches into their daily practice (Bowles et al, 2001); that participants’ knowledge of solution-focused brief therapy and use in routine clinical practice increased (Ferraz and Wellman, 2009; Miller, 2010); and that some reported significant changes in their relationships with clients (Smith, 2010). These studies report on training events for qualified nurses (apart from Miller’s counselling training evaluation) from a few disciplines. The training ranged from 2 days to 6 months and with a range of intensities. All reported an increase in the use of solution-focused approaches in their everyday work. The suggestions of adding either clinical supervision or update sessions appear to be valuable in promoting confidence with the newly acquired skills, and thus increase the likelihood of solution-focused skills being used in practice.
© 2013 MA Healthcare Ltd
Teaching a solution-focused approach to mental health nursing students The following template has been used for ten cohorts of mental health undergraduate students over the past 5 years. The size of the cohorts ranged from 16 to 40 students per group: all groups had male and female students of mixed age and varied educational backgrounds. The skills sessions were provided in the second year of the students’ 3-year mental health nursing course. The idea for offering this particular skill-based session came from student feedback requesting more skills teaching in the course. The solution-focused skills training began with an introduction to its theoretical basis. This drew on the fundamental assumptions underpinning the
British Journal of Nursing, 2013, Vol 22, No 21
approach, some research evidence and the key techniques that form the intervention. As part of the purpose was to link the students’ acquisition of theoretical knowledge with practical and research application, integrated within the day was a short Box 1. Guidance sheets for students Introducing the client to solution-focused therapy Not one session more than necessary Solvable problems Pre-session change Agree timescale Negotiate task Clarify goals Problem clarification What’s the trouble? [You’re here today about… You’re hoping I can help you with… ] Definition of highest-priority problem [In what way is it a problem… Why now… What is your hope about how I will help?] Solution amplification (1): miracle question You wake up tomorrow and that problem you’re here about is solved. What would be different? What else would [your sister/other] notice about you? What would your [sister] notice if you moved 5% towards the life you would like to be leading? Solution amplification (2): exceptions Are there pieces of the solution that are already happening? How did you do that? Solution amplification (3): scaling Scaling is a way of measuring how close we are to our desired outcomes On a scale of 0–10, where do you feel you are at the moment? Assessment of attempted solutions What have you tried? How did you do that? Exactly what did you say/do? Did it work? Feedback (1) Ask the client if they would like feedback: If yes—validate, e.g. ‘I don’t blame you for feeling distressed’ Genuine compliments, ‘I’m impressed that even in the face of… you have been able to…’ Suggestion or homework Feedback (2) If the client declines feedback: Encourage the client to do more of what works, paying attention to how they’re doing it. If what they are doing does not work, stop doing it. Do something different. Pay attention to how they cope with the problem Session end After giving the ‘message’ or feedback: Until next time we meet, I’d like you to observe what things are working well in your life/family/work Do you want a referral to another service? Intervention techniques Curious about how client copes Validate emotions Compliment strengths or achievement What is better? Explore benefits, no matter how small What would be next small sign of change continuing? If deteriorated, how has client hung on? Dialogue is future-orientated solution talk
1223
British Journal of Nursing.Downloaded from magonlinelibrary.com by 139.080.123.046 on July 19, 2015. For personal use only. No other uses without permission. . All rights reserved.
Method used for evaluating the teaching and learning strategy used The impact of this type of learning activity was evaluated from an educational perspective to establish if it was helpful for one cohort of the undergraduate mental health students. This was achieved with simple self-report measures before and after training, and by inviting informal verbal feedback from the students.The items on the self-report measure invited students to rate on a 1–10 scale how confident they were in explaining: what the solution-focused approach was; understanding the skills; describing its benefits; and understanding the role of clinical supervision in enhancing these skills.
Findings of the evaluation Students self-reported an increase in all four categories after receiving the training (Table 1). It is important to accept this evaluation at face value: it was not designed as a research study to produce statistically significant results, but more as an Table 1. Outcomes of self-report assessment of solution-focused approach for cohort X (n=26) Category
Pre-training (mean) [range]
Post-training (mean) [range]
Difference (mean)
Knowledge of solution-focused approach
4.19 [1–9]
7.37 [4–9]
3.18
Describing the skills
3.85 [1–9]
7.33 [5–10]
3.48
Describing its benefits
4.42 [1–9]
7.23 [5–9]
2.81
Understanding the role of clinical supervision to enhance these skills
3.81 [1–9]
7.26 [3–9]
3.45
1224
educational evaluation to assess, immediately after the session, whether the students felt confident in their own knowledge in the respective areas. A further weakness of this evaluation was that it was not repeated at a set time afterwards (for example, 3 months later) to establish what knowledge and skills had been retained. As students had been given the reading for the journalclub session a week before, they were expected to have some preparatory knowledge of the approach—so a more robust pre-session measure might have been obtained before students had done this advance reading. It is also worth noting that clinical supervision as a concept had not been covered during this session, nor in this whole theory block, and may have been outside students’ scope of knowledge at this point in their degree course. In addition to the self-report evaluation, students offered many comments about these sessions, including: ‘Good idea, would be helpful if the audio-video example were available on the virtual learning environment… sound quality was poor at times’ ‘liked seeing lecturers demonstrating skills’ ‘video better than live demonstration as lecturers sometimes get distracted and demonstrate differently each time’ ‘we know exactly what we’re meant to be doing by watching the skills first’ Evidently, some students preferred a live demonstration of the skills needed, while others preferred the pre-recorded video material, although its weakness was its poor technical quality (one solution would be to use commercially available material or recreate our own material with further assistance from a media resources team).
Discussion Students found these skills days intense. They were expected to have prepared for the day in advance by reading the required material. As well as practising new skills, they were also required to contribute to a group critique of related research literature. Although these two tasks were dissimilar, the aim was for students to recognise that they were thematically linked, thereby increasing their appreciation of the integration of theory and practice. But it may have been too challenging for them at this stage in their degree course. Nevertheless, students reported an increase in knowledge and skills regarding solution-focused therapy as a result of this approach to skills teaching. Having considered the brief volume of literature examining training in solution-focused therapy, it might be useful to offer students a refresher training day to recap and practise these newly acquired skills. This could be offered as a booster session in their third year and a recommendation that they engage with clinical supervision on graduation to maintain what they have learned.
Conclusion From the limited literature in this area, the authors’ experience and the students’ evaluations of learning solution-focused
© 2013 MA Healthcare Ltd
journal club idea in which a related research or practice paper related specifically to solution-focused therapeutic work was critiqued. This had the dual function of reinforcing the main principles of the solution-focused approach, albeit from a slightly different perspective from what was offered verbally in class, alongside the students’ opportunity to enhance their critical reading skills. The key skills of the solutionfocused approach (Box 1) were shown in vivo and a prerecorded simulated session was available for the purpose of consolidation if students were unsure (they could also access this later to remind them of aspects of the intervention). Students practised these skills in small groups with a hypothetical case they had been given. They took turns in each of the designated roles in the hypothetical cases and recorded themselves as practitioner using audio-visual equipment. This enabled them to review their own work so that they could identify how they might hone these skills. Feedback was given to each student during this skills rehearsal session, so that clarification of aspects could be sought. The structure of the day was therefore designed to encourage an integration of research evidence, theoretical concepts and skills development, thus showing student nurses how the three are inter-related. As an approximate timing guide, the morning was dedicated to the theory, research and demonstration, and the afternoon to skills practice and review.
British Journal of Nursing, 2013, Vol 22, No 21
British Journal of Nursing.Downloaded from magonlinelibrary.com by 139.080.123.046 on July 19, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key points therapy is a model of brief therapy
n The
solution-focused approach builds on the client’s strengths and is futurefocused
n Nurses
can acquire a useful level of skills and knowledge in a one-day training package
n Booster
sessions or clinical supervision could consolidate this learning
techniques, the authors’ believe there is an opportunity to increase the availability of this type of skills training. It is impossible to specify how long or intense the training needs to be, but student mental health nurses reported having a basic understanding of the theory and practice of key solutionfocused techniques after one training day. In the literature, there are examples of qualified nurses being confident in applying these skills after a 2-day training event. An important consideration of this training day was that students were not expected to have any prior knowledge or experience of this approach, meaning the training-day package lends itself to being suitable for other groups of nurses, either before or after their registration. The consensus is that further research in the form of largescale studies is needed to ensure that people using mental health services for even the briefest of periods can access useful, effective and structured support from a range of skilled staff. Booster sessions or clinical supervision could consolidate BJN this learning. Conflict of interest: none Boscart V (2009) A communication intervention for nursing staff in chronic care. J Adv Nurs 65(9): 1823–32 Bowles N, Coughlan A, Harnett P (2007) Becoming solution-focused in
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edited by John Fowler
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n Solution-focused
acute inpatient psychiatric wards, part 1: becoming solution-focused. Irish Nurse 8(5): 16–17 Bowles N, MacKintosh C, Torn A (2001) Nurses’ communication skills: an evaluation of the impact of solution-focused communication training. J Adv Nurs 36(3): 347–54 Christie D (2008) Dancing with diabetes: brief therapy conversations with children, young people and families living with diabetes. Eur Diabetes Nurs 5(1): 28–32 Coxon G (2012) Mental health competencies for practice and community nurses. Nurs In Pract 64: 24–6 De Shazer S (1985) Keys to Solution in Brief Therapy. Norton, New York Ferraz H, Wellman H (2009) Fostering a culture of engagement: an evaluation of a 2 day training for mental health workers. J Psychiatr Ment Health Nurs 16(4): 326–34. doi: 10.1111/j.1365-2850.2008.01374.x. Fowler J (2011) Supporting self and others: from staff nurse to nurse consultant, part 9: solution-focused support. Br J Nurs 20(17): 1138 Freeman S (2007) A focused solution to therapy. Prim Health Care 17(7): 32–4 Gupta V, Woodman C (2010) Managing stress in a palliative care team. Paediatr Nurs 22(10): 14–18 Hosany Z, Wellman N, Lowe T (2007) Fostering a culture of engagement: a pilot study of the outcomes of training mental health nurses working in two UK acute admission units in brief solution-focused therapy techniques. J Psychiatr Ment Health Nurs 14(7): 688–95 Kvarme L, Eboh W, van der Teijlingen E (2008) Use of solution-focused brief therapy in bullying. Br J School Nurs 3(7) 346–8 Miller JH (2010) Does teaching a solution-focused model of counselling work? A follow-up of graduates. Counsell Psychotherap Res 10(3): 173–82 Quick E (1998) Doing what works in brief and intermittent therapy. J Mental Health 7(5): 527–33 Ruddick F (2011) Coping with problems by focusing on solutions. Mental Health Pract 14(8): 28–30 Simm R, Hastie L, Weymouth E (2011) Is training in solution-focused working useful to community matrons? Br J Community Nurs 16(12): 598–603 Smith IC (2005) Solution-focused brief therapy with people with learning disabilities: a case study. Br J Learn Disabil 33: 102–105 Smith S (2010) A preliminary analysis of narratives on the impact of training in solution-focused therapy expressed by students having completed a 6-month training course. J Psychiatr Ment Health Nurs 17(2): 105–10. doi: 10.1111/j.1365-2850.2009.01492.x. Smith S, Adam D, Kirkpatrick P (2011) Using solution-focused communication to support patients. Nurs Standard 25(52): 42–7 Wakefield S, Day P, Stansfield K (2010) Taking a solution-focused approach to public health. Br J School Nurs 5(7): 338–43 Wand T (2011) Real mental health promotion requires a reorientation of nursing education, practice and research. J Psychiatr Ment Health Nurs 18(2): 131–8. doi: 10.1111/j.1365-2850.2010.01634.x. Ward T (2013) Positioning mental health nursing practice within a positive health paradigm. Int J Ment Health Nurs 22(2): 116–24. doi: 10.1111/j.1447-0349.2012.00848.x.
British Journal of Nursing, 2013, Vol 22, No 21
British Journal of Nursing.Downloaded from magonlinelibrary.com by 139.080.123.046 on July 19, 2015. For personal use only. No other uses without permission. . All rights reserved.
Key words: Solution-focused therapy ■ Mental health ■ Education ■ Skills acquisition
S
olution-focused brief therapy (De Shazer, 1985) is based on taking a solution-building, rather than a problem-solving, approach to individuals, couples or families wanting change in their lives. It encourages an exploration of the client’s current resources, in terms of their strengths, meaningful relationships and achievements, while also considering their future hopes and aspirations. The underpinning assumption of this model of therapeutic change is that the client presents as a motivated individual, wanting change and looking for a new direction. Working collaboratively in an equal relationship with the client, therefore, has the potential for the client to achieve a positive outcome. This approach is based on the person-centred idea that the client is the one who is best informed about their own life and able to draw on ‘exceptions’ from which possible solutions can emerge. As Quick (1998) suggests, where an aspect of a client’s world is functioning well for them, it makes sense to encourage them to continue with it.
Nicola Evans and Anne-Marie Evans are Lecturers in Mental Health Nursing at the School of Healthcare Science, Cardiff University, Wales Accepted for publication: October 2013
1222
Offering a solution-focused intervention generally involves between three and five sessions with an individual client, couple or family. There is value in offering frequent sessions, although the frequency and duration of sessions are negotiated between the practitioner and client. This approach can be offered as an individual intervention; as an adjunct to other therapeutic approaches; or as a preliminary therapeutic approach to engage the client in thinking about change. The overriding principle for the intervention is to do only as much as is required to enable the client to move on with their life. In colloquial language: ‘What’s the trouble? If it’s not broken, don’t fix it. If it works, do more of it. If it doesn’t work, stop doing it and do something different.’ Suggestions or interpretations of the client’s situation are only rarely offered and, if so, are tentatively framed. The focus of collaborative talk between the practitioner and the client is on the future, not the past, with the aim of achieving small changes that potentially have a big impact on the client’s life.
Using solution-focused approaches in practice There is evidence in the literature to suggest that solutionfocused approaches are used across a number of nursing specialties.Within mental health, solution-focused approaches are useful when doing mental health assessments (Ward, 2013); to promote service users’ engagement with services on in-patient facilities (Bowles et al, 2007); and as an optimistic approach to mental health promotion (Wand, 2011) and care generally (Ruddick, 2011). Coxon (2012) even suggests it is one of the core competencies that community mental health nurses should have. This approach is useful for nurses working with children in a number of settings. School nurses have used it both to address behavioural change for vulnerable families (Wakefield et al, 2010) and to tackle bullying by increasing children’s empathy with victims of bullying (Kvarme et al, 2008). Gupta and Woodman (2010) described a solution-focused approach was used to manage stress for a palliative nursing team who were caring for children with complex needs (Gupta and Woodman, 2010). There are also reports of solution-focused approaches to nursing work being effective in working with children with diabetes (Christie, 2008); in chronic care (Boscart, 2009); with people with learning disabilities (Smith, 2005); with asylum seekers (Freeman, 2007); and to help patients with long-term conditions self-manage (Smith et al, 2011). Aside from direct clinical work, Fowler (2011) suggested that self-affirming strategies and scaling questions
© 2013 MA Healthcare Ltd
Abstract
Solution-focused therapy is a model of therapy that builds on the client’s strengths, is future-focused and can be generally offered as a brief intervention. It can be used across multiple clinical settings and is not limited to being useful for clients accessing mental health services. Learning the underlying principles and developing a foundation level of skill in the approach was found to be achievable in an undergraduate nursing course, with students reporting an increase in their knowledge of the model and confidence in basic therapeutic skills in just one day of training. In this paper, we introduce the solution-focused approach in relation to nursing practice. We describe the template used for the training day offered to undergraduate mental health nurses. Students reported that this method of learning a therapeutic approach was helpful and increased both their knowledge and skill base.
Therapeutic approach when using solution-focused therapy
British Journal of Nursing, 2013, Vol 22, No 21
British Journal of Nursing.Downloaded from magonlinelibrary.com by 139.080.123.046 on July 19, 2015. For personal use only. No other uses without permission. . All rights reserved.
education were helpful in professional development activities for nursing staff wanting to improve their portfolios.
Review of the literature on training solution-focused approaches The literature was examined to establish what is already known about training nurses in solution-focused therapy skills. Ferraz and Wellman (2009) offered a helpful review of the literature, which concluded that solution-focused approaches are congruent with contemporary mental health nursing in particular, and can be safely incorporated into nursing practice without compromising other therapeutic interventions. In summary, these papers suggested that a range of techniques in solution-focused therapy can be acquired in a relatively brief period of time (Bowles et al, 2001; Hosany et al, 2007; Ferraz and Wellman, 2009) and that, once gained, these skills are incorporated quickly and effectively within the practitioner’s toolkit. The papers reported on the introduction and effect of solution-focused training for health staff. Four of these were training for nurses across specialties (Bowles et al, 2001; Hosany et al, 2007; Smith, 2010; Simm et al, 2011); the others for mental health workers (Ferraz and Wellman, 2009) and counselling students (Miller, 2010). The training programmes were short, ranging from a few days (Bowles, 2001; Ferraz and Wellman, 2009) to 6 months (Smith, 2010; Miller, 2010) and some included refresher training (Hosany et al, 2007; Simm et al, 2011) or clinical supervision afterwards to consolidate learning (Miller, 2010). Evaluations of the impact of these training programmes showed that students had begun to incorporate solution-focused approaches into their daily practice (Bowles et al, 2001); that participants’ knowledge of solution-focused brief therapy and use in routine clinical practice increased (Ferraz and Wellman, 2009; Miller, 2010); and that some reported significant changes in their relationships with clients (Smith, 2010). These studies report on training events for qualified nurses (apart from Miller’s counselling training evaluation) from a few disciplines. The training ranged from 2 days to 6 months and with a range of intensities. All reported an increase in the use of solution-focused approaches in their everyday work. The suggestions of adding either clinical supervision or update sessions appear to be valuable in promoting confidence with the newly acquired skills, and thus increase the likelihood of solution-focused skills being used in practice.
© 2013 MA Healthcare Ltd
Teaching a solution-focused approach to mental health nursing students The following template has been used for ten cohorts of mental health undergraduate students over the past 5 years. The size of the cohorts ranged from 16 to 40 students per group: all groups had male and female students of mixed age and varied educational backgrounds. The skills sessions were provided in the second year of the students’ 3-year mental health nursing course. The idea for offering this particular skill-based session came from student feedback requesting more skills teaching in the course. The solution-focused skills training began with an introduction to its theoretical basis. This drew on the fundamental assumptions underpinning the
British Journal of Nursing, 2013, Vol 22, No 21
approach, some research evidence and the key techniques that form the intervention. As part of the purpose was to link the students’ acquisition of theoretical knowledge with practical and research application, integrated within the day was a short Box 1. Guidance sheets for students Introducing the client to solution-focused therapy Not one session more than necessary Solvable problems Pre-session change Agree timescale Negotiate task Clarify goals Problem clarification What’s the trouble? [You’re here today about… You’re hoping I can help you with… ] Definition of highest-priority problem [In what way is it a problem… Why now… What is your hope about how I will help?] Solution amplification (1): miracle question You wake up tomorrow and that problem you’re here about is solved. What would be different? What else would [your sister/other] notice about you? What would your [sister] notice if you moved 5% towards the life you would like to be leading? Solution amplification (2): exceptions Are there pieces of the solution that are already happening? How did you do that? Solution amplification (3): scaling Scaling is a way of measuring how close we are to our desired outcomes On a scale of 0–10, where do you feel you are at the moment? Assessment of attempted solutions What have you tried? How did you do that? Exactly what did you say/do? Did it work? Feedback (1) Ask the client if they would like feedback: If yes—validate, e.g. ‘I don’t blame you for feeling distressed’ Genuine compliments, ‘I’m impressed that even in the face of… you have been able to…’ Suggestion or homework Feedback (2) If the client declines feedback: Encourage the client to do more of what works, paying attention to how they’re doing it. If what they are doing does not work, stop doing it. Do something different. Pay attention to how they cope with the problem Session end After giving the ‘message’ or feedback: Until next time we meet, I’d like you to observe what things are working well in your life/family/work Do you want a referral to another service? Intervention techniques Curious about how client copes Validate emotions Compliment strengths or achievement What is better? Explore benefits, no matter how small What would be next small sign of change continuing? If deteriorated, how has client hung on? Dialogue is future-orientated solution talk
1223
British Journal of Nursing.Downloaded from magonlinelibrary.com by 139.080.123.046 on July 19, 2015. For personal use only. No other uses without permission. . All rights reserved.
Method used for evaluating the teaching and learning strategy used The impact of this type of learning activity was evaluated from an educational perspective to establish if it was helpful for one cohort of the undergraduate mental health students. This was achieved with simple self-report measures before and after training, and by inviting informal verbal feedback from the students.The items on the self-report measure invited students to rate on a 1–10 scale how confident they were in explaining: what the solution-focused approach was; understanding the skills; describing its benefits; and understanding the role of clinical supervision in enhancing these skills.
Findings of the evaluation Students self-reported an increase in all four categories after receiving the training (Table 1). It is important to accept this evaluation at face value: it was not designed as a research study to produce statistically significant results, but more as an Table 1. Outcomes of self-report assessment of solution-focused approach for cohort X (n=26) Category
Pre-training (mean) [range]
Post-training (mean) [range]
Difference (mean)
Knowledge of solution-focused approach
4.19 [1–9]
7.37 [4–9]
3.18
Describing the skills
3.85 [1–9]
7.33 [5–10]
3.48
Describing its benefits
4.42 [1–9]
7.23 [5–9]
2.81
Understanding the role of clinical supervision to enhance these skills
3.81 [1–9]
7.26 [3–9]
3.45
1224
educational evaluation to assess, immediately after the session, whether the students felt confident in their own knowledge in the respective areas. A further weakness of this evaluation was that it was not repeated at a set time afterwards (for example, 3 months later) to establish what knowledge and skills had been retained. As students had been given the reading for the journalclub session a week before, they were expected to have some preparatory knowledge of the approach—so a more robust pre-session measure might have been obtained before students had done this advance reading. It is also worth noting that clinical supervision as a concept had not been covered during this session, nor in this whole theory block, and may have been outside students’ scope of knowledge at this point in their degree course. In addition to the self-report evaluation, students offered many comments about these sessions, including: ‘Good idea, would be helpful if the audio-video example were available on the virtual learning environment… sound quality was poor at times’ ‘liked seeing lecturers demonstrating skills’ ‘video better than live demonstration as lecturers sometimes get distracted and demonstrate differently each time’ ‘we know exactly what we’re meant to be doing by watching the skills first’ Evidently, some students preferred a live demonstration of the skills needed, while others preferred the pre-recorded video material, although its weakness was its poor technical quality (one solution would be to use commercially available material or recreate our own material with further assistance from a media resources team).
Discussion Students found these skills days intense. They were expected to have prepared for the day in advance by reading the required material. As well as practising new skills, they were also required to contribute to a group critique of related research literature. Although these two tasks were dissimilar, the aim was for students to recognise that they were thematically linked, thereby increasing their appreciation of the integration of theory and practice. But it may have been too challenging for them at this stage in their degree course. Nevertheless, students reported an increase in knowledge and skills regarding solution-focused therapy as a result of this approach to skills teaching. Having considered the brief volume of literature examining training in solution-focused therapy, it might be useful to offer students a refresher training day to recap and practise these newly acquired skills. This could be offered as a booster session in their third year and a recommendation that they engage with clinical supervision on graduation to maintain what they have learned.
Conclusion From the limited literature in this area, the authors’ experience and the students’ evaluations of learning solution-focused
© 2013 MA Healthcare Ltd
journal club idea in which a related research or practice paper related specifically to solution-focused therapeutic work was critiqued. This had the dual function of reinforcing the main principles of the solution-focused approach, albeit from a slightly different perspective from what was offered verbally in class, alongside the students’ opportunity to enhance their critical reading skills. The key skills of the solutionfocused approach (Box 1) were shown in vivo and a prerecorded simulated session was available for the purpose of consolidation if students were unsure (they could also access this later to remind them of aspects of the intervention). Students practised these skills in small groups with a hypothetical case they had been given. They took turns in each of the designated roles in the hypothetical cases and recorded themselves as practitioner using audio-visual equipment. This enabled them to review their own work so that they could identify how they might hone these skills. Feedback was given to each student during this skills rehearsal session, so that clarification of aspects could be sought. The structure of the day was therefore designed to encourage an integration of research evidence, theoretical concepts and skills development, thus showing student nurses how the three are inter-related. As an approximate timing guide, the morning was dedicated to the theory, research and demonstration, and the afternoon to skills practice and review.
British Journal of Nursing, 2013, Vol 22, No 21
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Key points therapy is a model of brief therapy
n The
solution-focused approach builds on the client’s strengths and is futurefocused
n Nurses
can acquire a useful level of skills and knowledge in a one-day training package
n Booster
sessions or clinical supervision could consolidate this learning
techniques, the authors’ believe there is an opportunity to increase the availability of this type of skills training. It is impossible to specify how long or intense the training needs to be, but student mental health nurses reported having a basic understanding of the theory and practice of key solutionfocused techniques after one training day. In the literature, there are examples of qualified nurses being confident in applying these skills after a 2-day training event. An important consideration of this training day was that students were not expected to have any prior knowledge or experience of this approach, meaning the training-day package lends itself to being suitable for other groups of nurses, either before or after their registration. The consensus is that further research in the form of largescale studies is needed to ensure that people using mental health services for even the briefest of periods can access useful, effective and structured support from a range of skilled staff. Booster sessions or clinical supervision could consolidate BJN this learning. Conflict of interest: none Boscart V (2009) A communication intervention for nursing staff in chronic care. J Adv Nurs 65(9): 1823–32 Bowles N, Coughlan A, Harnett P (2007) Becoming solution-focused in
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n Solution-focused
acute inpatient psychiatric wards, part 1: becoming solution-focused. Irish Nurse 8(5): 16–17 Bowles N, MacKintosh C, Torn A (2001) Nurses’ communication skills: an evaluation of the impact of solution-focused communication training. J Adv Nurs 36(3): 347–54 Christie D (2008) Dancing with diabetes: brief therapy conversations with children, young people and families living with diabetes. Eur Diabetes Nurs 5(1): 28–32 Coxon G (2012) Mental health competencies for practice and community nurses. Nurs In Pract 64: 24–6 De Shazer S (1985) Keys to Solution in Brief Therapy. Norton, New York Ferraz H, Wellman H (2009) Fostering a culture of engagement: an evaluation of a 2 day training for mental health workers. J Psychiatr Ment Health Nurs 16(4): 326–34. doi: 10.1111/j.1365-2850.2008.01374.x. Fowler J (2011) Supporting self and others: from staff nurse to nurse consultant, part 9: solution-focused support. Br J Nurs 20(17): 1138 Freeman S (2007) A focused solution to therapy. Prim Health Care 17(7): 32–4 Gupta V, Woodman C (2010) Managing stress in a palliative care team. Paediatr Nurs 22(10): 14–18 Hosany Z, Wellman N, Lowe T (2007) Fostering a culture of engagement: a pilot study of the outcomes of training mental health nurses working in two UK acute admission units in brief solution-focused therapy techniques. J Psychiatr Ment Health Nurs 14(7): 688–95 Kvarme L, Eboh W, van der Teijlingen E (2008) Use of solution-focused brief therapy in bullying. Br J School Nurs 3(7) 346–8 Miller JH (2010) Does teaching a solution-focused model of counselling work? A follow-up of graduates. Counsell Psychotherap Res 10(3): 173–82 Quick E (1998) Doing what works in brief and intermittent therapy. J Mental Health 7(5): 527–33 Ruddick F (2011) Coping with problems by focusing on solutions. Mental Health Pract 14(8): 28–30 Simm R, Hastie L, Weymouth E (2011) Is training in solution-focused working useful to community matrons? Br J Community Nurs 16(12): 598–603 Smith IC (2005) Solution-focused brief therapy with people with learning disabilities: a case study. Br J Learn Disabil 33: 102–105 Smith S (2010) A preliminary analysis of narratives on the impact of training in solution-focused therapy expressed by students having completed a 6-month training course. J Psychiatr Ment Health Nurs 17(2): 105–10. doi: 10.1111/j.1365-2850.2009.01492.x. Smith S, Adam D, Kirkpatrick P (2011) Using solution-focused communication to support patients. Nurs Standard 25(52): 42–7 Wakefield S, Day P, Stansfield K (2010) Taking a solution-focused approach to public health. Br J School Nurs 5(7): 338–43 Wand T (2011) Real mental health promotion requires a reorientation of nursing education, practice and research. J Psychiatr Ment Health Nurs 18(2): 131–8. doi: 10.1111/j.1365-2850.2010.01634.x. Ward T (2013) Positioning mental health nursing practice within a positive health paradigm. Int J Ment Health Nurs 22(2): 116–24. doi: 10.1111/j.1447-0349.2012.00848.x.
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