A 2-Day Postpartum CBT-Based Training for Nurses

Abstract

Background

Public health nurses (PHNs) are often a first point of contact for postpartum individuals seeking mental health support, but report limited training related to mental health.

Purpose

To determine whether a two-day cognitive behavioral therapy (CBT)-based training program focused on postpartum maternal mental health can improve PHN perceptions of their ability to deliver CBT techniques, their confidence working with distressed clients, and with managing client resistance to treatment recommendations.

Methods

A convenience sample of 45 PHNs working in the Family Health Division of Niagara Region Public Health in Ontario, Canada were assessed before and after they received a two-day CBT-based training program. Before attending training, PHNs reported their current professional position, years of experience working in public health, and any previous mental health training. Their confidence in delivering CBT techniques, working with distressed clients, and with managing client resistance to treatment recommendations was assessed pre- and post-training. Participants also rated their satisfaction with the training.

Results

Statistically significant improvements were seen in confidence using CBT techniques, and in supporting and managing distressed or resistant clients. The two-day training was highly rated overall by participants. Medium to large effect sizes were found for changes in confidence-related questions.

Conclusions

Providing PHNs with brief CBT-based mental health-related training can increase their confidence in this aspect of their practice, and could potentially improve the quality of care they provide.

Background

Public health nurses (PHNs) are a first point of contact for many individuals struggling with their mental health during pregnancy and/or the postpartum period (Noonan et al., 2016). Access to non-pharmacological mental health services can be quite limited often due to funding limitations and long wait-times, even in settings where healthcare is universally funded (Moroz et al., 2020). Given their frequent contact with patients, PHNs can be in the ideal position to support these individuals.

However, PHNs are in need of support themselves. Indeed, they frequently report receiving limited specialized training related to mental health (Hicks et al., 2022; McInnes et al., 2022; Noonan et al., 2019), and have consistently expressed a desire for more mental health-related training, including the identification of symptoms of various mental disorders, how to best support clients who are experiencing distress, handling psychiatric emergencies, and managing resistance to treatment recommendations (McInnes et al., 2022).

Postpartum depression (PPD) is one of the most common complications of delivery and can affect nearly 18% of birthing parents, with those who have a history of depression being at an even higher risk (Gheorghe et al., 2021). Left untreated, PPD can increase the risk of future depressive episodes and can have profound impacts on both parenting and mother-infant relationships (Slomian et al., 2019). Interestingly, those with PPD report preferring to receive resources and support from PHNs over other healthcare professionals (Feeley et al., 2016).

Despite the preferences and needs of their clients, PHNs may not have adequate skills or experience supporting individuals with postpartum mental health challenges due in part to gaps in the available training programs in their workplace (Layton et al., 2020). PHNs frequently report receiving only limited instruction in the use of specific psychotherapeutic techniques or how to manage acute psychiatric distress and/or suicidal ideation in clients (Layton et al., 2020; McInnes et al., 2022). These nurses also report low confidence levels working with distressed clients overall (Morreale et al., 2020), which can increase their avoidance of these individuals (McInnes et al., 2022), and could compromise their ability to provide high quality care. Even PHNs specializing in supporting new and expecting parents acknowledge the need for further training in mental health (Noonan et al., 2019), underscoring the need for opportunities to access enhanced training.

Professional development opportunities for PHNs are critically important to improve confidence and quality of care for those working directly with clients. It has been identified that opportunities should be more accessible and relevant to the needs of PHNs (King et al., 2021; Mlambo et al., 2021). Evidence suggests that the most effective mental health training programs include didactic teaching, practice opportunities, and the application of techniques (Westbrook et al., 2008). Previous research has also shown that PHNs have a desire for more professional development opportunities, particularly ones that align with the areas pertaining to their current practice (Mlambo et al., 2021). Given the existing literature, providing mental health training to PHNs working with new parents could support them in their practice.

Providing perinatal mental health training to PHNs could increase their comfort, confidence, and effectiveness in supporting distressed clients, which has the potential to improve clinical outcomes (Morreale et al., 2020). For example, recent efforts by Van Lieshout and colleagues (Huh et al., 2023; Layton et al., 2020; Van Lieshout et al., 2020) involved trained PHNs to deliver a nine-week group cognitive behavioral therapy (CBT) intervention to treat birthing parents with PPD. Not only was the intervention effective, the PHNs reported a positive experience with the training process (Layton et al., 2020). In addition to providing nurses with high levels of confidence with delivering the specific CBT intervention, PHNs also reported that training improved their confidence in their roles working with clients in and outside of the therapy group, addressed gaps in their knowledge and skills, and empowered them both in their professional and personal lives (Layton et al., 2020). Providing PHNs with perinatal mental health training could therefore help to ease their stress working with clients struggling with symptoms of PPD, and improve the quality of care they provide (Layton et al., 2020).

At Niagara Region Public Health, the nurse management team from the Family Health division expressed interest in providing a perinatal mental health training program to their PHN team that met the expressed needs of their staff, particularly those working directly with new and expectant parents. To help build skills as nurses transitioned from COVID-19 related duties back to their typical work in the Family Health division, and in response to the increased mental health needs of their clients, the training was developed in collaboration with those who would attend the training. Based on previous work with perinatal psychiatry experts (Huh et al., 2023; Layton et al., 2020; Van Lieshout et al., 2020), a brief training program was developed that aimed at providing their nurses with basic CBT knowledge and skills, as well as guidance for managing the challenging situations that they reported encountering most frequently (i.e., acute psychiatric distress, resistance to treatment recommendations).

Given the expressed need for specific training, the purpose of this study was to evaluate the effectiveness of a two-day CBT-based training program focused on the postpartum period at improving PHNs’ perceptions of their ability to deliver CBT content, their confidence working with clients in acute psychiatric distress, and responding to those struggling to comply with treatment recommendations.

Methods

Sample

This study was approved by the Hamilton Integrated Research Ethics Board (#14430). A convenience sample of PHNs working in the Family Health division at Niagara Region Public Health, who worked directly with new and expectant parents, were recruited for this study. Nurses were notified of the training opportunity by their management team and invited to participate in the study. The training was offered as an optional opportunity for professional development. Attendance at the training did not require PHNs to complete the study questionnaires assessing the training package, and their decision to attend did not impact their employment status.

Design

This study used a pre-post design without a control group. The training sessions were conducted over two consecutive days, with both sessions delivered via the online platform Zoom^®. Data were collected from participants the week before training and immediately following the second day of training.

Intervention

The two-day training program assessed in this study took place twice: first in November 2021 and again in April 2022, with different groups of PHNs in attendance at each session. The training content was developed collaboratively between two perinatal psychiatry experts, experienced PHNs, and Family Health division managers at Niagara Region Public Health. Before training, the nurse management team asked their staff for specific examples of situations from their practice that they found the most difficult, as well as any other topics they would like to have included in the training. The intervention content was then shared with the leadership team to provide the opportunity for feedback on the training content, which was then incorporated into the training by the perinatal psychiatry experts.

Each training day consisted of six total hours of instruction, with two 15-min breaks and one 60-min lunch break. The first day of training reviewed core psychotherapy and CBT-specific skills that PHNs could use with and/or teach to their clients. This content was based on a previously effective one-day CBT-based workshop for those experiencing PPD (Babiy et al., 2024; Van Lieshout et al., 2021; Van Lieshout et al., 2023). The content of this workshop was adapted for delivery to PHNs and consisted of four modules: the role of cognitions in PPD etiology, the cognitive and behavioral techniques used in CBT, and action planning and goal setting. Day two involved teaching an approach to clients struggling with acute psychiatric distress and strategies for helping to manage resistance to treatment recommendations and/or poor engagement by clients. Participants were also invited to discuss relevant clinical scenarios and difficult clinical experiences with session leaders on day two. These experiences were shared among the group, and both the perinatal psychiatry expert facilitators and other members of the group contributed to discussions around these scenarios.

Measures

The pre-training questionnaire was sent by email one week before training and asked participants to report their current role and number of years working in public health, as well as any previous mental health training they had received. Three questions were given to assess their current confidence levels using CBT techniques, managing acute psychiatric problems, and supporting clients showing resistance to treatment recommendations. These three questions were adapted from an established training-satisfaction questionnaire (Westbrook et al., 2008), and asked participants to address the following questions: “How confident are you in applying and teaching cognitive behavioral therapy skills in your practice?”; “How comfortable are you working with distressed clients?”; and “How confident are you working with resistant clients?” on a six point scale ranging from 0 (not at all) to 5 (completely).

The post-training questionnaire was sent immediately after day two of training and included the same three confidence-related questions that were provided prior to training, as well as the following five questions assessing their satisfaction with the training they received (Holgado Tello et al., 2006; Westbrook et al., 2008): “Was the training useful for your job?”; “Was the course content and its teaching appropriate for your level of knowledge?”; “How much did the training meet your needs?”; “How likely are you to recommend the training to a colleague?”; and “How would you rate the training overall?”. These questions were also rated from 0 (low) to 5 (high). Both pre- and post-training questionnaires were collected using Research Electronic Data Capture (REDCap), a secure data collection website (Harris et al., 2009).

Statistical analysis

Repeated measures t-tests for continuous variables were used to compare differences between pre- and post-training questionnaires. Cohen's d was used to express the effect size of the change from pre- to post-training on the three confidence questions. Means and standard deviations were used to describe items appearing at post-training only.

Results

Participation in the study was optional for attendees at the training. Fifty participants attended the 2-day training sessions. Forty-five training participants completed pre-training questionnaires, and 36 (80%) of them completed post-training questionnaires. Table 1 presents the characteristics of the participants who complete the first questionnaire. Nurses had spent an average of 13.5 years at public health, with the majority (77.8%) reporting fewer than five days of mental health-related training throughout their careers. Notably, 13 participants (28.9%) had received no mental health-related training since starting their careers in public health.

Table 1.

Participant characteristics.

Number of participants, n	45
Working for Public Health, Years, mean (SD)	13.45 (11.57)
Number of days of previous mental health training
No training received, n (%)	13 (28.89)
≤1 day of training received, n (%)	11 (24.44)
2–5 days of training received, n (%)	9 (20.00)
More than 5 days of training received, n (%)	10 (22.22)
Did not report number, n (%)	2 (4.44%)

Table 2 shows changes in confidence-related responses from pre- to post-training. All three questions asked about PHN confidence in their skills and abilities were found to have statistically significant improvement following the two-day training for confidence teaching CBT skills (t(34)=-15.03, p < .001), working with distressed clients (t(34)=-4.35, p < .001), and with resistant clients (t(34)=-6.34, p < .001). They also showed medium to large effect size improvements seen for each response.

Table 2.

Changes in public health nurse confidence from pre- to post-training.

	Mean Pre-	Mean Post-	Mean Diff.	St Dev	p-value	Cohen's d
Confidence Teaching CBT Skills	1.60	3.61	1.94	.76	<.001	2.46
Confidence with Distressed Clients	2.91	3.50	0.57	.78	<.001	0.72
Confidence with Resistant Clients	2.56	3.42	0.91	.18	<.001	1.19

CBT, cognitive behavioral therapy.

Participants also provided scores for their satisfaction with training, scored out of a possible five points. Average scores on the five post-training satisfaction questions were high across all questions; how useful the training was for their job: 4.86 (sd = 0.57), appropriateness of the content and teaching: 4.54 (sd = 0.55), how well the training met their needs: 4.48 (sd = 0.55), how likely they were to recommend this training to colleagues: 4.82 (sd = 0.37), and overall score: 4.96 (sd = 0.17).

Discussion

This two-day CBT-based training program designed for PHNs working with pregnant persons and birthing parents was associated with statistically significant medium to large effect size improvements in practice confidence. Nurses reported that it was both highly useful and met their needs, and was very highly rated by participants.

These findings are consistent with those of a previous study that informed the development of this two-day training, which reported that the training was well-received (Layton et al., 2020). The high overall rating by the participants may be attributable to the collaborative development process involving PHNs and managers from the Family Health division with the intention to provide training to address the specific gaps identified by the PHNs working there.

The significant changes in confidence scores and their relatively large effect sizes found in this study are a good indicator of the potential benefit of this training. While the size of the effects seen in this study were large, the size of reported confidence working with distressed clients was not as large as the other confidence questions. Given that many participants had more than 10 years of experience working in public health, with a group average of 13.45 years, despite not having formal psychiatric training, at least some of this time would have been spent working with distressed clients, so their pre-training confidence was already relatively high. This may have limited the room for improvement that could have resulted from the training that they received. In comparison, the other two confidence areas, teaching CBT skills and handling resistance from clients, showed larger effect sizes. While a few training participants had already received some training in mental health, many had very limited training in psychotherapeutic and CBT-related skills (24 out of 45 received one day or no training at all), and as a result were able to learn more from the training.

Those who attended the two-day training reported high satisfaction. The collaborative approach to developing training allowed for the inclusion of specific content that those who would attend the training were interested in learning more about. Additionally, dedicated time to group discussion at the end of the training allowed for shared experiences to be discussed, which could contribute to improving confidence by facilitating discussions about difficult situations between coworkers for which they could support one another.

Limitations

Due to time constraints of the busy schedules of the PHNs’ involved, the study adopted a pre-post design without a control group. Participants did not have the opportunity to practice the skills that were taught during the training prior to completing the post-training questionnaire, which could have impacted their confidence scores. The inclusion of a control group could have also allowed for observation of changes in confidence levels among PHNs that occurs from more interactions with clients alone.

Our reliance on only self-report data limits the findings, as no objective assessment of skill application was used. While improving confidence is essential, assessing skill application would have provided more insights into the effectiveness of the training. Future studies should observe PHNs after receiving the training to assess if it improves the application of skills and/or their functioning with acutely distressed clients and/or those who demonstrate resistance to treatment recommendations. Observed interactions with live clients or assessments using patient actors could be used, as could measures such as the Cognitive Therapy Awareness Scale, which could more objectively assess the understanding participants developed from pre- to post-training period. While the questions used to assess confidence and satisfaction questionnaires were derived from measures used in previous studies to assess these constructs, they may have been limited in their scope.

Another limitation involving the measures used are the satisfaction questions from Westbrook et al. (2008) do not report the psychometric properties of their questions. While these questions were chosen based on similarity to the present study, psychometrically validated satisfaction questions would be an area for improvement in future studies.

Additionally, the study's small sample size of PHNs employed in a single division within a Public Health Unit in Ontario, Canada, could raise questions about the generalizability of the findings to other public health units or divisions. Variability in the context of the trainee's practice and resources across different settings may show different outcomes.

Lastly, the training took place over two successive days, which limited the depth in which CBT can be taught. While the training was well-received by those who participated, and the duration was determined by PHN time and resources, the short duration limited the scope and depth of content and specific CBT-related skills. This could potentially be a limiting factor in the application of these skills within PHN practice, as they may not have a deep enough understanding of the skills being taught to apply them as effectively. Longer training sessions could be beneficial, however the duration of training would have to be determined by the time and resources available within respective public health units.

Future directions

To definitively determine the effectiveness of the training, an adequately powered randomized control trial should be conducted that assesses both knowledge and the application of CBT and the other skills taught during the training to determine the effectiveness of the intervention. This trial should incorporate both self-report measures to assess their knowledge and confidence, and observation-based evaluations of performance by an external rater to gauge adherence to the content and skill proficiency. Evaluations should also be conducted after a set period, such as several months post-training, to allow for skill consolidation and integration into their practices. Such studies could provide additional insights as to how confidence and skills could change for PHNs with increased exposure to clients and additional time working within their practice.

Given the importance of mental health education and training for nursing practices, it is imperative that PHNs receiving training are given an opportunity to express their needs and identify areas that they lack confidence and knowledge to guide training development. Future training programs should consider surveying prospective participants and public health units during training design periods to ensure it aligns with their needs. It should also consider piloting the training session with a smaller group of participants before widespread use. As the present study did not pilot the training first, this could show areas for improvement and ensure that PHNs needs are being fully met.

Conclusion

The findings of this study suggest that providing PHNs with two days of CBT-based training could enhance their confidence and competence in supporting prenatal and postpartum clients experiencing mental health challenges. By addressing specific areas of need identified by PHNs through training interventions have the potential to increase the quality of care they provide their clients.

Despite its limitations, this two-day training program represents a potential means by which PHNs’ confidence and skill in working with postpartum clients with mental health struggles can be enhanced. It is an easily applied, portable, and scalable means of improving PHNs’ confidence working with postpartum clients and improve quality of care, with the potential to make improvements in mental health outcomes of parents and their children.

Acknowledgements

The authors would like to thank the nurse management team from the Family Health Division at Niagara Public Health for their collaboration, and the public health nurse participants for their valuable contributions.

Author Biographies

Madisyn Campbell is a student in social work at York University and research assistant in the Department of Psychiatry and Behavioural Neurosciences at McMaster University.

Erika Haber-Evans is Manager of the Anxiety Treatment and Research Centre at St. Joseph's Healthcare Hamilton, and Co-director of Elle Psychotherapy.

Amanda Hicks is a Public Health Professional and Educator, and a PhD student in Nursing at McMaster University.

Ryan J Van Lieshout is a Professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University, Canada Research Chair in Perinatal Mental Health, and the Albert Einstein/Irving Zucker Chair in Neuroscience.