Cognitive behavioral therapy training for multidisciplinary inpatient psychiatric teams: a novel curriculum using animated simulations

Abstract

Problem:

Nurses assume primary responsibility teaching children self-management skills, yet few of them have formal training in evidence-based treatments such as cognitive behavioral therapy (CBT).

Methods:

We developed a novel CBT training curriculum specifically tailored for nurses and other child psychiatric inpatient team members. The curriculum was anchored in three components: 1) a structured manual; 2) instructional videos of common clinical scenarios using animated simulations; and 3) interactive role play exercises. The CBT curriculum was implemented through small group training sessions. We then conducted focus group sessions with the 20 participants to assess change in self-reported knowledge of, and utilization of CBT skills in clinical practice.

Findings:

The curriculum was well received by staff members, who found its content relevant and applicable to their daily inpatient work. Staff reported four main themes: 1) Routine clinical care (feelings, challenges and approaches); 2) CBT utility in practice; 3) CBT training components that facilitated learning of the discrete skills; and 4) Professional development needs.

Conclusions:

We were able to implement the curriculum within the time and staffing constraints of a clinically active inpatient setting. Future refinements of the model will include videotaped interactions between expert clinicians and simulated patients in high acuity situations.

The rates of emergency psychiatric hospitalizations for children and adolescents have increased substantially over the last decades, reflecting growing clinical needs in this population (Blader, 2011; Torio, Encinosa, Berdahl, McCormick, & Simpson, 2015). Additionally, hospital-based studies have revealed that behavioral dysregulation in the form of severe anger outbursts and aggression are frequent precipitants for inpatient hospitalization in children (Carlson et al., 2020). Practice guidelines for addressing aggression during psychiatric hospitalization have emphasized preventive multimodal interventions, including: 1) establishing a calming therapeutic milieu in which aggression is less likely to develop; 2) employing specific strategies such as verbal de-escalation techniques, cognitive-behavioral techniques, and recognizing triggers for aggression; and (3) the use of pharmacologic intervention for treating the underlying psychiatric illness (Gaynes et al., 2017).

Nurses frequently assume primary responsibility for ensuring the safety and behavioral stability of youth during inpatient hospitalizations. Delaney (2018) described the unique contributions of nursing interventions to inpatient treatment as falling within four categories, alliteratively termed the Four S-Model: 1) Safety: creating a physically safe environment by closely monitoring patient safety, utilizing de-escalation strategies, and reducing use of physical restraints; 2) Structure: establishing a predictable, developmentally flexible schedule and maintaining consistent unit rules and expectations; 3) Support: expressing genuine empathy, investment and interest in patients’ life experiences; and 4) Self-management: providing evidenced-based interventions that teach child patients new sets of coping and self-regulation skills for their psychiatric symptoms.

Cognitive behavior therapy (CBT) has a strong evidence base for the treatment of a broad range of child psychiatric conditions (Bennett et al., 2016; Kazdin, 2018). The use of CBT for the treatment of anger, irritability and aggression across transdiagnostic groups has also been well supported (Sukhodolsky, Smith, Mccauley, Ibrahim, & Piasecka, 2016). The core CBT components for treatment of anger, irritability and aggression include: 1) systematic identification of the antecedents (triggers) for episodes of anger; 2) cognitive restructuring techniques; 3) social problem-solving strategies; and 4) use of various relaxation skills for reducing anger arousal.

Historically, CBT treatments have been provided in the U.S. by licensed mental health professionals in a one-to-one model of care. The primary limitation of this approach is the reliance on a highly limited workforce that does not meet the growing need of a population of children and adolescents who require mental health treatments (Kazdin, 2018). There is mounting evidence however that nontraditional care providers such as nurses, teachers, clergy and youth workers can be trained to administer evidence-based mental health interventions, such as CBT, with fidelity and that their interventions significantly reduce symptom burden in diverse populations (Hoeft, 2017; Kazdin, 2018; Patel et al., 2010).

Within child psychiatric inpatient units, patients spend many hours of their day under the care of nurses, yet many nurses do not have formal training in evidence-based psychological approaches such as CBT (Vella, Page, Edwards, & Wand, 2017). At present, there is limited research regarding CBT educational models specifically designed to train nurses in child psychiatric inpatient settings. The need for such training extends to providers other than nurses, including: behavioral technicians, therapeutic milieu counselors, therapeutic recreation, and education staff. There is an emerging literature regarding the dissemination of CBT training to nurses who practice in schools and community outpatient settings (Codd & Ludgate, 2016; Lusk, Hart Abney, & Melnyk, 2018; Mazurek Melnyk, Kelly, & Lusk, 2014). One promising training model developed by Lusk et al. (2018) provided CBT training to advanced practice nursing students by emphasizing the following instructional components: 1) in-person or synchronous video lectures covering the content of a CBT treatment manual; 2) presentation of clinical case examples; 3) demonstration of a videotaped therapy session; and 4) small group role-play sessions for nursing students to practice their skills in the therapist role.

Similarly, Codd & Ludgate’s review (2016) of the evidence base for CBT training of nontraditional providers suggests that novice learners benefit from educational methods that include: 1) brief didactic presentations; 2) clinical demonstrations (live or filmed); 3) behavioral rehearsal (such as role plays); 4) handouts with practical guidance about skills; and 5) guided practice in clinical settings. Additional best practices for training nontraditional providers in CBT also include: 6) tailoring the training program for the unique needs of the setting; 7) emphasizing active learning methods; and 8) including follow-up components such as continued skills practice, booster sessions, and ongoing supervision/consultation.

1 |. The current study

We developed and implemented a novel CBT curriculum specifically tailored for nurses and other child psychiatric inpatient team members. We conducted small group CBT training sessions anchored in: 1) a structured manual; 2) instructional animated videos of common clinical scenarios; and 3) interactive role play exercises. We conducted focus group sessions with study participants to assess change in their self-reported knowledge of, and utilization of CBT skills in clinical practice. We had two specific aims: 1) to assess the feasibility of implementing this curriculum within the time and logistic constraints inherent to an active and busy child psychiatric inpatient unit; and 2) to understand the participants’ educational experience and its applicability to their everyday clinical work through a qualitative-phenomenological approach to data collection and analysis (Hanson, Balmer, & Giardino, 2011).

2 |. Methods

2.1 |. Setting, sample, and ethics approval

We conducted the study in a 16-bed children’s psychiatric inpatient service (CPIS) located within an urban university-affiliated hospital. The CPIS serves over 400 children between the ages of 5–13 each year, with a 2019 mean (SD) length of stay of 12 (± 11) days. Most children (86%) are admitted from the hospital’s emergency room, many presenting with high rates of disruptive behaviors and significant risk for self-injury. An earlier study conducted in this setting revealed that even once hospitalized, over half of the children, across all diagnostic categories, continue to demonstrate physical aggression during their inpatient admission (Sukhodolsky, Cardona, & Martin, 2005).

The 20 participants for this study (13 females) represented 38% of the entire unit staff of 53. We recruited participants through convenience sampling designed to include all disciplines and a broad range of time working on the unit. Our final sample included 11 nurses, 5 milieu counselors (MCs), and 4 child psychiatry residents. Participants had worked in the inpatient unit for a median of 16 months (range, 2 months to 10 years).

Before starting data collection, we obtained institutional review board approval from the Yale Human Investigations Committee (Protocol #2000027553). Subjects were encouraged to participate but informed that their participation was neither mandatory nor relevant to their performance evaluation.

2.2 |. Curriculum development

We developed a training program conceptually grounded in the framework by Thomas, Kern, Hughes, & Chen (2015). As a first step, the lead author (LC) conducted a targeted needs assessment through a semi-structured interview with the CPIS nursing director. The needs assessment revealed that 16 out of 17 nurses (94%) and 14 out of 16 MCs (87%) had no formal mental health training or clinical work experience prior to their employment on the unit. Instead, most of them had received training in child mental health through informal, ‘on the job’ training. There was no professional development or educational curriculum on the CPIS to train staff in evidence-based psychotherapies such as CBT. Nurses and MCs did receive an institutionally approved training session on nonviolent crisis intervention strategies (Crisis Prevention Institute, Milwaukee, Wisconsin).

The nursing director identified numerous training topics that would benefit the staff. Through a collaborative discussion, a decision was made to focus on developing a training curriculum on CBT for anger management given the high frequency of anger and aggression as a presenting problem for patients. A critical component of the consultation with the unit’s nursing director was obtaining a commitment to release staff to participate in the training program during normal work hours. Securing this type of administrative support is often a critical component toward the successful implementation of system-based educational interventions (Thomas et al., 2015), including this unit’s earlier work with Collaborative Problem Solving (Martin, Krieg, Esposito, Stubbe, & Cardona, 2008).

The learning objectives of the curriculum were tailored for the CPIS staff, in order to: 1) increase self-reported knowledge of CBT concepts and interventions for anger management in children; and 2) promote self-reported use of CBT skills. To meet these objectives, we drew the curriculum content from the current literature and published manuals on CBT for anger management (Kellner, 2001; Sukhodolsky & Scahill, 2012). Additionally, we selected specific instructional methods that have been identified as best practices for CBT training of nontraditional providers (Codd & Ludgate, 2016). We used teaching methods to address both our cognitive / knowledge and behavioral / skills objectives (Codd & Ludgate, 2016; Thomas et al., 2015).

2.3 |. Curriculum components

The first component of the curriculum is a set of five animated videos that vary in length from 7 to 14 minutes. The instructional content for the videos was written by LC and they were subsequently produced by one of the coauthors (DG) with a commercially available software platform (Vyond by GoAnimate; San Mateo, CA). The videos, freely available online for download at https://figshare.com/s/ae6f745456d5b38e6cdd, address the content outlined in Table 1. Each of the animated videos follows a similar storyboard sequence: 1) the instructor character provides an explanation of key CBT concepts and related skills; 2) demonstration of a patient-counselor simulation in which CBT skills are taught to the child (see Figure 1); and 3) summary comments provided by the instructor character.

Table 1:

Video Content

Component	Salient content	Description	Video duration (mins:secs)
1. Introduction to CBT for anger management	Connecting thoughts-feelings-behaviors	An explanation of the cognitive triad consisting of the thoughts-feelings-behaviors connection	8:30
2. Anger triggers	Take-a-break plan	Identifying personal anger triggers and teaching positive behavioral distraction as a coping skill	7:46
3. Automatic negative thoughts	Hot and cool thoughts ANTS	Identifying hot thoughts, cool thoughts and automatic negative thoughts (ANTS)	11:38
	STOP plan	STOP = Situation, Thoughts, Other thoughts, Practice calming thoughts
	STOP the ANTS	Replacing ANTS with calming self-statements through the STOP plan
4. Systematic problem-solving	Problem solving with a SOAP plan	A four-step approach to social problem solving (SOAP: Situation, Options, Assess options, pick a safe Plan)	13:29
5. Managing physical arousal	Deep breathing, Muscle relaxation, Guided imagery	Recognizing signs of physical arousal and reducing tension through 3-step deep breathing, 3-step muscle relaxation, and guided imagery	14:04
	Relaxation practice checklist	A daily log for tracking use of deep breathing and relaxation skills

Note: all videos and supporting didactic materials are freely available for download at https://figshare.com/s/ae6f745456d5b38e6cdd

Figure 1:

Sample image from video animation clip

The second component is a training manual (written by LC) with instructor guidelines and practice exercises for all the CBT skills presented in the videos. The training manual, (also available as supplementary online content through the same Figshare link), includes child-friendly worksheets and acronyms to facilitate the teaching, learning, and practicing of concepts among clinician-learners and child patients.

The third component is a series of role plays about common challenging behaviors typically exhibited by patients in a child psychiatric inpatient setting. The role play prompts, included in the manual, are intended for participants to practice one or more of the CBT skills learned during the training session.

2.4 |. Training session procedures

All training sessions were conducted by LC. Participants were divided into four training groups comprised of 4–6 members each. Three of the groups included nurses and MCs; a fourth group included child psychiatry trainees. All participants received two training sessions over a two or three-week period; each training session was 60–75 minutes in duration. Thus, each group of participants received three cumulative hours of training. During the first session, participants viewed videos 1, 2, and 3, followed by an explanation of the relevant exercises in the training manual. Training sessions also included time for participants to engage in role plays with the aim of practicing the CBT skills. After the conclusion of the first training session, participants were given the ‘homework’ assignment of practicing the CBT skills with a child on their caseload over the following week.

During the second training session, time was allotted for discussion of the participants’ experiences and reactions to using the CBT skills with patients. The session included videos 4 and 5, along with discussion, role plays and review of the relevant sections of the training manual. Participants were encouraged to continue practicing all the CBT skills with children on their caseload during the subsequent week.

2.5 |. Data collection and qualitative analysis

After completion of the training sessions, participants met with a co-author not involved in the training (AM) for semi-structured focus group interviews. Over the course of five focus group sessions, he asked participants to describe their routine practices in working with patients who struggle with anger management and to assess the CBT training program and their experiences applying its lessons in clinical practice. Consenting participants agreed for interviews to be digitally recorded. Audio files were then transcribed and deidentified prior to analysis using thematic analysis aided by NVivo 12 software (QSR International, Melbourne, Australia).

We used a thematic-phenomenological analysis to examine the participants’ experiences (Aggarwal et al., 2013; Hanson et al., 2011). We analyzed the transcripts using thematic analysis (Braun & Clarke, 2006; Kiger & Varpio, 2020), which provides theoretical freedom and flexibility to identify commonalities, and in which writing and analyzing data occur recursively alongside one another. Thematic analysis includes a rich and detailed account of the data and welcomes attention to the investigators’ reflexivity. Two authors worked independently to identify and compare codes before sharing them with the other investigators for further refinement and finalization into a streamlined codebook and set of overarching themes. Each key theme was supported by multiple quotes. We analyzed transcripts iteratively until we reached theoretical sufficiency (Saunders et al., 2018) and followed best practice guidelines for the analysis, drafting, and submission of qualitative studies (Creswell, Klassen, Plano, & Smith, 2011; Tong, Sainsbury, & Craig, 2007).

3 |. Findings

Through iterative analysis we arrived at the four-theme model summarized and exemplified through representative quotes in Table 2. We go on to address each of these themes and subthemes in turn.

Table 2:

Themes, subthemes and sample quotes

Themes / subthemes	Sample quotes
1. Routine clinical care
1.1 Feelings	I think it’s easy to want to be defensive, or to get your back up, or get into a struggle with the kid. I usually try to suppress any of those urges and really try to remain very calm and speak to them in the way that I hope they would speak to me. Doesn’t always work, but that’s usually what I’m trying to keep in mind.
	There is a certain feeling of helplessness when you have these patients that nothing works on.
1.2 Challenges	The biggest things that I’ve heard over the past five years with almost everyone coming off orientation was…people felt they didn’t have the tools.
	It’s easier to give them the answer in that moment because we have 4000 other things to do, but it’s really not that beneficial to the child or us because we’re not teaching them any skills to use tomorrow or the next day.
	[I]t’s on a fundamental level the lack of cohesion that really plays a part a lot of the time.
1.3 Routine approaches	When we process with them after each blowout or whatever they have, we go through “Okay what happened? What was the trigger? Why did you get so upset? What are some coping skills that could have been used or what’s something we can do different next time?”
	Just try and figure out what’s wrong and how we can help for them not to spiral out of control, where we [would] have to put hands on.
2. CBT Utility in practice	It goes back to just realizing that I need to work with them more on their thoughts and how it’s contributing to their behaviors and their emotions and tying it all together instead of just saying “you did this, you need to do this instead.”
	Applying it in children does kind of make you analyze yourself and understand other people better.
	There are moments for each one of [the tools] to be used and obviously we’re not going to use them all at once but I found moments to at least attempt to start to use each one with different kids.
	It got me thinking about how much more proactive we need to be instead of just crisis management.
3. CBT Training components	I really liked that it was almost formulaic in some ways. I like some of the acronyms and some of the terminology, not even so much for me to remember, but I think it’s much easier to convey to our kids. Some of these are pretty complex topics and ideas, but to be able to distill that down into bite-sized pieces of information that makes sense to them, and that they can remember and try to recall when they’re in that situation in the future. I thought that was really helpful.
	The aspect for me that I found helpful was how child-appropriate the mnemonics were, with the ANTS and the hot and cold thoughts. Little things that I would even remember on a normal day and I think talking to a child with the correct language is really important. You don’t want to use big words, like cognitive, behavioral. But things like ANTS can get the kid engaged.
	It would be beneficial to have more time to practice these skills with your fellow learner in that setting because it gives you a chance to practice deliberately, so the person that you’re practicing with knows what you’re supposed to be doing, even though they’re pretending to be a patient…I think immediate feedback goes a long way when working with these skills.
4. Professional development
4.1 Implementation needs	I feel that we should just have these on the floor in a folder in a drawer for us to have easy access to so that if we do have one of those moments where we’re like, oh my gosh, you want to know what would work really well right now? One of the worksheets. Go and fetch them and spend those 15 minutes with the kid.
	I think it would be important if nursing staff could incorporate this on admission, or soon after admitting a patient, at least some of the basics like what their triggers are and what helps them cope.
	I think that if it was just built into the orientation, like you come in the days that you’re planning on coming in, and one of those days you do the CBT training, you get to watch the videos, you get to do all of those things.
	It would be helpful in terms of all staff being on the same page. I think that’s the most important piece for me…consistency is so key for these kids, so if some of us are using some of these terms and other staff aren’t familiar with them yet, or if we’re approaching a situation in one way and they’re getting very different responses from other staff, I can imagine that would be really confusing.
	I wish we could spend more time doing the training. When we were sitting in there for an hour, it went by like nothing, and I was like, “Wow I could do this 100 more times and probably still learn something from it.”
4.2 Other recommendations	I think it would be good for them [patients] to sit through and see, like how we watched it, because maybe they’d get more of an idea of how to use it. Because I think a lot of time, they wake up every day and they hear this stuff repetitively, but then it doesn’t stick. So, I think that’s why a lot of them keep coming back…so I feel that it would be beneficial if they knew that CBT was something that might work for them.
	It would be a great idea to have it acted out by staff in a situation that’s difficult, difficult to de-escalate, difficult to manage…a little bit of a challenging situation depicted would be excellent.
	It might be useful to see for each skill an example of a child who was cooperative and an example of a child who was really resistant.

3.1 |. Theme 1: Routine clinical care

3.1.1 |. Subtheme 1.1: Feelings

In response to how they typically ‘feel when dealing with an angry or aggressive child’, several participants reported experiencing emotions such as ‘frustrated’, ‘sometimes angry’, and ‘anxious a lot of the time’. They also commented on feeling ‘disheartened’ and ‘helpless’ about the severity of patients’ symptoms, struggling with self-doubt about their ability to impact children’s progress, as well as pessimism about observing changes in children’s behaviors. Notably, several respondents recognized that they too have ‘automatic negative thoughts’, about patients’ functioning, which in turn impacts their clinical expectations. A respondent’s comment is representative: “Am I doing something wrong? What’s going on here? Kind of beating yourself over the head. Like what am I doing wrong? What can I do? What can I do?”

3.1.2 |. Subtheme 1.2: Challenges

Several participants identified the lack of consistent and structured professional training within the work setting as a challenge for themselves and colleagues in caring effectively for patients. They noted that in prior years there had been a training curriculum which introduced staff to psychological approaches to care, but that the training had ‘gone to the wayside’. Participants lamented that there was limited time for individualized training of staff and therefore most staff learned about strategies for managing challenging behaviors by observing more senior staff. A participant noted, “When I started, there were a lot of role models who had been here for ten-plus years, and many of those people have moved on now, so a lot of the newer staff are being trained by people who are also newer staff. So, it would be good to have standardized norms for the unit.”

An additional source of challenge was lack of consistency or ‘cohesion’ among staff in caring for patients. It was reported that ‘not being on the same page’ during a shift could be pervasive and that the varying approaches to disruptive behaviors can result in “encounters that could potentially be avoided.” Importantly, a participant noted that lack of cohesion was perpetuated by poor communication among the disciplines: “…doctors and staff: I feel like there’s kind of this divide between what they do and what we do.”

Several participants reported feeling stressed by needing to work under significant time constraints with individual patients due to the high census and at times an unpredictable and ‘chaotic’ milieu. Even when there was time to work individually with children, the work often felt rushed and incomplete: “When I’m in the hall putting out fires, just talking to a kid or processing, it’s like, okay, we’re talking for them, and then, move on to the next kid.”

3.1.3 |. Subtheme 1.3: Approaches

Most providers relied on interviewing patients about their feelings and attempting to learn about sources of distress. One respondent’s comment is representative: “My main goal is to figure out what sets them off, what works, what doesn’t work, and how much time do we have in between the blowup to intervene.” Several respondents noted that this approach has its limitations because of the tendency to want to resolve the stressor rather than guiding the child to reflect on their thoughts and behaviors: “We tend to give the answers without letting them get in there a little bit more; we so want to solve things.”

3.2 |. Theme 2: CBT utility in practice

Most participants identified CBT concepts as highly beneficial to their clinical work. For instance, participants commented that the training helped them have a deeper appreciation for the connections between thoughts, feelings and behaviors: “I need to start thinking more about their thoughts than necessarily just their behavior, like what’s going on with them internally rather than what they’re showing us externally”; “I don’t need to do the thinking for them, letting them do the thinking and talking.”

Nearly all participants also identified several specific CBT skills that were immediately applicable to the unit’s children, including: identifying automatic negative thoughts and replacing them with cool calming thoughts (‘Stop the ANTS’), deep breathing, muscle relaxation, creating a behavioral distraction plan (‘Take-A-Break Plan’), and systematic problem solving (‘SOAP’). Several participants reported that the CBT skills were also applicable to themselves: “I think this is translatable to our every-day interactions”; “Automatic negative thinking applies to me just as much as it applies to them.” Respondents also commented on the potential utility of CBT across settings and populations: “You can use it in any setting. You can teach anyone how to use these techniques to calm down or cope with anger”; “I feel like its something that probably parents and schools should get too.” Several reported they had begun to utilize specific skills with assigned patients. Some even reported that they had been previously using some of the skills with children but had not been aware that they were CBT-based skills, so they felt reassured to know they are “doing what I should be.”

3.3 |. Theme 3: CBT training components

Participants voiced satisfaction with various aspects of the training methods and curriculum components. Regarding the instructional level, participants commented that concepts were presented ‘at a good level’ that facilitated both their learning and their ability to teach the skills to patients. The participants uniformly appreciated the small group / interactive format for learning. Additionally, participants commented that the animated videos were sufficiently concise, ‘straight to the point’, and contained ‘engaging’ and effective animations. Respondents stated that the patient simulations contained within the videos were especially useful demonstrations for how to teach CBT skills to a child: “seeing it in practice I feel is a really big takeaway because I loved the sims in the videos, even though they were just cartoons.”

Participants also appreciated the training handbook which contained worksheets for each CBT skill. They commented that the use of acronyms for teaching cognitive restructuring and systematic problem solving were memorable for both adults and children. Of note, there were mixed reactions to the in-session role-plays. Some participants reported feeling socially inhibited, but others reported that simulated practice was a very useful training tool and suggested even more time for role-plays.

3.4 |. Theme 4: Professional development

3.4.1 |. Subtheme 4.1: Implementation needs

Participants had several recommendations for improving the CBT training and for facilitating its dissemination among the staff. Respondents suggested that the training be extended beyond two sessions so that there would be additional opportunities for practice. There was a consensus for CBT training to be provided to all existing staff and that it become a ‘mandatory’ component of new staff orientation. There were also ideas for increasing staff access to the materials for review, such as uploading the videos on hospital computers and placing handouts at various locations on the unit. Participants suggested that patients be introduced to CBT skills as early as their admission day by reviewing some of the key handouts from the training manual. Finally, participants suggested regularly scheduled ‘refresher’ sessions to practice skills and review cases, even though they had divergent recommendations about their suggested frequency (ranging from monthly to yearly).

3.4.2 |. Subtheme 4.2: Other recommendations

Recommendations from participants included for: 1) select members of the staff to receive preparation to become CBT trainers (‘super-users’) following ‘train the trainer’ guided sessions; 2) the study’s videos to be shown to the children and their parents as an engaging form of psychoeducation; and 3) more challenging role play simulations during practice sessions, which would more closely approximate some of the difficult cases seen on the unit. For example, a new set of videos could depict ‘more difficult to de-escalate, difficult to manage scenarios’, and ideally utilizing actors who would portray the children and counselors.

Some participants also made suggestions for continuing education sessions covering an even broader variety of topics in child mental health (ex. racism and diversity; introduction to dialectical behavior therapy, trauma-focused CBT; caring for children on the autism spectrum, approaches to pediatric psychopharmacology).

4 |. Discussion

4.1 |. Animating CBT

The aim of this study was to train nurses, MCs, and other direct care providers to utilize evidence-based CBT skills for anger management in an inpatient child psychiatric setting. There are several CBT training programs that are already available (Mazurek Melnyk, et al., 2014; Sukhodolsky & Scahill, 2012), including an approach specifically adapted for multidisciplinary treatment teams on an adolescent psychiatric inpatient unit (Wolf, et al, 2018). However, training programs are rarely tailored to the specific needs of nurses and other direct care providers working with young children in multidisciplinary inpatient psychiatric settings. We sought to fill this gap by developing a curriculum that is at once rooted in best evidence-based practices (Cod & Ludgate, 2016), while being practical, engaging, applied, and relevant in its ‘hands on’ approach. To this end, and in an effort to make CBT concepts resonate and ‘come alive’, we created a novel curriculum with case simulations presented through animated videos, which proved to be an engaging medium to facilitate the learning process for novice mental health providers. The training is rooted in case demonstrations, the practice of clinical skills, and the application of educational strategies for adult learners (Arseneau & Rodenberg, 1998). For example, we encouraged participants to discuss prior knowledge and experiences in order to actively involve them in constructing personal meaning from the content. Additionally, we drew all clinical examples in the animated videos and role plays from typical patient encounters so that the CBT concepts might be viewed as applicable to the realities of clinical care on the inpatient unit.

We were able to roll out and implement this structured training within the time and logistic constraints that are a reality in any active inpatient setting, and to do so within the working hours of the staff involved. Our goal was to create a training program that could be implemented within these realities. We recognized that a longer or more theory-based curriculum would not have been feasible or optimally pitched. To this end, our goal was not encyclopedic, but rather focused on the subject areas covered in each of the curriculum’s five components which targeted skills for anger management.

In an effort to understand the active components of the training program and how they were received and incorporated by staff, we conducted focus group sessions in order to help refine and optimize the curriculum. Of the four main themes in our qualitative analysis, the first one (routine clinical care) comprised the feelings, challenges, and approaches that unit staff reported about their work with behaviorally challenging children before participating in the new curriculum. The second theme, in direct response to the first, addressed the utility in practice of the new set of CBT skills, a statement on the relevance and applicability of the training program. The third theme (training components) addressed the more educationally ‘sticky’ or relevant parts of the training, and a fourth (professional development) was helpful in pointing out refinements and future directions, which we go on to elaborate.

4.2 |. Next steps and future directions

Participants were uniformly enthusiastic about the training program, and eager to see it go ‘from research to routine’ or ‘from a pilot to a practice’. In a first subtheme within professional development (implementation needs), nurses and MCs had a number of practical recommendations, including how to make materials easily accessible on site, how to make the training an integral part of new staff onboarding, and how to incorporate refresher booster sessions for more experienced staff.

Participants were clear in prioritizing the availability of training to all unit staff; there was a shared sense of urgency in achieving this next step promptly. Recognizing that it would be challenging for a single trainer to take on the educational role for an entire unit, participants were eager to explore the possibility of developing ‘super-users’ through a train-the-trainer model, as has been effectively implemented in nursing practice (Kalisch, Xie, & Ronis, 2013). An unexpected insight from participants was the observation that the training materials, and their animated case examples and work sheets in particular, could be useful for patients and their families, and not just for the staff responsible for their care, who had been our intended educational target audience.

A fair critique of the curriculum made by two participants was that the case examples, accurate and evocative as they were, were not challenging enough for the difficult clinical realities of an inpatient setting. A corollary to that critique was a suggestion to consider creating simulations of higher-intensity situations, such as those that can lead to the need for physical holds, seclusion, or other emergency management interventions (Carlson et al., 2020). We consider this is a viable and useful next step and are planning ahead to the creation of video-taped materials of experienced nursing and MC staff interacting with professional actors in high-acuity scenarios. Of note, simulation with child actors is possible under clear ethical guidelines (Budd, Andersen, Harrison, & Prowse, 2020). Simulation-based videos have been usefully applied to teach affectively charged material in a supportive setting that facilitates psychiatric skill-building (Drozdowicz et al., 2020; Kitay et al., 2020).

4.3 |. Limitations

We recognize several limitations to this study, starting with the small number of participants during its pilot implementation and feasibility stage. Findings from this phase of the study have already informed our next steps in disseminating the training within the unit, which will include additional practice sessions, routine review sessions, and incorporation of the curriculum into the training of all staff. Second, we did not attempt to directly observe, ensure fidelity in application, or measure participants’ implementation of the skills taught but relied instead on self-reports. Following implementation across all staff members, future studies could benefit from incorporating quantitative measures or objective assessments of application-in-practice, as well as tracking possible impacts on patient outcomes (such as reductions in seclusion or PRN medication use), or on staff outcomes (such as self-efficacy or job satisfaction). Third, our training of staff relied on a single educator (LC), which could ultimately limit the dissemination and long-term sustainability of the curriculum. To that end, and as noted before, we are committed to promoting further development of a workforce trained to deliver evidenced based mental health care for children. Finally, we should note that we conducted all training sessions during the COVID-19 pandemic, which translated into small groups capped at a maximum of six participants, wearing face masks, and not engaging in any physical contact or proximity beyond six feet. Even though we do not consider these unique circumstances affected the training program, we point them out, as we have no experience in training larger groups. In contemplating training for larger groups, educators should balance the benefits of smaller educator-to-learner ratios with the logistic challenges of having multiple training sessions.

4.4 |. Implications for nursing

In summary, we designed a novel CBT curriculum specifically tailored for the needs of nurses and other direct care staff in a multidisciplinary child psychiatric inpatient setting. We were able to successfully implement the pilot roll out of the curriculum within the time and staffing constraints inherent to a clinically active child psychiatric inpatient unit. In addition to refining and disseminating our model within our site, we are eager to see others join us in this educational effort. To that end, all of our materials are freely available online and ready to be implemented toward the ultimate benefit of the children and families we are privileged to serve.

Data availability statement

The data that support the findings of this study are openly available in Figshare at https://figshare.com/s/ae6f745456d5b38e6cdd.