Emergency departments can often be the first place to which people present when in mental health emergencies, although these departments and staff are not always adequately supported to meet the needs of these patients. This study aimed to evaluate the impact of simulation-based training for mental health crisis in the emergency department on knowledge, confidence and attitudes towards interprofessional collaboration.
Healthcare professionals (n = 85) from a range of professions participated in a multicentred simulation-based training activity. Questionnaires evaluating participant knowledge, confidence and interprofessional attitudes were administered pre- and post-activity, and analyses were conducted. Thematic analysis was conducted on free-form participation simulation training evaluation forms.
Participants reported that the simulation training improved their communication skills, clinical practice, encouraged reflective practice and promoted interprofessional collaboration between emergency department and mental health professionals. Significant improvements were seen in participant knowledge and confidence in providing care to individuals presenting to emergency departments in mental health crises. Attitudes towards interprofessional collaboration in a variety of domains improved because of taking the simulation training.
The pedagogical qualities of the in-situ simulation-based training presented fostered interprofessional collaboration and allowed participants to achieve challenging outcomes. It is suggested that further research should investigate the impact of simulation-based training on mental health related patient care outcomes in the emergency department.
Presents the outcomes of a novel multicentred in-situ simulation-based training activity focused on mental health crises in the emergency department Describes the benefits of interprofessional education focusing on emergency department and mental health professionals Seeks to evaluate the role of attitudinal change in promoting interprofessional collaboration
Media coverage has brought to public attention examples of poor care being administered by emergency departments (EDs) to individuals presenting in mental health (MH) crises [
Prior literature has established that providing training to EDs improves patient outcomes. One study [
Simulation-based training (SBT) is increasingly being utilized as an educational intervention within mental healthcare [
This study employed a mixed-methods pre-post evaluation design using
At each hospital site emergency department nurses, psychiatry liaison nurses, drug and alcohol specialist nurses, emergency medicine trainee doctors, liaison psychiatrists and security personnel were invited to sign up to take part in the simulation training. The simulation activity was delivered to 85 attendees over 12 occasions (average class size included 7 participants) who were recruited using opportunity sampling and consented prior to the training. The professions of the attendees included ED nurse (n = 21), ED doctor (n = 17), psychiatric liaison nurse (n = 23), psychiatric trainee (n = 5), security (n = 12), and other (n = 7). Participants completed pre-post training surveys which collected limited demographic data.
The SBT was delivered in EDs across London and Southeast England, using clinical areas for both simulated scenarios and reflective debriefs. A short didactic session which provided an introduction to simulation training, in addition to outlining the ground rules and aims of the simulation activity, followed introductory steps to ensure psychological safety. Three different simulation scenarios were offered: (1) triage, (2) assessment and (3) treatment, which required participants to engage with a simulated patient in MH crises. The three-part evolving scenario followed the simulated patient’s journey from triage through to majors and was designed to draw out learning points around assessing risk, mental capacity and the interface between mental and physical health. The simulated patient was presented with character background information, as well as instructions for each scenario. Please see appendices A, B and C for scenario scripts. The simulation activity was based on Kolb’s experiential learning cycle [
Overview of the SBT course
Course learning objectives | To improve collaborative working with colleagues across different professions when managing patients with physical and mental health co-morbidity To encourage reflection on the barriers to effective management of medical problems in patients presenting psychological or behavioural difficulties To increase confidence in the appropriate management of patients who refuse treatment in the ED |
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Time | Title | Learning activity |
08.15–08.30 | Welcome | Registration, filling in consent forms and pre-course assessment |
08.30–09.00 | Introduction | Ice-breaker games. A PowerPoint presentation detailed what simulation training is, what the ground rules of the course were, and the aims and objectives of the course. |
09.00–09.15 | Scenario 1 | Introduction to ED patient. History of schizophrenia, uncontrolled diabetes and comorbid alcohol misuse. The task is to perform a brief assessment in order to triage the patient and make a brief risk management plan. |
09.15–10.00 | Debrief 1 | Participants asked to write down risk factors and risk management plan, in the format Description, Technical Skills, Analysis, Application. |
10.00–10.15 | Scenario 2 | Participant is instructed to carry out a medical assessment including vital signs, obtaining a BM, and, if appropriate, taking blood samples. Confer with professional from another team. |
10.15–11.00 | Debrief 2 | Discussion around the capacity of the patient in the format Description, Technical Skills, Analysis, Application. |
11.00–11.15 | Break | |
11.15–11.30 | Scenario 3 | Participant is instructed to start treatment – intravenous fluids and antibiotics. Additional observations required. Negotiate plan with patient. |
11.30–12.00 | Debrief 3 | Actor is encouraged to reflect on participants’ actions. This may cover, assessment of capacity, legal framework, restraint, rapid tranquilization in the format Description, Feedback from Actor, Technical Skills, Analysis, Application |
12.00–12.15 | Summary | Wrap up of the course and closing. |
12.15–12.30 | Break | |
12.30–13.00 | Post-course evaluation | Participants were required to fill out post-course evaluation forms comprised of free-text questions (for example, |
13.00 | End |
Two pre- and post-activity self-report measures, a Confidence & Knowledge measure and TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) [
The 22-item Confidence and Knowledge measure contained two parts and was created
The reliable and validated T-TAQ assessed changes in participants’ interprofessional collaboration attitudes, looking specifically at Team Structure, Leadership, Situation Monitoring, Mutual Support and Communication. The T-TAQ consists of 30 questions (6 per dimension) and requires participants to rate their level of agreement on a 5-point scale from
A self-report simulation activity evaluation questionnaire, consisting of 12 items, was administered to all participants post-SBT. It was comprised of free-text questions which aimed to capture the attendees’ experiences and opinions regarding the impact of the simulation training. Please see
Paired-sample t-tests using IBM SPSS statistics 24 explored changes in participant confidence, knowledge and attitudes towards interprofessional collaboration pre- and post-all simulation activities. Braun & Clarke’s (2006) validated method of thematic analysis [
The half-day SBT was run by Maudsley Simulation and Learning on 12 occasions across 9 hospital sites in Southeast England between May 2016–May 2017. One commissioned simulation activity was cancelled due to a lack of interest – only 5/12 spaces were filled. The simulation training had a fill rate of 78% (112/144 spaces filled) and an attendance rate of 76% (85/112 attended).
Paired-sample t-tests found that participants’ mean confidence and knowledge scores improved statistically significantly from pre- to post-activity. Progressive improvements in participants’ confidence (t(75) = 9.289, p <.001) and knowledge (t(75) = 6.927, p <.001) were found as the learning journey progressed.
Paired-sample t-tests were used to analyse the T-TAQ data and statistically significant improvements were found in all domains, team structure (t(64) = 5.94, p <.001), leadership (t(64) = 2.48, p = .016), situation monitoring (t(64) = 5.41, p <.001), mutual support (t(64) = 2.81, p = .007), and communication (t(64) = 3.47, p = .001). Participants’ attitudes towards interprofessional collaboration, (t(64) = 5.981, p <.001), improved as the learning journey progressed when comparing mean pre- and post-activity scores. For a detailed description of the confidence, knowledge and T-TAQ inferential statistics, please see
Qualitative data explored participants’ views and experiences of the simulation activity. Thematic analysis [
Respondent 2; R2: It was really helpful and a great opportunity to work with colleagues from the ED away from a clinical setting.
Further, they reported improvements in their understanding of procedures, pressures and limitations their professional counterparts face which they believed would facilitate increased interprofessional collaboration and a better working environment in the future.
R7: [I learnt that] that the ED need support from mental health professionals to manage a patient for their best interest.
R1: Integrating people from different specialities and putting them together in a simulated environment [aids] learn[ing about] the strengths and weaknesses of these specialities and encourages people to get advice from these specialities in the future.
Respondents noted that the simulation activity ‘reinforced that communication is important’ (R29), especially when employing ‘de-escalation tactics’ (R14) with patients experiencing MH crises and when conversing with colleagues of different professions.
R8: [It is important to] discuss with colleagues in A+E.
R14: [The simulation activity] helped me to reassess that there may not be an ‘expert’ who know it all, so sharing ideas is important to make a collaborative decision.
Improved knowledge regarding procedure, protocols, mental health conditions and the pathways of one’s own and others’ professions, was commonly reported. Specifically, participants reported an improved awareness and appreciation of the role played by other professions when managing a mental health crisis. Participants also noted improved knowledge of applying the Mental Capacity Act (MCA) and Mental Health Act (MHA), which was further reiterated by improvements in the knowledge scale. Ultimately, through improving their knowledge on interprofessional collaboration and the relevant clinical and legal protocols, participants reported improved understanding of caring for individuals during a MH crisis.
R6: [I learnt about] the role of the ED doctors and their knowledge of mental health.
R17: [The activity improved my] understanding the legalities of MCA/MHA.
R30: I [now] understand how to care for [individuals experiencing MH issues in the ED].
Respondents also indicated that the simulation activity gave them the opportunity to reflect thus enabling them to empathize more, modify their attitudes, and have more patience with individuals experiencing MH crises.
R10: [I found it useful to] focus on reflecting back to patient to confirm / clarify. R17: [The activity] increased my compassion and tolerance of duration of symptoms. R:19: [The activity helped me to become] more reflective of approaches and how things can be approached in different ways.
The findings suggest that SBT is well received by both MH and ED employees, with participants reporting that the simulation activity benefited their interprofessional collaboration, communication skills and provision of care and encouraged reflective practice. Currently, the provision of care to those presenting to ED departments in MH crises is poor. A lack of confidence and knowledge on the part of ED professionals is posited to result in poor provision of care. SBT training programs have been found to promote interprofessional collaboration [
This study extends from the literature by creating a multicentred SBT activity for ED and MH professionals aiming to improve responses to MH emergencies in the ED. Improving interprofessional collaboration is particularly important in this context as often professionals are required to function collectively in multidisciplinary teams at short notice so to achieve high quality, safe care [
The results of this study should be considered in the context of its limitations. Firstly, recruitment presented a challenge, with one simulation training activity being cancelled due to lack of interest. Findings suggest that ED and MH professionals are keen to receive SBT, and that participant outcomes benefit from greater attendance. Yet, structural issues such as workload and staffing pressures, low availability of cover and orchestration across different trusts limited attendance. This could introduce bias into our findings as professionals from lower-resourced institutions were less likely to attend the simulation training. Limited demographical information was collected, thus comparisons between different institutions were not possible. Further, the reporting of demographical information is salient when determining the generalizability of result findings. Factors such as age, gender or ethnicity can influence the extent to which the simulation activity improved participants’ confidence, knowledge and interprofessional collaboration. Thus, lack of adequate demographical information is a methodological weakness of this study. Another limitation is that the confidence and knowledge measure used had not been previously validated; the measures were created
This pilot study holds multiple implications for wider SBT research, with study findings providing a basis for future research with a range of considerations. This study used a
The presented SBT activity has the potential to improve outcomes in the ED through educating ED professionals on MH issues and promoting interprofessional collaboration. The pedagogical qualities of in-situ SBT allow participants to achieve challenging outcomes and learn in an environment which mirrors the workplace. Further, through educating ED professionals on MH emergencies, interprofessional SBT programs have the potential to reduce the level of burnout in MH and ED professionals. The successful implementation of a multicentred, interprofessional SBT program could improve the care of patients in MH crises presenting to EDs across numerous institutions.
Maya Ogonah and Marta Ortega Vega led on drafting the manuscript, while all other authors contributed to the overall project.
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Ethical approval was obtained from the Psychiatry, Nursing and Midwifery (PNM) Research Ethics Subcommittee at King’s College London (ref. no. PNM/13/14–173) and informed consent was obtained before participation.
The authors declare that they have no competing interests.
Scenario 1 script
Basic scenario (15 min) | This scenario is divided into 2 parts and takes place in 2 adjacent environments: triage room and PLN office (where a private discussion can take place). The Mr O’Neil remains in the triage room throughout. |
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(5 min) TRIAGE |
Mr O’Neil has self-presented to ED. The ED nurse’s task is to perform a brief assessment in order to triage the patient and make a brief risk management plan. | |
(5 min) PLN office |
The ED nurse has been primed that she may wish to consult with a PLN/Psychiatry trainee in the PLN office. Together, they should discuss any available risk history and make an immediate risk management plan. The PLN/Psychiatry trainee had already been provided with a print-out of the patient’s electronic records. | |
(5 min) TRIAGE |
The ED nurse +/- the PLN/Psych trainee return to triage to explain the initial management plan to Mr O’Neil. | |
You are assessing Mr O’Neil in triage. He has self-presented to ED. As part of your initial assessment, you will need to conduct a brief risk assessment. You may wish to discuss with the PLN/Psychiatry trainee who are available in the PLN office next door in order to make an initial management plan. You will need to communicate this plan to Mr O’Neil. | ||
You may be asked by the ED nurse to look Mr O’Neil up on the electronic records and provide some background information. Together with the ED nurse, you are tasked with making an initial management plan to contain any immediate risks. The ED nurse may want you to join him/her to communicate this plan to Mr O’Neil. | ||
You were born and raised in Chatham. You are a lifelong Gillingham FC fan. You moved to Surrey (for a girl) 30 years ago. You were rehoused to supported accommodation Chertsey 5 months ago. You have never held a long-term job due to periods in hospital or street homelessness since your youth. You had worked as an ‘odd job man’ for short periods in your 20s. Both of your parents have passed away. You believe your father was an alcoholic. You have 5 older siblings, but are only in occasional phone contact with your sister, Shelagh, who lives in Dover. You are not currently in a relationship. You have a daughter (Maeve) who’s in her mid-20s. You have not had any contact with her for 20 years. You are working class, and talk with a Kent (or vaguely estuarine) accent. Feel free to be liberal with expletives and colloquialisms. | ||
In recent weeks, you have been increasingly erratic with compliance with your physical health and mental health medications. You can’t remember what you are on, but recall that you have blood pressure problems and diabetes. You are fed up of having injections for your diabetes. You have a nasty foot ulcer, and walk with a limp (you have an ulcer on the ball of your right foot). You become angry if this is mentioned: ‘it’s nothing’. | ||
You appear dishevelled and have a soiled bandage around your right foot. If anyone comments on it, you dismiss their concern. Do not allow the candidate to examine your foot. You behave as if you are intoxicated. Your speech is slightly slurred and, at times, incoherent. You become angry if anyone brings up alcohol. You are perplexed but a little irritable. You mutter to yourself and appear suspicious, looking round the department. Your speech is slightly muddled and you are disorientated in time and place (sometimes thinking that you are in Chatham). You are highly distractible. You are paranoid about being under surveillance by the police. If this is enquired about in a sensitive manner, you reveal that you are convinced that you have been accused of being a member of the real IRA and have been monitored by the Met anti-terrorism squad for 30+ years. You are guarded, and may accuse participants that their conversation is being recorded. | ||
You do not have any thoughts of harming yourself. You have often thought about confronting your fellow residents about your suspicions that they are going through your things. You did, in fact, confront Faizer (who lives in the neighbouring room) last night, whom you also believe is part of IS (Islamic State), which led to an argument. You are very guarded if asked about possession of weapons. |
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You respond positively if the candidate is calm. If he or she dismisses your concerns about your accommodation, you become more irritable. Regardless of the candidate’s approach, you remain muddled and distractible. I would be grateful if you could try and look as dishevelled as possible, with several layers of clothing, carrying a lager or cider can. We will provide you with a bandage to put around your ankle. |
Scenario 2 script
Basic scenario (20 min) | This scenario is divided into 2 parts and takes place the same environment: a cubicle in majors. Props: Obs equipment, BM machine |
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(5 min) MAJORS |
Mr O’Neil has now been moved through to majors, mainly so that staff members are able to keep a closer eye on him, since he has continued to be visibly agitated. He has been wandering in and out of neighbouring cubicles. He is heard muttering to himself, and occasionally cursing loudly. Other patients and relatives appear visibly anxious in response. It had been agreed earlier that a security officer would be available to ‘keep an eye’ on Mr O’Neil. An HCA has already attempted to check Mr O’Neil’s vital signs and take some blood samples. He has refused both. The participant is tasked with carrying out a nursing assessment. |
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(5 min) MAJORS) |
The participant has been asked to join the ED nurse to commence a mental health assessment. | |
(5 minutes) PLN office or MAJORS |
The participants (apart from the security officer) may wish to discuss the patient with an ED doctor in the PLN office. If this does not take place after 10 minutes, the ED doctor will be asked to check on the participants in majors, and ask if they need support. | |
You are tasked with negotiating with Mr O’Neil with regards to carrying out a nursing assessment, including vital signs, obtaining a BM and, if appropriate, taking blood samples. Together with the Liaison Psychiatry team, you will need to communicate a joint management plan to the patient at the end of your assessment. |
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You are tasked with performing a parallel assessment of Mr O’Neil’s mental state alongside your ED colleague. Together with the ED team, you will need to communicate a joint management plan to the patient at the end of your assessment. |
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Following the initial risk assessment, you have been asked to provide ‘within eyesight’ level of observation of Mr O’Neil. | ||
You have been busy in majors managing other patients, but are available should the team wish to discuss Mr O’Neil with you. | ||
You are fed up of waiting around. You feel that nothing is being done about your accommodation. You want to leave. You have no plans about where you are going to go, but are prepared to sleep on the streets: ‘I slept rough for 10 years’. You don’t feel safe in the department, and are becoming concerned that people are watching you and might be providing the police and MI5 with information about your whereabouts. | ||
You don’t see what checking your blood pressure and taking blood tests has anything to do with sorting out somewhere for you to live. You’ve ‘wasted enough time’ in the department and have ‘important things to do’. ‘You’re f***ing’ useless’ anyway, as no one has bothered sorting out alternative accommodation for you. | ||
If asked, you state that you have not had any insulin for about a week. You have been suspicious that the district nurses are involved with the police. You don’t believe that you have diabetes anyway; you think it may have been some kind of elaborate ruse to keep you ‘drugged up’. You are vague about when you last took Risperidone. You don’t need it; ‘never have needed it; just take it to keep them off my back’. You do not have any | ||
feeling in both hands and feet (longstanding – secondary to complications of diabetes). You have an ulcer on the ball of your right foot. The ulcer has not been looked at for over a week. Again, you have not trusted the district nurses to do this: ‘she works for Again, you respond well if participants remain calm and offer possible solutions to your concerns, particularly with regards to your housing problems. Respond positively if they suggest contacting a family member (you still speak to Shelagh, your sister, on the phone). If no attempt is made to talk about your worries about your housing and your fellow residents, you become increasingly frustrated: ‘you’re not f***ing listening to me!’. In the final stages of the scenario, if you feel that the participants have been particularly calm and empathic in manner, you eventually sit down and agree to participate in the examination. |
Scenario 3 script
Basic scenario (15 min) | This scenario is divided into 2 parts and takes place the same environment: a cubicle in majors. | |
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(5 min) MAJORS |
Mr O’Neil eventually cooperated with an initial assessment, which revealed marked clinical dehydration and an infected foot ulcer. Blood tests supported this, and indicate that he has acute kidney injury. He has also had a foot X-ray which is suggestive of osteomyelitis. Mr O’Neil has already been referred to the medical team, who have accepted; he awaits transfer to the medical assessment unit. There has been a shift change. The decision from the previous team was that he should be started on intravenous fluids and antibiotics whilst awaiting a medical bed. Meanwhile, he is observed to be becoming increasingly irritable. He has been pacing around the cubicle, and has pulled out his cannula. He is muttering to himself and is stating that he wants to go home. The ED nurse has been asked to perform a second set of observations. The ED doctor/Psych trainee has been asked to explain the management plan to Mr O’Neil. |
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(5 min) PLN office or MAJORS |
The participants (apart from the security officer) may wish to discuss the patient with a senior doctor in the PLN office. If this does not take place after 5 minutes, the senior doctor will be asked to check on the participants in majors, and ask if they need support. | |
(5 min) MAJORS |
The participants will return to majors to negotiate a plan with the patient. | |
You are looking after Mr O’Neil in majors and have just come on shift. You would like to perform another set of observations. | ||
You have just taken over from your colleague and have been asked to explain to Mr O’Neil the management plan. | ||
You have taken over from your colleague in providing ‘within eyesight’ observation of Mr O’Neil. You have not received any instructions as to whether or not it is appropriate or not to restrain Mr O’Neil if he is attempting to leave. | ||
You are available to provide senior support to trainees in the department. You do not have immediate access to patient records, therefore are reliant on presented information in order to make a decision. | ||
You have become more confused and incoherent since the last scenario. You are You become increasingly agitated and aggressive as the assessment proceeds. You are erratic and unpredictable. If anyone comes too near you shout and swear at them. You threated to ‘sort them out’ if they come close to you. Remember, your world and that of the participants is not quite connected. Perhaps don’t make eye contact or plead with them directly. Your speech is not directed at anyone in particular, at least not for long periods. Again, you are easily distracted (perhaps by voices). You can stop abruptly, midsentence. After 10 minutes, if participants try to negotiate with you and explain their concerns in easy-to-understand language, you start to calm down a little, but will flare up if they mention treatment. You will only calm down and agree to sit down if they offer to talk to your sister, Shelagh, or your keyworker, Derek. |
Statement | True | False | Don’t know | |
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Only mental health practitioners should assess patient’s decision-making capacity. | ||||
A central principle of the Mental Capacity Act is to assume capacity. | ||||
Section 5(2) cannot be used to hold patients in the Emergency Department against their wishes. | ||||
Patients presenting with a mental disorder always lack capacity with regards to treatment decisions. | ||||
The best predictor of future risk events is past behaviour. | ||||
Current mental state is an example of a static risk factor. | ||||
Risk to self includes risk of self-neglect. | ||||
A risk management plan should include steps to modify dynamic risk factors. | ||||
Altered and fluctuating level of consciousness is a common feature of schizophrenia. | ||||
Psychiatric assessment should not take place until the patient’s physical health assessment and management plan is complete. |
Confidence (0–100) | ||
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Identify when I need for perform an assessment of a patient’s decision-making capacity. | ||
Initiate an assessment of a patient’s decision-making capacity. | ||
Perform a brief risk assessment. | ||
Ask for necessary assistance from colleagues. | ||
Ask for necessary information from colleagues. | ||
Make a risk management plan. | ||
Communicate useful information effectively with colleagues. | ||
Work with colleagues to effectively manage an agitated patient. | ||
Understand the legal frameworks that can be used when managing patients who refuse treatment. | ||
Take a leadership role in an emergency clinical care situation. | ||
Work as part of a team to manage a challenging clinical situation. | ||
Provide compassionate care to all my patients. |
Physician □ | Registered General Nurse □ | Registered Mental Health Nurse □ | |
Psychiatrist □ | Allied Health Professional □ (please specify) ……………………………. |
Other profession □ (please specify) ………………………….. |
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a) b) c) |
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Inferential statistics (paired samples differences) for confidence and knowledge measures and the T-TAQ
Mean (SD) | SE | df | t | p | |
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Knowledge | −1.24 (1.56) | .179 | 75 | −6.927 | .000* |
Confidence | −155.90 (146.31) | 16.783 | 75 | −9.289 | .000* |
Structure | −1.79 (2.42) | .300 | 64 | −5.944 | .000* |
Leadership | −.79 (2.55) | .317 | 64 | −2.478 | .016* |
Situation monitoring | −1.65 (2.45) | .304 | 64 | −5.412 | .007* |
Mutual support | −1.01 (3.09) | .384 | 64 | −2.806 | .001* |
Communication | −1.01 (2.50) | .310 | 64 | −3.470 | .000* |
Note. *