The following protocol will be used during the implementation of the evidence-based practice change project devoted to the adoption of the National Institute for Health and Care Excellence guidelines for depression management at VEGA Medical Center (Miami, FL):
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- Depression is a significant issue that is rather prevalent in the geriatric population of the United States. Some of the negative consequences of depression include reduced quality of life of patients and their families and increased healthcare expenditures, highlighting the importance of the appropriate treatment of the condition in the vulnerable geriatric population. However, VEGA Medical Center does not employ any specific depression management guidelines at this point in time, resulting in some discrepancies in treatment and deprives nurses of a powerful tool that can assist them in working with patients with depression. The proposed study intends to resolve this issue by introducing high-quality, evidence-based guidelines developed by the National Institute for Health and Care Excellence at VEGA.
- The following PICOT question will be considered during the project: in nursing staff at VEGA Medical Center (Miami, FL), how does the implementation of the National Institute for Health and Care Excellence guidelines affect the accuracy of diagnosing and management of depression in the geriatric population within 10 weeks?
- The project is of interest to multiple stakeholders. The critical decision-makers of VEGA are its Administrator and Manager, Facility Owner, and Medical Director. The project has been approved by these people, and the letter of support has already been provided. Apart from that, the nurses of the institution are significant stakeholders, and their support is crucial to the project’s success. An organizational needs assessment demonstrates that the nurses of VEGA are interested in the project.
- The number of participants amounts to 10 nurses working at the VEGA Medical Center. Nurses with any education and levels of experience will be included. They will be recruited with the help of flyers distributed at their workplace (VEGA).
- The implementation of the project will take place at VEGA and last for ten weeks. It will involve the following activities.
- At the beginning of the first week, the participants will sign an informed consent form with a detailed description of the activities required of them.
- At the beginning of the first week, the participants will be provided with the guidelines and related tools to assist in their adoption.
- At the beginning of the first week, the participants will take part in the first weekly discussion, during which the guidelines will be discussed. Any questions on the adoption activities will also be answered.
- At the beginning of the first week, the baseline information on nurse performance will be collected using the performance measures employed by VEGA and the quality standards created by the National Institute for Health and Care Excellence (see Appendix A).
- The participants proceed with their everyday workplace activities, during which they will employ the guidelines and quality standards (see Appendix A) to manage depression cases and document the process.
- Once a week, nurses will participate in a discussion aimed at tracking and facilitating the process of adoption. The tool for the discussions (which will be framed as group interviews) can be found in Appendix B.
- During the tenth week of implementation, the nurses will submit their guidelines-based documentation for data analysis.
- The data will be analyzed with the help of the quality standards developed by the National Institute for Health and Care Excellence (see Appendix A).
- The statistical analysis of the quantitative data will be carried out with the help of the paired t-test.
- The analysis of the qualitative data will be carried out with the help of thematic analysis.
- The ethical considerations of the project include the review of the risks and benefits of participation, confidentiality concerns, and the introduction of the informed consent form.
- Participation risks are minimal. It is acknowledged that the participants might experience some discomfort as a result of participating in the interviews, even though the issue is relatively unlikely because the interview does not contain invasive questions. Still, the participants will be able to refuse to answer questions during interviews if they appear offensive or invasive to them (see Appendix B). Also, the change process may cause some stress. This problem will be controlled by the application of modern change theories during the project. The benefits of the project include the introduction of a helpful tool that will facilitate nurses’ working process. The benefits of participation outweigh the risks.
- The confidentiality of participation will be ensured through the following procedures. No personal information about the nurses and patients will be collected because it is not needed for the study. The nurses will be anonymized with the help of individual codes, and these codes will be used to label the performance and interview information. The raw data will be available only to the investigators (the principal investigator and the preceptor); it will be stored in accordance with the requirements of the Chamberlain IRB. No participants will be identifiable from the final report.
- The informed consent form will be used to inform the participants about all the specifics of the project, their role in it, and all the risks and precautions employed by the investigators.
- The project will use two tools that are located in Appendices.
- The summative assessment tool is the thirteen quality standards developed by the National Institute for Health and Care Excellence; they are presented in Appendix A. The tool focuses on the description of the activities performed by nurses (for example, the use of correct procedures during diagnosing, the reassessment of treatment-resistant cases, and so on). This information is predominantly presented in the form of the percentage of correct and incorrect activities, which are in line with the guidelines. The application of the tool produces quantitative (ratio) data; it will be used as the pre- and post-implementation measure to detect any changes in the quality of depression diagnosis and management that can be attributed to the introduction of the new guidelines.
- The formative assessments will be carried out during the weekly discussions with the help of their tool (see Appendix B). This tool will produce qualitative data; the latter will be gathered with the help of transcription and employed to describe and analyze the process of guideline adoption. In particular, it will focus on the challenges and problems, solutions, facilitators, and successes.
- The National Institute for Health and Care Excellence quality standards are reliable and valid because their development has been carried out by a large team of professionals. Permission to use the tool has been requested.
- The interview tool has been developed specifically for the project while considering the guidelines relevant for group interviews. Its reliability and validity will be tested during pilot interviews with the help of expert advice, and changes can be made to improve the tool.
- All the data will be stored in accordance with the practice that is recommended by Chamberlain IRB. In particular, all the hard copy data, including the product of the application of the quality standards and the transcripts of the interviews, will be located in a password-protected device in a secure location for seven years. After that, the data will be destroyed.
- The results of the project will be presented in the form of the final report, a copy of which will be provided to the VEGA center that will employ the results to ensure the sustainability of the innovation and for future reference. Apart from that, the project is a DNP project of the principal investigator, and a copy of the final report will be provided to the educational institution. Finally, both institutions will also host the presentation of the results in the form of a PowerPoint-assisted speech, which will assist in the dissemination of the pertinent information and its discussion. No journal publications or conference presentations are planned for the time being.
Data Collection Tool for Evaluation (National Institute for Health and Care Excellence Quality Standards).
Note: every statement contains one or several quality indicators. They can be found by clicking the links in the text.
List of statements
- Statement 1. People who may have depression receive an assessment that identifies the severity of symptoms, the degree of associated functional impairment, and the duration of the episode.
- Statement 2. Practitioners delivering pharmacological, psychological, or psychosocial interventions for people with depression receive regular supervision that ensures they are competent in delivering interventions of appropriate content and duration in accordance with NICE guidance.
- Statement 3. Practitioners delivering pharmacological, psychological, or psychosocial interventions for people with depression record health outcomes at each appointment and use the findings to adjust the delivery of interventions.
- Statement 4. People with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.
- Statement 5. People with persistent subthreshold depressive symptoms or mild depression are prescribed antidepressants only when they meet specific clinical criteria in accordance with NICE guidance.
- Statement 6. People with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity cognitive behavioral therapy or interpersonal therapy.
- Statement 7. People with moderate depression and chronic physical health problems receive an appropriate high-intensity psychological intervention.
- Statement 8. People with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual cognitive behavioral therapy.
- Statement 9. People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care.
- Statement 10. People with depression who benefit from treatment with antidepressants are advised to continue with treatment for at least six months after remission, extending to at least two years for people at risk of relapse.
- Statement 11. People with depression whose treatment consists solely of antidepressants are regularly reassessed at intervals of at least 2 to 4 weeks for at least the first three months of treatment.
- Statement 12. People with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.
- Statement 13. People who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.
In addition, quality standards that should also be considered when commissioning and providing a high-quality depression service are listed in related NICE quality standards.
Weekly Discussion Group Interview Tool
The facilitator greets the participants, reminds them of the rules, as well as some of the pertinent details from the previous discussion (if appropriate), and states the goals of the meeting.
The rules of the discussion are presented below.
- There are no incorrect answers. Feel free to express any sentiment and report any information.
- You are encouraged to engage in dialogues and debates, but you must also be respectful towards each other.
- Only one person can speak at a time. You can disagree with a person, but you cannot interrupt them. You are encouraged to use paper and pen or another method to write down your thoughts and avoid forgetting them.
- You do not have to answer the questions that seem invasive or rude or otherwise cause you any discomfort.
- If you feel that we need another rule, feel free to make suggestions.
The goals of the discussion are:
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- to review the process of guidelines adoption, including positive and negative events, difficulties, successes, and facilitators,
- to indicate pertinent issues and consider possible solutions for them,
- to promote consideration of the potential improvements.
Key questions should include the variations of the following ones.
- Let us review the events of this week that are pertinent to the guideline adoption.
- Have you encountered any challenges this week? What area were they pertinent to (organizational, clinical, decision-making, other)?
- How can we address these challenges?
- What are the successes of this week?
- What remains to be done for successful adoption?
Throughout the discussion, the facilitator should prompt the participants to elaborate by using pauses and guiding questions. Examples of guiding questions:
- Would you like to provide some details?
- Could you possibly elaborate?
- You described (a phenomenon). What about (a related phenomenon)?
- Do you mean that (shortened idea)? Have I understood you correctly?
The facilitator recaps the goals of the discussion, recites key ideas and decisions (if any), and asks the participants to add any details if anything important has been left out. The facilitator makes a conclusion about achieving the goals of the discussion and thanks to the participants for the collaboration.