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In this article the author name ‘Agustin Ibanez’ was incorrectly written as ‘Augustin Ibanez’. The original article has been corrected.

The purpose of this study was three-fold: 1.) to address the gap in our understanding of the factors that facilitate the use of community-based transitional support services post-release from jail when transitioning into the rural community for adults with mental illness and 2.) to address the gap in our understanding of the factors that inhibit the use of community-based transitional support services post-release from jail when transitioning into the rural community for adults with mental illness and 3.) to determine the acceptability of a biological sample to measure interlukin-6 (IL-6) for future research. Annually, nearly one million people are incarcerated in jails throughout the United States, with over 80% of them experiencing a mental illness. Rural communities have greater rates of disease burden and fewer community-based resources. These factors combined with the lack of mandated jail-to-community transition programs complicate the transitional experience for individuals living with mental illness. The transitional period, from jail to the community is filled with competing demands and can cause stress and anxiety. Acute stress has been associated with inflammation. This population often expresses resistance in providing biological samples, so aim three will allow for planning for future research involving biological specimen collection. This qualitative descriptive study provided a rich account of the inhibitors and facilitators experienced among individuals transitioning from the rural jail to the rural community while experiencing mental illness. Meleis’ Transitions Theory provided the conceptual underpinnings for this study. Data sources included interviews, a demographic data questionnaire and field notes. Data analysis was developed through qualitative content analysis through open coding, which allowed the researcher to build concepts and categories, forming themes. This iterative approach allowed for the grouping of similar codes and clusters. The

BACKGROUND: American Indian and Alaskan Native (AIAN) populations experience disproportionately higher rates of type 2 diabetes and diabetes-related complications compared to other racial and ethnic groups in the United States (US). Studies have demonstrated that diabetes education can effectively improve self-care practices and metabolic control, thereby preventing or delaying the onset of diabetes-related complications. Since culture plays a significant role in decision-making and health, cultural adaptation of diabetes education has been at the forefront of combating diabetes in tribal communities. PURPOSE: The purpose of this dissertation was to investigate how a culturally adapted diabetes intervention affects diabetes outcomes among Diné people with type 2 diabetes. The study included the development, implementation and evaluation of a tribe-specific diabetes education curriculum called Diné Health (DH). METHODS: The first stage of the study consisted of conducting key informant interviews with Diné (Navajo) cultural experts and collaborating with community partners to develop a culturally grounded diabetes curriculum and intervention. The second stage used a mixed-methods semi-quasi experimental design to pilot the feasibility, acceptability and satisfaction of the DH among intervention and control participants; and to determine whether intervention participants, compared to controls, would demonstrate greater improvement in A1C. RESULTS: Key themes that emerged from the key informant interviews included the importance of discipline, positivity and mindfulness in the context of Hózhó, a Diné wellness philosophy; and were included in the DH intervention and offered in a tribal community. Thirty-four participants were enrolled in the intervention group and received the intervention and 34 controls were retrospectively selected for comparison of results to the standard program condition. Eighty-two percent of intervention participants attended a diabetes educati

Purpose: The purpose of this quality improvement (QI) project was to create, implement, and evaluate an evidence-based delirium prevention protocol in a post-acute care facility in Sonoma County, California.Background: Delirium is a neurocognitive syndrome common in the older adult (65 years or older) population characterized by rapid onset, fluctuating attention, and disorganized thinking. Delirium is costly, under-recognized, and can be fatal. Delirium can lead to numerous short- and long-term complications, including long-term cognitive decline, functional decline, increased risk for 30-day readmission, and institutionalization. Despite these factors, delirium is preventable in up to 40% of older adult post-acute care patients. Method: This QI project followed the Plan-Do-Study-Act (PDSA) model. Skilled nursing facility staff were given in-service training specific to delirium risk factors and prevention. A delirium prevention protocol was then implemented for all new admissions. Pre- and post-implementation chart audits were conducted to assess new-onset delirium incidence in the older adult post-acute care population. Additionally, the staff was surveyed after implementation to evaluate their perception of the protocol. Results: In the pre-implementation chart audit sample, 8% of patients were diagnosed with new-onset delirium during their post-acute care stay. The post-implementation sample group had 0 cases of new-onset delirium. The licensed nurses found the protocol simple to use. This group also reported the protocol to moderately change their daily practice. The CNAs reported the education and protocol significantly changed their daily practice. Conclusion: This QI project’s results suggest that the implementation of a delirium prevention protocol can positively change nurse and CNA daily practice and has the potential to decrease the incidence of new-onset delirium.

Purpose: The purpose of this quality improvement initiative was to expand the provider’s knowledge and intent in promoting the use of patient health questionnaire-9 (PHQ-9) screening. Background: Depression is one of the most common and devastating mental health illnesses that negatively affects adolescents worldwide. The consistent rise has made depression a leading cause of disability and a significant burden globally. One reason for this is the lack of screening in primary care (PC) settings, causing depressive symptoms to remain undetected. The American Academy of Pediatrics now recommends routine depression screening for adolescents 12 to 18 years of age in PC settings. Though no universal tool is currently accepted, the PHQ-9 screening has proved to be one of the most reliable tools to help identify depression in the adolescent population.Method: This quality improvement project consisted of a pretest-posttest quantitative design. An evidence-based educational intervention was conducted via an asynchronous learning format, discussing current recommendations for adolescent depression screening and the importance of conducting PHQ-9 screening in the PC setting. Pretest-posttest questionnaires were delivered using Qualtrics to generate, collect, and analyze data effectively. The participants were given seven days to complete the pretest-posttest questionnaire. Results were shared with the implementation site. Results: Data collection took place over one week. Three providers completed the pretest- posttest questionnaires. Upon completion, providers’ knowledge increased by 13.4% after participating in the educational intervention. A six-point increase in the Likert scale was noted whereby providers were in stronger agreement to become compliant with utilizing PHQ-9 screening, better understood the Guidelines for Adolescent Depression in Primary Care (GLAD- PC), agreed with GLAD-PC, and better understood the common risk factors that are associated with adolescent d

Purpose: The purpose of this quality improvement project was to present a skin assessment form that could be used for documentation during teledermatology consult at Mariposa Community Health Center (MCHC). Background: Dermatologic conditions are a major disease burden in the United States and worldwide. About 85 million Americans sought care for skin conditions in 2013. With the increasing number of skin conditions and shortage of dermatologist, patients have limited access to dermatologist. Teledermatology is a branch of telehealth currently being used to bridge the dermatologist gap in most areas especially rural areas. There is limited information on efficient documentation form for providers. As a result, documentation of a skin condition for teledermatology varies based on provider discretion. A skin assessment form (SAF) could make documentation easy, straight forward and consistent among providers. Method: The logic model was used to implement the project. Thirty health care staff at MCHC were invited to participate in the project. Participants were invited through email. A pre-survey assessing participant knowledge about teledermatology program guidelines at MCHC was completed. Health providers and medical assistants participated in a one-day in-service on a skin assessment form that can be used for teledermatology documentation. After the in-service education, participants completed a post survey. Results: Eighteen invitees attended the in-service. Six participants (33.3%) completed the pre- survey and post-survey. Responses from the participants indicated the skin assessment form was well received and they were agreeable to using the form in practice. Other benefits of the form are it is simple, easy to use, straightforward and contains relevant dermatology information. 9 Conclusion: The education on the use of the skin assessment form was well received as evidenced by the agreement of the health center participants to pilot the form. Similar program eval

BACKGROUND: American Indian and Alaska Native (AIAN) youth experience disproportionately high rates of health inequities in multiple areas, including: suicide, unintentional injuries, obesity, sexually transmitted infections, substance abuse, teenage pregnancy, and sexual violence. Despite the increasing support for integrating cultural protective factors (“cultural assets”) to address these health inequities, literature on formative processes for identifying and incorporating such factors is sparse. OBJECTIVES: This dissertation study addresses the gap in literature by applying mixed method and Indigenous research methodologies to identify cultural assets and foundational elements critical for developing a culturally grounded mother daughter intervention that aims to reduce substance abuse, prevent teenage pregnancy, and promote reproductive health among pre-pubescent (age 9 – 11 years) Diné (Navajo) girls. METHODS: Cultural assets and foundational elements were identified through the following aims: 1) a systematic review of strengths-based intergenerational interventions in North American Indigenous (NAI) communities; 2) a cross-sectional, community-based survey of 200 adult Diné women; and 3) focus group and in-depth interview/storytelling sessions with Diné women age 8 years and older. RESULTS: For the systematic review, 115 articles were initially identified and 7 met the review inclusion criteria. Major themes of promising methods were: 1) community-based participatory research or participatory action (CBPR/PAR) approaches; 2) qualitative methods; 3) storytelling as data collection; 4) bridging historical trauma to healing; 5) mothers as a source of support; 6) collectivist cultural values; and 7) strengthening interventions with cultural teachings. For aim 2, the survey revealed that 66% women admired their mother/grandmother most during puberty; 29% of women were 10-11 years old when someone first spoke to them about menses; and 86% felt their culture was a

Schizophrenia spectrum disorders are psychiatric illnesses that have a high incidence of patients not adhering to their antipsychotic medications. There are multiple factors that contribute to medication nonadherence in patients with a schizophrenia spectrum disorders. Nonadherence with antipsychotic medications can cause poor patient outcomes for patients with these psychiatric illnesses. There is evidence to support that the therapeutic communication intervention, motivational interviewing, can improve medication adherence in patients with schizophrenia spectrum disorders. This quality improvement project used a pre- and post-test design to assess medication adherence pre- and post-intervention. The main outcome of this project was to improve the patient outcome, medication adherence. This project included a study sample of two participants that met inclusion criteria. Patient A’s pre-intervention medication adherence rating scale (MARS) score was 7 out of 10 and Patient B’s score was 4 out of 10. The higher the score on the MARS, the more favorable medication adherence. Patient A was unable to receive a therapeutic session of motivational interviewing because he was acutely psychotic and paranoid. Patient B received one face-to-face motivational interview session and behavioral changes were discussed on how to maintain medication adherence. The one-month follow up post- intervention could not be completed due to appointments being rescheduled by the patients and provider. The post-intervention MARS were not completed and motivational interviewing was unable to be evaluated for effectiveness. Despite the lack of result findings on medication adherence, administering the MARS and utilizing motivational interviewing offered insight about the patient’s beliefs and feelings about their antipsychotic medication. It is recommended for future projects to expand the PDSA cycle to recruit more participants and fully implement the study protocol. Keywords: motivational inte

The purpose of this project was to identify facilitators and barriers to novice PMHNP role transition in Arizona and provide recommendations for a new graduate psychiatric-mental health nurse practitioner (PMHNP) transition plan for a clinical agency/project partner. Core concepts for this project included novice, expert, PMHNP, transitions, nurse practitioner (NP) role transition, facilitators, and barriers. Meleis’ Transitions Theory was the theoretical framework supporting the project. Applying Transitions Theory to NP role transition, PMHNP role transition is a situational transition mediated by facilitators and inhibitors (barriers), patterns of response, and outcome indicators. Methods: A descriptive, cross-sectional anonymous survey was administered to PMHNPs in Arizona (N=24). The survey consisted of a valid and reliable instrument for this population which measures NP role transition: The Nurse Practitioner Role Transition Scale (NPRTS). Eleven additional custom survey questions sought to identify statistically significant relationships between pre-certification and post-certification antecedents and participants’ NPRTS score data. Pre-certification antecedents queried about included: working in another NP role prior to PMHNP certification; the number of clinical hours in one’s PMHNP educational program; years of previous psychiatric nursing experience; years of previous medical nursing experience; and the degree of supervised, full practice during PMHNP clinical rotations. Post-certification antecedents in the survey included: receiving a formal orientation; participating in a residency or fellowship program; receiving informal mentoring or formal mentoring; months/years of PMHNP experience; and state of residence during the PMHNP role transition experience. Findings: A statistically significant relationship was found for one antecedent: formal orientation during the NP role transition experience. Participants’ comments were solicited in an open text-quest

There is a healthcare provider shortage in the U.S., particularly in rural areas which results in rampant health disparities. Telemedicine allows health access to these areas through various applications of communication technologies, yet multiple barriers exist which prevent the adoption of telemedicine by healthcare providers. This quality improvement project assessed New Mexico VA Health Care System (NMVAHCS) nurse practitioner’s telemedicine knowledge, through surveys administered pre- and post- and an in-person educational intervention. This intervention consisted of educating nurse practitioners on the Eight Risk Domains that are associated with telemedicine practice. This quality improvement project assessed nurse practitioner perceived risks and the impact of education on the telemedicine risk perception of advanced practice registered nurses (APRNs). The pre-test indicated ARPNs demonstrated minimal exposure to and awareness of the eight telemedicine risk domains and the post-test indicated new insights gained by the APRN group after an educational session on telemedicine and the 8 risk domains. Some challenges experienced in this QI project include a small sample size; limited time for the intervention; and additional time required for education about the QI process for site approval. This project offered insights on APRN knowledge of risk perceptions about telemedicine and may guide the development of educational strategies in undergraduate and graduate nursing curriculum. Addressing APRN knowledge of risk in telemedicine may reduce barriers and may enhance the adoption of telemedicine among nurse practitioners.

Millions of undocumented immigrant women of Mexican-origin (UIWM) currently reside in the U.S. (American Immigration Council, 2014), with the majority living in border states (Massey, Rugh, & Pren, 2010). National data suggest that thousands of these women will experience a rape during their time in this country (Black et al., 2011). Their marginalized status makes them uniquely vulnerable to rape sequelae (Bryant-Davis, Chung, Tillman, & Belcourt, 2009), yet few studies have focused on the needs of this unique group of rape survivors. This study used a critical ethnographic approach to explore the cultural and socio-political influences on the post-rape decision-making processes and behaviors (i.e. discloser and help-seeking) of UIWM that experienced a rape in the U.S. border region. Thirteen key informants, including six UIWM that survived rape and seven stakeholders (individuals with knowledge of, or contact with, UIWM that have survived rape) participated in interviews; survivors also participated in a PhotoVoice activity. Data were analyzed according to Carspecken’s (1996) guidelines for critical qualitative research and incorporated photographic analysis. Three domains were revealed: Helping Survivors, Barrier After Barrier, and Overcoming, which were united by the overarching theme Struggling to Heal. Findings were plotted on an adapted matrix of oppression and organized into an illustrative diagram. Findings suggest that although help is available for survivors, for UIWM healing is a constant struggle against cultural, social, and political barriers that make moving forward difficult. These findings fill a gap in current literature and will allow rape crisis centers and other organizations to garner a better understanding of the specific needs of UIWM following rape.

Background: Compassion fatigue (CF) impacts medical professionals, especially the nursing staff. Nursing staff who work at long-term care (LTC) facilities commonly experience CF, comprised of burnout (BO) and secondary traumatic stress, related to increased patient-to-nurse ratio, physical demands of patient care, and patient workload. Quality improvements addressing CF are slowly rising among the American Indian population. Scarce data exist on rates of CF among LTC facilities in American Indian tribes. Outcome: This project studied the prevalence and severity of CF among the nursing staff at a rural LTC facility located on the Navajo Nation and provided an educational workshop to prevent and manage CF. Design: A quantitative descriptive approach described how CF impacted the nursing staff. Prevalence and severity of CF and the effectiveness of an educational intervention were evaluated using quantitative surveys at baseline and post-intervention. Setting: A long-term care facility, located on the Navajo Nation with approximately 60 residents and over 60 clinical staff. Participants: A target of 10 participants, with a minimum of five and maximum of 25 were comprised of licensed nurses and nursing assistants with the exclusion of administrative nurses. Methods: Participants completed a pre-intervention survey to collect baseline sociodemographic and workplace characteristics. The Professional Quality of Life (ProQOL) scale screened for prevalence and severity of CF before and after the intervention. Post-intervention, survey questions evaluated the satisfaction of the workshop. Intervention: A one-hour educational workshop provided strategies on how to recognize and address CF and an opportunity for reflective journaling that focused on responses to emotional triggers about CF. Findings: Six participants participated in this project, 10% of the nursing staff. Post-intervention, nursing staff’s high level of compassion increased from 33% to 67%, and low level of bur

Background: Depression is a grave mental health condition in the United States, and 3.4% of the older adult population experiences depression (Centers for Disease Control and Prevention, 2011). Older adults with depression may not engage in mental health treatment because of the cost of co-pay, treatment duration, the stigma of having depression and seeking mental health services and intolerance to medication side effects. Traditional care for treatment of depression, including antidepressant medicines, cognitive behavioral therapy, and supportive treatment, continue to be utilized. However, there is also an increase in the use of naturalistic and more holistic treatment options which include exercise therapies such as yoga (Prathilkanti et al., 2017). Evidence suggests that yoga reduces symptoms of depression (Cahoon, 2012). Objective: The purpose of this project was to educate mental health providers in an Arizona clinic on the benefits of yoga for older adults with depression. Setting: A private solo-practitioner psychiatry practice serving adults in the suburban Phoenix, AZ area Findings: Post yoga education questionnaire was completed by the mental health providers in an Arizona clinic to determine the participants knowledge on yoga as a therapeutic treatment option for older adults with depression. Results revealed positive findings that mental health providers in an Arizona clinic agreed to the facts that yoga would be beneficial as a treatment modality for depressive conditions among older adults. Discussion: Participants indicated they were open to recommending yoga as an adjunct therapy to older adults with depression and identified additional education on yoga education would be helpful. The ability of the mental health providers to participate in yoga education session indicates willingness to recommending yoga as a treatment option to older adults with depression. Further study is indicated to identify the efficacy of educating mental health providers o

Cardiovascular disease is the leading cause of death in the United States contributing to over 600,000 deaths each year. Native Americans are at greater risk for heart disease, with higher mortality rates related to this disease than other population. The prevalence of coronary artery disease in Native Americans is 11.6 %, compared to 6.5% for African Americans, 6.1% for Hispanics 6.1%, and 5.8% for Whites (Centers for Disease Control & Prevention, 2011). Patient education plays a critical role in the awareness of risk factors to prevent cardiovascular disease. The purpose of this study is to conduct a quality improvement project at an urban primary care clinic for Native Americans to assess the general knowledge and perceptions of cardiovascular disease and risk factors among Southwestern Native Americans who receive care at this site to guide providers in their primary prevention efforts. Participants 18 years of age and older who receive primary care from this care clinic will be invited to complete a quantitative survey evaluating knowledge and perceptions of their risk for cardiovascular disease, as well as perceived effectiveness and preferences for patient education. Descriptive data analysis will be performed to evaluate participant knowledge and perceptions. Evidence-based recommendations will be made to enhance patient education initiatives at this site. This paper outlines the PDSA steps implemented in developing this project and recommendations for next steps for implementation.

Depression is a psychiatric illness with a high incidence of medication non-adherence, which is a challenge in treating patients with depression. Non-adherence influences the effectiveness of treatment and the direct and indirect costs associated with untreated depression. Design: This study used a pre-post one-group design with medical record audit to examine the effectiveness of motivational interviewing (MI) in increasing medication adherence in patients with depression. The main outcome of this quality improvement study was medication adherence, an objective measure of the Medication Possession Ratio (MPR) and Proportion of Days Covered (PDC) of the pharmacy refill records defined as a calculated PDC and MPR ≥ 80%. Sample: The sample of this study consisted of patients with depression (N = 5). Intervention: The patients each received MI sessions that lasted 15-20 minutes in two sessions. The pharmacy refill records were used to determine medication adherence rate through calculations of the MPR and PDC before and after the intervention. Baseline data were obtained by reviewing the pharmacy refill records three months prior to the first MI session and the patient self-report at baseline confirmed the data. The pharmacy refill records were reviewed over a period of one month after each MI session. The percentages of the MPR and PDC of the patients were compared at the pre-test, post-test, and at one-month follow-ups. Result: A significant increase was noted in the medication adherence rate. While there was no statistical increase after the second MI session with the PDC adherence rates, there was an overall significant increase in medication adherence from baseline. Conclusion: MI is an effective intervention for improving adherence to medication but does not determine if the patient is actually taking the medications. Keywords: motivational interviewing, medication adherence, major depressive disorder, adherence, and psychiatric conditions.

Greater than half of the population of patients with schizophrenia struggle to comply with their antipsychotic medications due to various factors. Psychiatric providers heavily rely on their patients to comply with their antipsychotic medications to improve their overall quality of life. The purpose of this DNP Project was to implement Psychoeducation via a Teach-Back Method intervention in adult Schizophrenic patients who are voluntarily noncompliant with their antipsychotic medications among residents in Las Vegas, Nevada. The Model of Improvement framework was utilized to help develop the project’s aims, and goals and the Plan-Do-Study-Act (PDSA) cycle was used to develop the project’s intervention, implement the intervention, and evaluate the results. Psychoeducation was used to educate the patients about the pathophysiology and symptoms of schizophrenia and how antipsychotic medication counteract their symptoms to improve their overall quality of life. The Teach-Back Method helps psychiatric providers provide psychoeducation in layman’s term so patients can understand the information. Understanding can be assessed by asking patients to verbalize the educational information back to the provider. Five participants ages 18 years old and older, diagnosed with schizophrenia who are voluntarily noncompliant with their antipsychotic medications were included in the DNP Project. Each participant was assessed for their baseline medication noncompliance, and the Psychoeducation via Teach-Back Method was implemented. Each participant had a follow-up visit 2 weeks Post-Intervention to evaluate their medication compliance. The data was analyzed using descriptive statistics to determine if the participant was compliant or noncompliant with their antipsychotic medications per definition. The data showed that all five participants showed an improvement in medication compliance (Post-Intervention) compared to their baseline medication noncompliance (Pre-Intervention). The data

Benzodiazepine dependence is a significant national problem. Although benzodiazepines — a class of drugs that includes drugs such as alprazolam, lorazepam, temazepam, clonazepam, and diazepam—have a wide range of uses including the treatment of insomnia, anxiety, and seizures; they are addictive. Individuals taking these drugs can quickly develop dangerous tolerances. Therefore, these drugs should not be selected as first choice nor used for more than short periods, yet a significant portion of the population uses benzodiazepines for long periods. This problem is significantly more pronounced in the elderly, a population that scholars have agreed should not use these drugs outside of extreme circumstances. Because benzodiazepines may be wrongfully perceived as an easy treatment for so many common afflictions, providers continue to prescribe them, and patients may be reluctant to discontinue use due to the symptoms associated with withdrawal (i.e., insomnia and anxiety). To avoid these symptoms, the standard discontinuation approach seen in an outpatient setting is a long-term taper that may take eight to 12 weeks of gradual reduction. However, in an inpatient setting, this long-term approach is unfeasible due to the short length of patient stays. The literature has given little consideration to this problem. Thus, it was necessary to review evidence and develop a guideline for benzodiazepine tapering in elderly patients receiving inpatient psychiatric care. The purpose of this project was to develop a guideline to taper benzodiazepines in the elderly using the Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP). The guideline was validated by expert peer reviewers using the AGREE II instrument. The completed guidelines offer recommendations on the tapering of benzodiazepines in an inpatient geropsych unit and best practices for interventions to increase the success rate of discontinuation.