Date of Conferral

11-19-2024

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Mattie Burton

Abstract

Summary Poor treatment retention rates are significant problems in mental health, with adverse outcomes being more profound for vulnerable populations, such as individuals experiencing homelessness. The current project was vital because the lack of engaging strategies in working with individuals experiencing homelessness contributes to high rates of treatment dropout. The purpose of the project was to equip mental health clinical staff with knowledge and skills in motivational interviewing (MI) to use MI in clinical settings to improve treatment retention for homeless populations. The practice-focused question that guided the project was: For staff in a mental health clinic, will training on MI techniques increase knowledge toward the goal of using this evidence-based strategy to improve retention rates among the homeless population? I employed descriptive analysis to analyze the data collected in the project. According to the pre- and posttraining data, the education program resulted in a 42% overall increase in knowledge and 43% increase in skills. Leadership also reported 15% increase in treatment retention and 11% increase in treatment completion rates based on 3 months of evaluation data. These findings support the conclusion that MI has excellent potential for engagement and treatment retention in mental health settings. The implications of these findings include the potential of MI to enhance provider-patient communication, eliminating power differences while empowering practitioners with additional skills and knowledge. Regarding social change, equity, diversity, and inclusion, the project could improve health and well-being, empowerment, and access to services, reducing health disparities between homeless people and the general population.   Background Homelessness is a risk factor for mental illness, and at the same time, mental illness is a risk factor for homelessness; Hence, the interaction between homelessness and mental health conditions is a vicious cycle with the outcome of a high prevalence of mental illnesses among individuals experiencing homelessness. Several studies have reported alarmingly high rates of various mental health problems in the homeless population versus the general population. According to Gutwinski et al. (2021), the overall prevalence of mental disorders in the homeless population from a systematic review and meta-analysis was between 76.2% and 86.6%. Among the common mental and behavioral health problems were alcohol use disorder, schizophrenia, and depression, in that order (Gutwinski et al., 2021). Investigating the prevalence of mental disorders in homelessness in high-income countries, Hossain et al. (2020) noted that the most common mental health conditions in this population, included depression, anxiety disorder, suicidal behavior, alcohol use disorder, bipolar disorder, and psychotic disorders. More so, homeless individuals tend to experience high rates of multiple mental health conditions and a co-occurrence of mental and physical health problems. While this population is exposed to a greater risk of mental health problems and presents with a high prevalence of existing mental and behavioral health conditions, they experience the lowest access to treatment because of multiple barriers. Therefore, they experience the highest treatment dropouts because of accessibility issues and poor engagement problems, with studies reporting figures as high as between 65% and 90% of treatment dropouts for homeless individuals receiving mental health and behavioral treatment (Klarare et al., 2024). These dropouts, who are homeless people with mental health conditions, never get complete treatment and, thus, do not recover from mental illnesses. A low treatment completion rate is problematic because it points to the failure to address the underlying mental health issues impacting people experiencing homelessness. Subsequently, failure to address the mental and behavioral health conditions affecting the homeless population translates to poor psychological well-being, exacerbation of mental health issues, and risk of developing multiple mental health illnesses. Ultimately, failure to complete treatment increases the mortality rates of individuals experiencing homelessness. According to Gutwinski et al. (2021), higher rates and morbidity directly associated with mental health disorders are reported among the homeless population compared to the general population. One of the effective strategies to promote positive mental health and overall health outcomes in the homeless population is creating programs that encourage engagement in treatment, enhancing treatment retention and completion. Evidence has linked integrating MI with enhanced patient engagement and motivation to evoke treatment adherence and completion. According to Santa et al. (2021), MI significantly improved the engagement and motivation of individuals experiencing behavioral and mental health problems, successfully necessitating a reduction in alcohol use and recovery from alcohol use disorder and other mental health issues. While MI is supported by evidence as an essential strategy to enhance motivation and engagement in treatment, the application of the technique in a practice environment is limited. According to research evidence, MI is effective in enhancing retention through engagement and motivation of patients to maintain treatment adherence. According to Shaul et al. (2020), MI has a direct link to treatment engagement and results in positive outcomes. In a randomized trial, the participants in a 12-month follow up demonstrated the ability not only to recover but also secure employment contrary to the control group (Shaul et al., 2020). Similarly, Lawrence et al. (2017) also linked MI to user-friendliness, encouraging treatment attendance and compliance among individuals experiencing mental health issues. According to John Hopkin’s evidence-based practice model, these studies present Level I evidence. Eldaghar et al. (2021) showed that MI enhances the tendency of individuals to comply with the objectives and treatment instructions, leading to adherence and retention in treatment until completion. This evidence is consistent with a 3-month follow-up study on the application of MI, which revealed its connection to social support (Tse et al., 2022). By enhancing social support, MI techniques enhance the engagement of treatment participants, encouraging them to achieve the mutually set goals that lead to treatment completion. Boom et al. (2022) also conducted a study to evaluate MI in mental health and behavioral treatment for individuals experiencing homelessness and found a positive connection with outcomes for substance use disorder and other mental health conditions. Orciari et al. (2022) stressed the importance of the long-term application of MI to ensure its effectiveness in the engagement and motivation of patients undergoing treatment for mental health issues. The evidence presented in the aforementioned studies is of high quality and based on robust methodologies; hence, the strength of the evidence is high. Despite the overwhelming evidence of its efficacy, MI was not in place at the project site, prompting leadership to desire its implementation and, thus, support for the current project. Staff Education Program Development The treatment approach/strategy used substantially determines the level of engagement of the homeless clients in treatment, influencing treatment outcomes. The chosen site for this staff education program provides mental and behavioral health services to the surrounding communities and beyond. The primary populations served by the facility are primarily vulnerable and underserved, including individuals who are experiencing low-socioeconomic status and homelessness. Given the unique characteristics of the population and the tendency for barriers to access health care services, creating engagement is critical for the success of treatment. The clinical staff lacked adequate knowledge and skills in the MI approach linked to engagement and a high chance of enhancing client treatment retention. As the evidence has demonstrated, MI is an effective strategy for enhancing engagement and motivation, positively influencing an individual’s choice (Bischof et al., 2021). MI is used in mental and behavioral health interventions to target ambivalent patients and influence them to change their behavior. The technique purports that with the right motivation, a person can readily change behavior by making positive choices (Bischof et al., 2021). For example, it is commonly used in interviewing people with alcohol use disorder to enable them to visualize the destructiveness of their addictive behavior and become motivated to change to improve their health, finances, and relationships. According to Dobber et al. (2018), MI has four processes: engaging, focusing, evoking, planning, and influencing behavioral change. The staff education program was implemented at the project site to enable the staff to gain skills and competencies in applying MI in their daily practice to enhance engagement, especially with vulnerable populations, such as homeless individuals. All clinical staff, including mental health nurses, psychologists, psychiatrists, advanced practitioners, case workers, and other mental health staff who provide mental health support services to individuals experiencing homelessness, were eligible to participate in the program. Participation was voluntary, but nearly all the clinical staff members enrolled in the program having understood its practice value. The participants and other stakeholders managed resistance to change throughout the process, from the planning phase to completion. Involving the participants in the planning phase enhanced communication, their understanding of the project, and their perspective on the design and delivery of the teaching program. According to the change management theory, stakeholder engagement in the project’s process from the initial steps is critical for a successful outcome (Pollack & Pollack, 2014). Understanding the needs of the stakeholders and allowing their participation in planning was valuable to the training program’s success. I collected data relevant to the outcome evaluation through pre- and posttraining knowledge-based assessments. Before the training sessions began, a preassessment analysis was conducted to collect baseline data and develop an understanding of the participants’ attitudes and perceptions regarding MI and the training program. I conducted the pretraining assessment using a questionnaire that measured the participants’ knowledge and understanding of MI, including its principles, techniques, and importance. Baseline information was also collected on the retention and engagement rates of individuals receiving mental health care using hospital record data without identifiers. I organized the staff education and training program into manageable modules and sections. The entire duration of training was 3 weeks, with two sessions being held each week. Each training session was recorded for future access and to enable those who could not attend to have access and learn MI techniques. The training sessions incorporated role plays, case study scenarios, and posters to enable practical demonstration of the theoretical knowledge presented to the learners. After the training period, the participants could apply the knowledge and skills gained into practice both under observation and independently while working with patients. I employed a posttraining assessment to determine the effectiveness of knowledge gained and the participants’ ability to apply the knowledge into practice. Evaluation approaches included role plays, surveys, peer feedback, treatment retention metrics, quizzes, and skills checklists. I used a descriptive approach to compare baseline data with measurements recorded after 3 months. Results A comparison of the pre- and posttraining assessment results indicated that the staff who participated in the program had a considerable gain in skills and knowledge related to MI principles and techniques. Regarding knowledge, the pretraining assessment average score was 45%, and the posttraining assessment average score was 87%, indicating a 42% improvement in staff knowledge of MI and its techniques. Regarding skills, the average score for the pretraining assessment was 35%. In comparison, the posttraining assessment average score was 78%, showing a 43% increase in skills gain and confidence in applying MI in clinical practice. Similarly, a survey of the participants indicated they were satisfied with the education and training program and the skills and knowledge gained from the activity. The satisfaction rate of the staff with the training was 86%. Leadership included measures to further assess the effectiveness of the training. The metric they measured was treatment engagement, determined by the interaction of the target population with the treatment sessions. This included the number of sessions attended, adherence to treatment sessions, and the interaction during the sessions. Survey responses from the staff reiterated that using MI in client sessions enhances positive interaction, making clients more engaged with the treatment sessions and more likely to return for more sessions. For instance, unlike before, more homeless clients returned for the second and succeeding sessions. Therefore, the high likelihood of engagement resulted in better treatment session adherence. This is consistent with the principles of MI, which encourages positive change, enabling individuals to adhere to treatment for better chances of recovery (Bischof et al., 2021). Treatment retention was the ultimate measurement and goal of this project. Short-term improvement in treatment retention indicated the effectiveness of the training program and the usefulness of MI in promoting treatment engagement and adherence. In the pretraining evaluation, I determined that the treatment retention rate was 25% for the homeless population receiving mental health interventions. In comparison, the posttraining rate was 40%, indicating a 15% improvement in the homeless treatment retention rate. Likewise, treatment completion rate preassessment were 17% compared with the postassessment data showing a 28% treatment completion rate. The posttraining data were collected 3 months after the implementation of training; therefore, the positive results indicate that integration of MI into sessions with individuals experiencing homelessness presents an excellent potential for enhancing treatment retention and completion rates. To sustain the practice of using MI techniques in working with homeless people, the staff should be able to translate the knowledge gained into the practice environment when working with clients. The posttraining evaluation indicated that staff can apply the acquired knowledge and skills. Coupled with the evidence of increased treatment retention and completion rates, these trends confirm the success of MI integration and the associated positive outcomes with applicability for a range of mental and behavioral health conditions. This outcome is helpful for the project site organization in creating a positive impact on the communities it serves, which is its core mission. Additionally, the project equipped providers with skills that directly benefit the organization in promoting safe and quality care. The project is essential to the organization and beyond as it builds on evidence that supports the use of MI in engaging difficult-to-reach populations. The first limitation encountered was the complex socioeconomic context of homelessness, which acts as a barrier to accessing mental health services. Another limitation was the variability of staff skills, making providing uniform training more difficult. Conclusions With this project, I sought to implement a staff training program on MI to enable mental health providers to gain knowledge and skills in applying MI techniques to work with clients experiencing mental and behavioral health issues. The findings indicated a link between MI techniques and treatment engagement, leading to higher treatment retention and completion rates. Mental health providers need to sharpen their skills in engaging with vulnerable populations, and this project is essential for nursing practice in improving

Download

Included in

Nursing Commons

Share

 
COinS