Date of Conferral

12-17-2024

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Margaret Harvey

Abstract

Executive Summary: Staff Education Project Staff Education to Improve Depression Management Using Mindfulness Meditation Intervention by Ndubuisi Obioha MSN, Walden University, 2021 BSN, Grand Canyon University, 2017 Executive Summary Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University November 2024 Summary The problem of poor depression management guided this quality improvement staff educational project due to treatment nonadherence issues. The providers at the project site had minimal knowledge of self-help interventions that can be used to assist individuals with depression who often face treatment barriers. Failing to address the problem could result in increased healthcare costs due to chronicity and relapses among adults with depression and risks of suicidality. The purpose was to educate the healthcare providers on a mindfulness meditation intervention to improve the knowledge needed by the providers to prescribe the intervention to adults with depression. Six psychiatric nurse practitioners took part in the project. An educational PowerPoint presentation was used to deliver the staff's educational intervention. Pre- and postinterventional knowledge surveys were used to collect knowledge levels from the participants before and after the intervention. The average preintervention knowledge level was 80.00 (SD = 12.65), which increased to 96.67 (SD = 5.16), and the difference was statistically significant (p = .011). The above outcomes support the idea that the project intervention improved the knowledge needed to implement the mindfulness meditation intervention. A recommendation that could be considered is that healthcare providers should prescribe mindfulness meditation to promote holistic treatment and reduce the burden of healthcare disparities on mental healthcare access. The project intervention can promote diversity, inclusion, and equity as it can be implemented as a universal self-care intervention for all individuals with depression. Background Depression management is often stifled by nonadherence to treatment interventions, leading to poor patient outcomes such as relapse and chronicity (Unni et al., 2023). This quality improvement staff educational project was developed to address a gap in depression management. The project site was an outpatient mental healthcare clinic that provided treatment for outcomes such as mood disorders and substance abuse. A provider working at the clinic highlighted that many individuals visiting the clinic have depression diagnoses, but about 40% have challenges with honoring treatment appointments and being adherent to antidepressant regimens. A review of the facility records also supported the outcomes, showing that of the 76 adults with depression diagnoses at the facility, about 30 individuals were nonadherent and failed to follow up with medication refills. The above outcomes guided the recognition of the need to develop and implement a low-cost self-care intervention to assist individuals with depression in managing the condition to promote mental wellness and better health outcomes. Therefore, the practice-focused question guiding the project stated, "Among healthcare providers working at an outpatient clinic, does education on mindfulness meditation among adults with depression aged 18 to 65 years increase the knowledge needed to care for these patients within 6 weeks effectively?" The purpose was to educate the healthcare providers on a mindfulness meditation intervention to improve the knowledge needed by the providers to prescribe the intervention to adults with depression. Several studies have attempted to unravel the challenges contributing to nonadherence. Mu et al. (2022) highlighted that depression contributes to low energy, demotivation, and poor social interactions, which lead to poor treatment compliance. Perceived ineffectiveness, including lack of immediate relief after using antidepressants, along with the social stigma of mental health issues, often discourages individuals from becoming compliant with treatment interventions (Aisenberg-Shafran & Shturm, 2022). Unreliable information on depression and antidepressants, lack of social support, high treatment costs, and lack of adequate patient education and follow-up also contribute to the recalcitrant issue of antidepressant nonadherence (Unni et al., 2023). If the problem of depression treatment nonadherence is not addressed, there could be significant ramifications to individuals, including increased risk of suicidality, increased healthcare costs due to chronicity and relapses, and increased risk of suicidality and substance abuse as a form of self-medication (Calarco & Lobo, 2020; McGovern et al., 2023). Considering the socioeconomic and attitudinal factors impacting antidepressant nonadherence, low-cost, accessible interventions are crucial to assisting many individuals with depression. Serrano-Pérez et al. (2022) highlighted that multifaceted interventions covering the structural aspects of depression healthcare are more effective than single-component interventions. Therefore, an intervention that could be used as a personalized alternative or adjunct to conventional antidepressant intervention may be impactful in promoting depression management. Mindfulness meditation has emerged as a well-known intervention for managing depression (Lopez-Maya et al., 2019). It is a therapeutic practice that focuses on the present moment while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations (Lopez-Maya et al., 2019). The intervention could be integrated with psychotherapy and pharmacotherapy to improve treatment outcomes, including enhancing emotional regulation among adults with depression (González-Valero, 2019). Thus, educating healthcare providers on mindfulness meditation could contribute to improving depression management, especially in adults facing challenges with adherence, social stigma, and demotivation to continue receiving depression treatment. The mindfulness meditation intervention could result in better patient and facility outcomes, including reduced psychiatric emergencies related to untreated depression. The mindfulness meditation intervention was evidence-based, using scholarly evidence supporting its application in depression management to guide its implementation. A literature review involving databases including PubMed, CINAHL, Sage Pub, and the Cochrane Library was conducted. The keywords that guided the literature review were depression management, mindfulness meditation, mindfulness, self-care, and adults. The Johns Hopkins Nursing Evidence-Based Practice appraisal tool was used to appraise the evidence from the retrieved studies (Dang et al., 2021). Eight Level I studies were identified and used in the literature review. Lopez-Maya et al. (2019) and Lynn and Basso (2023) supported the impacts of mindfulness meditation on depression symptoms. When compared to health education, a mindfulness meditation intervention/mindful awareness practices (MAP) was more impactful in reducing depression symptoms among Spanish speakers. The MAP intervention could also be applied in a community setting, as many adults with depression may self-isolate. Therefore, the MAP intervention could promote socialization and group interaction, reducing depression symptoms and providing social support for optimal well-being. In Lynn and Basso (2023), neuroscience-based education on medication was found to be impactful in improving self-compassion and reducing depression symptoms. Mindfulness and self-regulation emerged as crucial aspects of depression management, which led to better treatment outcomes. Mindfulness meditation intervention has holistic benefits for individuals with depression. A study by Zou et al. (2023) revealed that mindfulness intervention reduces anxiety and stress levels and improves sleep quality, a significant determinant of mental well-being. In another study involving a university student sample, a mindfulness meditation intervention contributed to improvements in depressive symptoms and insomnia but resulted in minimal improvements to anxiety outcomes (Gallo et al., 2023). Structured mindfulness interventions have been developed, including the mindfulness-based stress reduction (MBSR) intervention. In a study by Ding et al. (2023), an MBSR intervention reduced depression symptoms by enhancing self-awareness. Similar outcomes were reported by Galante et al. (2021), who highlighted that mindfulness-based programs were impactful in nonclinical settings and, more specifically, among people with subclinical symptoms or with higher risks of depression. The above outcomes support the usability of a mindfulness meditation intervention as a self-care intervention that individuals can use at home to manage depression symptoms. Mindfulness interventions can also be incorporated into eHealth interventions to promote accessibility and convenience. Walsh et al. (2019) highlighted that using mindfulness meditation smartphone apps improved mental health outcomes. Macrynikola et al. (2024) explained that mindfulness intervention contributes to mental health by reducing negative thinking and rumination and improving attention regulation. The available Level I studies reiterated the impacts of mindfulness meditation in reducing depression and could guide the staff education intervention in adopting the evidence-based intervention. Two Level II studies were also included in the literature review and supported the impact of a mindfulness meditation as an evidence-based intervention. González-Valero et al. (2019) highlighted that mindfulness meditation interventions effectively reduced depression, anxiety, and stress and were more impactful than cognitive behavioral therapy by enhancing consciousness. Individuals practicing mindfulness meditation were found to live each moment and pay attention to current experiences without judgment, thus realizing better mental health outcomes. Mindfulness can also improve mental well-being by enhancing emotional regulation and social functioning (Westphal et al., 2021). Overall, the 10 studies included in the literature review supported the project by highlighting that mindfulness meditation was an evidence-based intervention that was impactful in managing depression and a practical self-care intervention for both clinical and nonclinical populations. Staff Education Project Development The staff educational project involved six psychiatric nurse practitioners as the participants. The above participants worked in the project setting in an outpatient mental healthcare clinic. The project leader developed the teaching content as an educational PowerPoint for implementing the staff educational project (Appendix A). The project's primary quantitative outcome was the participants' knowledge levels, which were collected using knowledge surveys (Appendix B). The knowledge survey had 10 questions. Before the project implementation, the validity and usability of the teaching content and knowledge survey were evaluated by submitting the materials to a panel of content experts, which consisted of three nurse practitioners with more than a decade of experience working with adults with depression. The feedback from the panel supported the validity of the above project materials. The educational PowerPoint presentation focused on several aspects. Key to the objectives of the staff educational intervention were challenges with depression management, such as nonadherence to standard treatment interventions, how mindfulness meditation works, and the benefits of mindfulness meditation in managing depression. The project leader implemented two educational sessions to accommodate shift differences among the participants. The educational sessions lasted one and a half hours and were structured to facilitate the collection of knowledge survey data and the implementation of the educational presentation. At the beginning of each educational session, the project leader welcomed the participants and administered the knowledge pre-survey to the participants. After completing the knowledge survey, the participants were educated for a session of 45 minutes that involved an educational PowerPoint on mindfulness meditation for depression management. The educational session was interactive, and the project leader answered several questions from the participants. After the educational session, the project leader administered the knowledge postsurvey to the participants to collect postintervention knowledge outcomes. The pre- and postsurvey outcomes were compiled and entered into a data file on the Statistical Package of Social Sciences (SPSS) version 29 for analysis. A paired samples t test was selected to analyze the pre- and postinterventional knowledge outcomes. Results Pre- and postinterventional knowledge surveys were completed and collected from the six participants who participated in the project. Statistical analysis of the knowledge outcomes using a paired samples t test revealed significant findings. The average preintervention knowledge level was 80.00 (SD = 12.65), which increased to 96.67 (SD = 5.16). The difference was statistically significant after comparing the pre-and postinterventional outcomes (p = .011; see Table 1). Table 1 Paired Samples t Test Comparing Pre- and Postintervention Knowledge Levels Pretest Posttest 95% CI Outcome M SD M SD df t p Staff educational intervention 80.00 12.65 96.67 5.16 5 [-27.51, -5.83] -3.953 .011 Note. N = 6. The staff educational intervention was impactful in improving the knowledge of the psychiatric nurse practitioners concerning mindfulness meditation for depression management. The education on mindfulness meditation could guide psychiatric nurse practitioners in prescribing mindfulness meditation among adults with depression, which could result in better patient outcomes and self-care intervention for depression, thereby reducing the challenges with nonadherence to standardized interventions. Improving depression treatment through mindfulness intervention could improve patient emotional regulation and social functioning, leading to better support and reduced depression symptoms or remission. Increased prescribing of mindfulness meditation intervention as an adjunct for depression management could result in a comprehensive approach to depression management, which could improve patient satisfaction with treatment along with the clinic's brand image. Notably, the clinic's outcomes for depression would improve, thereby leading to increased confidence in the community with the facility's healthcare service delivery. The clinic may also see a reduction in emergencies caused by undermanaged depression, such as increased facility spending on depression management. The staff educational project had a few limitations. The knowledge data were based on self-reported outcomes on the knowledge surveys, which were likely to become influenced by reporting bias and exaggerations, which could reduce the reliability of the project outcomes. The generalizability of the project outcomes could be limited because the project was implemented within a single clinical site, which may have different sociocultural and demographic outcomes compared with other clinical settings in other regions. Although the paired samples t-test analysis was critical in analyzing the project outcomes, the assumption of randomization of the participants was violated as the project used a nonrandomized sample. The sample adequacy for the project was also limited, as only six participants were involved. The minimal sample adequacy may have reduced the rigor of the project outcomes. With the limitations notwithstanding, several outcomes were noted through the project implementation. The staff educational intervention was impactful in improving the knowledge needed by healthcare providers to facilitate the implementation of a mindfulness meditation intervention for depression management. Mental healthcare providers working with adults with depression could promote the use of mindfulness meditation among adults with depression, as the intervention is evidence-based and has been shown to improve depression outcomes. Conclusions It is crucial to promote depression management, as many individuals prematurely discontinue treatment due to issues such as demotivation, lack of social support, high treatment costs, and the stigma of mental health issues (Aisenberg-Shafran & Shturm, 2022; Unni et al., 2023). This project focused on educating healthcare providers on a mindfulness meditation intervention to promote depression management. The education led to improved knowledge of mindfulness meditation, which could be an appropriate intervention to assist adults with depression as it is a low-cost and convenient depression self-care intervention. The intervention can promote healthcare providers' confidence in managing depression by prescribing an evidence-based self-care intervention to assist individuals facing several barriers to depression healthcare, thereby reducing the burden of disease among individuals and facilities. The intervention could improve the available range of interventions for routine depression healthcare, thereby leading to patient-centered interventions and robust support for evidence-based interventions. Several recommendations can be made based on the outcomes of the staff educational project. The project highlighted the importance of self-care interventions that could be utilized as adjuncts to conventional treatments, as many individuals face barriers to treatment. Therefore, healthcare providers working with adults with depression should be aware of the potential challenges that such individuals face and prescribe mindfulness meditation to promote holistic treatment and reduce the burden of healthcare disparities on mental healthcare access. Mental healthcare facilities should ensure the implementation and sustainability of the intervention by monitoring facility outcomes for depression management, holding quarterly meetings to reeducate providers on the need to prescribe mindfulness meditation, and incorporating the intervention as part of the facility's routine interventions for depression management. The mindfulness meditation intervention could contribute to social change by equipping individuals with a self-care intervention for depression management, thereby reducing the burden of depression outcomes such as suicidality, substance abuse, and productivity losses to society (Saka et al., 2023). The mindfulness meditation intervention can promote diversity, inclusion, and equity as it can be used as a universal self-care intervention for all individuals with depression. The intervention is also evidence-based and low-cost, thus reducing the impact of healthcare disparity on accessing depression mental healthcare and promoting health equity. Equipping healthcare providers with the knowledge of a mindfulness meditation intervention may improve the awareness of challenges faced by adults with depression and the need for adjunct interventions such as mindfulness meditation to support such individuals. The intervention can contribute to effective depression treatment, thereby realizing healthy populations.   References Aisenberg-Shafran, D., & Shturm, L. (2022). The effects of mindfulness meditation versus CBT for anxiety on emotional distress and attitudes toward seeking mental health treatment: A semi-randomized trial. Scientific Reports, 12(1), Article 19711. https://doi.org/10.1038/s41598-022-24256-9 Calarco, C. A., & Lobo, M. K. (2020). Depression and substance use disorders: Clinical comorbidity and shared neurobiology. International Review of Neurobiology, 157, 245-309. https://doi.org/10.1016/bs.irn.2020.09.004 Ding, F., Wu, J., & Zhang, Y. (2023). Can mindfulness-based stress reduction relieve depressive symptoms? A systematic review and meta-analysis. Journal of Pacific Rim Psychology, 17, 1-16. https://doi.org/10.1177/18344909221145814 Galante, J., Friedrich, C., Dawson, A. F., Modrego-Alarcón, M., Gebbing, P., Delgado-Suárez, I., Gupta, R., Dean, L., Dalgleish, T., White, I. R., & Jones, P. B. (2021). Mindfulness-based programmes for mental health promotion in adults in nonclinical settings: A systematic review and meta-analysis of randomised controlled trials. Plos Medicine, 18(1), Article e1003481. https://doi.org/10.1371/journal.pmed.1003481 Gallo, G. G., Curado, D. F., Machado, M. P. A., Espíndola, M. I., Scattone, V. V., & Noto, A. R. (2023). A randomized controlled trial of mindfulness: Effects on university students’ mental health. International Journal of Mental Health Systems, 17(1), Article 32. https://doi.org/10.1186/s13033-023-00604-8 González-Valero, G., Zurita-Ortega, F., Ubago-Jiménez, J. L., & Puertas-Molero, P. (2019). Use of meditation and cognitive behavioral therapies for the treatment of stress, depression, and anxiety in students. A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 16(22), Article 4394. https://doi.org/10.3390/ijerph16224394 Lopez-Maya, E., Olmstead, R., & Irwin, M. R. (2019). Mindfulness meditation and improvement in depressive symptoms among Spanish- and English-speaking adults: A randomized, controlled, comparative efficacy trial. Plos One, 14(7), Article e0219425. https://doi.org/10.1371/journal.pone.0219425 Lynn, S., & Basso, J. C. (2023). Effects of a neuroscience-based mindfulness meditation program on psychological health: Pilot randomized controlled trial. JMIR Formative Research, 7(1), Article e40135. https://doi.org/10.2196/40135 Macrynikola, N., Mir, Z., Gopal, T., Rodriguez, E., Li, S., Cox, M., & Torous, J. (2024). The impact of mindfulness apps on psychological processes of change: A systematic review. NPJ Mental Health Research, 3(1), Article 14. https://doi.org/10.1038/s44184-023-00048-5 McGovern, M. P., Dunn, J., Bonnell, L. N., Leibowitz, G., Waddell, E., Rose, G., & Littenberg, B. (2023). The association between depression and substance use among primary care patients with comorbid medical and behavioral health conditions. Journal of Primary Care & Community Health, 14. https://doi.org/10.1177/21501319231200302 Mu, Y., Xu, X., Xu, Y., Dong, D., Zhou, N., Dai, N., & Shen, Z. (2022). Association between self-care disability and depressive symptoms among middle-aged and elderly Chinese people. Plos One, 17(4), Article e0266950. https://doi.org/10.1371/journal.pone.0266950 Saka, M., Bone, L., & Jacobs, R. (2023). The role of mental health on workplace productivity: A critical review of the literature. Applied Health Economics and Health Policy, 21(2), 167-193. https://doi.org/10.1007/s40258-022-00761-w Serrano-Pérez, P., Álvarez, C. R., Bejarano-Quisoboni, D., & Trujillo-Martín, M. M. (2022). Effectiveness of interventions to improve medication adherence in adults with depressive disorders: A meta-analysis. BMC Psychiatry, 22(1), Article 487. https://doi.org/10.1186/s12888-022-04120-w Unni, E. J., Gupta, S., & Sternbach, N. (2023). Reasons for non-adherence with antidepressants using the medication adherence reasons scale in five European countries and United States. Journal of Affective Disorders, 344, 446-450. https://doi.org/10.1016/j.jad.2023.10.010 Walsh, K. M., Saab, B. J., & Farb, N. A. (2019). Effects of a mindfulness meditation app on subjective well-being: Active randomized controlled trial and experience sampling study. JMIR Mental Health, 6(1), Article e10844. https://doi.org/10.2196/10844 Westphal, M., Wall, M., Corbeil, T., Keller, D. I., Brodmann-Maeder, M., Ehlert, U., & Kleim, B. (2021). Mindfulness predicts less depression, anxiety, and social impairment in emergency care personnel: A longitudinal study. Plos One, 16(12), Article e0260208. https://doi.org/10.1371/journal.pone.0260208 Zuo, X., Tang, Y., Chen, Y., & Zhou, Z. (2023). The efficacy of mindfulness-based interventions on mental health among university students: A systematic review and meta-analysis. Frontiers in Public Health, 11, Article 1259250. https://doi.org/10.3389/fpubh.2023.1259250   Appendix A: Educational Presentation   Appendix B: Knowledge Survey 1. What is Mindfulness Meditation? (a) A form of therapy involving medication (b) A relaxation technique focusing on present-moment awareness (c) A physical exercise regimen (d) A dietary intervention? 2. Which of the following is a key benefit of mindfulness meditation for individuals with depression? (a) Improved sleep patterns ( b) Increased physical strength (c) Enhanced concentration and emotional regulation (d) Faster metabolic rate 3. True or False: Mindfulness meditation requires years of practice to be effective in managing depression. 4. What is the primary focus of mindfulness meditation? (a) Future goals ( b) Past experiences (c) Present-moment awareness (d) Problem-solving strategies 5. Which of the following is NOT a component of a typical mindfulness meditation session? (a) Deep breathing exercises (b) Reflecting on future plans (c) Body scan techniques (d) Guided imagery 6. How does mindfulness meditation help in the self-management of depression? (a) By promoting acceptance and reducing negative thought patterns (b) By encouraging individuals to ignore their symptoms (c) By providing immediate relief from all symptoms (d) By replacing the need for any other treatment 7. True or False: Mindfulness meditation can be combined with other treatments for depression, such as medication and psychotherapy. 8. Which age group is being targeted in the PICO(T) question for mindfulness meditation intervention in the context of depression management? (a) 12-18 years (b) 18-65 years (c) 65-80 years (d) 80 years and above 9. In the PICO(T) question, what is the expected outcome of educating healthcare providers on mindfulness meditation? (a) Increased patient visits (b) Increased knowledge needed to effectively care for patients with depression (c) Decreased use of medication (d) Increased administrative workload 10. Over what time period is the effectiveness of the education on mindfulness meditation being assessed in the PICO(T) question? (a) 2 weeks (b) 4 weeks (c) 6 weeks (d) 8 weeks

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