Date of Conferral

4-28-2025

Date of Award

April 2025

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Barbara Barrett

Abstract

Summary Despite the potential benefits of long-acting injections (LAIs) in schizophrenia treatment, current literature reveals a severe knowledge gap among psychiatric practitioners about their use. This knowledge gap may also contribute to underutilizing LAIs in clinical practice and at the project site, reducing patients' access to this effective treatment therapy. This staff education project was developed and conducted to determine if focused education about the use of LAIs in the management of schizophrenia in psychiatric providers improved provider knowledge of their usage. Medication nonadherence in psychiatric patients can result in increased relapse rates and hospitalizations, poor medication adherence, increased healthcare costs, and poor patient outcomes. This staff education project incorporated a pretest and posttest design. Detailed training was provided to participants, and the project data were evaluated using descriptive statistics and a paired t test that revealed a p-value of -7.88, which was < 0.001, indicating statistical significance. Statistically significant improvement in participants’ mean posttest scores following the educational intervention (36.36% to 90.90%) depicted improved provider knowledge, which highlighted the successful outcome of the training program. Improved knowledge can result in improved prescriber confidence, resulting in increased utilization of LAIs in eligible patients and the potential for improved patient adherence to medication, reduced hospitalizations and healthcare costs, reduced patient relapses, and individualized patient-centered care. This project can serve as an exemplar Exfor other projects and facilities desiring to implement an educational program on the safe and effective use of LAIs, which can foster culturally responsive care, reduce health disparities, support equitable treatment for marginalized groups, and positively impact social change, diversity, equity, and inclusion. Background LAIs improve medication adherence, reducing relapse rates and hospitalizations in schizophrenia patients (Kim et al., 2020). Studies show that LAIs significantly increase treatment adherence compared to oral medicines, lowering the risk of nonadherence-related exacerbations (Blackwood et al., 2020; Ozguven & Kir, 2021). Furthermore, LAIs ensure consistent drug administration, reducing plasma level variations and improving therapeutic outcomes (Milz et al., 2023). Psychiatric providers must understand these benefits to improve treatment adherence and efficacy in schizophrenia care. Understanding the distinct characteristics of LAIs enables physicians to adjust treatment regimens to patient needs, maximizing therapeutic response while minimizing adverse effects (de Filippis et al., 2021). LAIs are effective for patients who struggle with medication adherence or prefer less frequent doses, increasing treatment engagement and satisfaction (Blackwood et al., 2020). Despite the potential benefits of LAIs in schizophrenia treatment, data reveal a severe knowledge gap among psychiatric practitioners about their use. This knowledge gap may contribute to underutilizing LAIs in clinical practice, reducing patients' access to this effective treatment method. Furthermore, misconceptions and stigma associated with LAIs among providers may impede their adoption and incorporation into schizophrenia treatment guidelines (Jin et al., 2021; Keenan et al., 2022; Lewis & Rodgers, 2022). Evidence suggests that limited provider awareness of LAIs might lead to underutilization of this effective treatment modality, resulting in higher recurrence rates, hospitalizations, and healthcare costs (Kane et al., 2021; Yu et al., 2021). Without adequate information, providers may rely entirely on oral drugs, ignoring the benefits of LAIs in enhancing treatment adherence and lowering the risk of treatment termination (Lin et al., 2023). As a result, untreated or poorly managed schizophrenia can lead to more prolonged illness duration, higher impairment, and lower quality of life for those affected (Schwarz et al., 2022). Failure to address psychiatric provider education on LAIs may prolong treatment gaps, aggravate disease burden, and stymie progress toward optimum schizophrenia therapy, which was the issue at the intended project site. Project Question and Purpose As a result of the lack of staff knowledge on the use of LAIs, a staff education project was conducted to answer the following project question: Did educating psychiatric providers regarding the use of LAIs in the management of schizophrenia increase their knowledge about the use of these injections? The project aimed to improve the knowledge scores of psychiatric prescribers regarding LAIs utilizing an educational intervention. Improved provider knowledge can improve patient care and outcomes, improve medication adherence, provide personalized therapy, reduce relapse rates and hospitalizations, maximize therapeutic response while minimizing adverse effects, foster patient-centered care, and allow effective patient education and collaborative decision-making. We hope that with this newly gained knowledge, providers can dispel myths, reduce fears, and promote informed treatment choices through comprehensive education, resulting in increased treatment acceptance among schizophrenia patients. Gap in Practice Evidence suggests that limited provider awareness of LAIs might lead to underutilization of this effective treatment modality, resulting in greater rates of recurrence, hospitalizations, and healthcare costs (Kane et al., 2021; Yu et al., 2021). According to studies, psychiatric practitioners lack knowledge regarding LAIs, including their efficacy, suitable patient selection, and delivery practices (Blackwood et al., 2020; Correll, 2020; de Filippis et al., 2021; Haddad & Correll, 2023; Lin et al., 2023; Linden Mayer et al., 2020; Ratna, 2021; Schwarz et al., 2022). The practice gap identified in the literature also applied to the project site. Evidence Supporting Change Training psychiatric practitioners about LAIs promotes a thorough awareness of these formulations' complex pharmacokinetics and pharmacodynamics (Sreeraj et al., 2022). Lewis and Rodger (2022) established that educational intervention improved the total knowledge, attitudes, and practice competency of psychiatric prescribers. Addressing these knowledge gaps through focused educational interventions is critical for increasing clinicians' expertise and confidence in implementing LAIs into routine clinical practice, eventually improving patient outcomes and quality of care (Mahlich et al., 2021; Ozguven & Kir, 2021; Ratna, 2021; Schwarz et al., 2022). Project-related keywords and Boolean commands were used to conduct a comprehensive literature search. Keywords included psychiatric providers, long-acting injections, schizophrenia, knowledge, awareness, and knowledge regarding long-acting injections. Various databases, including Google Scholar, Walden University Library, Cochrane Library, Ovid, PubMed, Embrace, IHI, AHRQ, CINAHL, and EBSCOhost, were searched for peer-reviewed relevant and current literature dating back to 2020. The search results revealed 108 articles, out of which 24 were appropriate, and ultimately 10 articles were chosen as the most relevant to the topic. Of the 10 articles selected, four were level II, four were level III, and two were level V. Staff Education Project Development A global practice gap relating to the current level of knowledge among psychiatric providers was identified, and that practice gap was also identified as the project site. Current practices at the psychiatric clinic were observed, and gaps in knowledge regarding LAIs were noted and fueled the development of this targeted educational program. Participants Six psychiatric providers, two psychiatrists, and four psychiatric nurse practitioners working at the community-based mental healthcare organization participated in the staff education program. Both phone calls and emails were used to send out invitations to facility staff. Each invitation included information about the project, such as the aim of the project, justification, benefits, and a schedule of educational intervention. Participation was voluntary, and the participants were informed that completing the pretest would serve as their consent to participate in this program. To preserve confidentiality, participants were provided a unique identifier to ensure no sensitive or identifying information was obtained. Procedure The staff educational program incorporated a pretest/posttest questionnaire and other training material garnered from current evidence-based literature about the use of LAIs in the treatment of schizophrenia. An expert panel that included a psychiatrist, a psychiatric nurse practitioner, and the project mentor provided feedback on the content of the educational program, and changes were made accordingly. The pretest/posttest is reflected in Appendix A. The educational intervention included a PowerPoint presentation with learning objectives, interactive discussions, and a question-answer session. The PowerPoint presentation is reflected in Appendix B. The data obtained were analyzed using SPSS Version 26 and descriptive statistics. A paired t test was conducted to evaluate the change in knowledge based on the pretest and posttest scores. After participants completed the posttest, a program evaluation was provided to gather feedback about the overall program. The program evaluation is in Appendix C. Results Six providers participated in the educational program, of which two were psychiatrists and four were psychiatric nurse practitioners. Analysis of the participants’ pre- and posttest scores revealed that after the educational intervention, participants successfully improved their posttest scores, which translated to improved knowledge. The participant pre- and posttest scores are reflected in Table 1. Table 1 Preintervention and Postintervention Participant Scores Participants Pretest score Posttest score % improvement Participant 1 4 10 54.54 Participant 2 3 11 72.72 Participant 3 5 9 36.36 Participant 4 4 10 54.54 Participant 5 3 9 54.54 Participant 6 5 11 54.54 Following educational intervention, the mean posttest score improved to 90.90% (SD = 8.13) based on a minimum score of 81.81% and a maximum score of 100%, from a mean pretest score of 36.36% (SD = 8.13). (See Table 2.) To evaluate the strength of change, a paired t test was used and revealed a p-value of < 0.001, indicating a statistically significant change in score after the educational intervention. The T statistic was noted to be -7.88, with a statistically significant positive change in posttest scores, signifying the successful implementation of educational intervention. A graphical depiction of the pretest and posttests scores is reflected in Figure 1. Table 2 Pre- and Postintervention Scores for Psychiatric Providers on LAI Use for Schizophrenia Statistics Pretest Posttest Mean (%) 36.36 90.90 Standard deviation 8.13 8.13 Min (%) 27.27 81.81 Max (%) 45.45 100 Variance 66.11 66.11 Figure 1 Change in Pretest and Posttest Scores Following Educational Intervention on LAIs in Six Psychiatric Providers Based on program evaluation, participants’ improved knowledge was highlighted in the following areas: advantages of antipsychotics LAIs over oral medication, issues that revolve around medication reconciliation in long-term care centers, and various generations and formulations of LAIs. The participants also showed improved knowledge about the criteria for LAI use in any patient, and they were able to determine the candidates who were most suitable for LAI treatment. Participants were more knowledgeable about the challenges associated with LAI use and proper administration methods. Organizational Impact The project has the potential to positively impact the organization through improved adherence to medication in patients resulting from improved confidence amongst prescribing professionals in incorporating LAIs into patients’ treatment. Increased provider knowledge can translate into improved confidence amongst psychiatric professionals prescribing LAIs, which has the potential to reduce hospitalizations, reduce patient relapses, provide crisis intervention options, and improve patient outcomes. By decreasing hospital readmissions for mental emergencies, LAIs can reduce the total need for inpatient treatment, resulting in greater economical and effective uses of hospital resources, like staff, beds, and expenses. Providers can furnish patient-centered care and individualize treatment plans, leading to decreased side effects and improved compliance. Starting and monitoring LAIs can be expedited with improved provider understanding, which lessens the need for frequent prescription modifications and thorough patient follow-ups, enabling medical professionals to concentrate on other patient needs. Focused education gives psychiatric providers the abilities and information needed to employ the use of LAIs successfully, boosting their confidence in making treatment decisions. Ongoing educational efforts in the facility can foster professional development and improve job satisfaction, which can reduce staff turnover and increase employee retention. Educating staff can lead to the uniform adoption of evidence-based procedures across the organization, enhancing the quality of care offered to patients diagnosed with schizophrenia. Organizations that successfully implement innovative treatments like LAIs can be seen as leaders in the field of mental care, which can improve the business's standing and attract clients (Blackwood et al., 2020). By keeping healthcare professionals abreast of the most recent clinical recommendations and standards for managing schizophrenia, focused education can enhance the practice of evidence-based medicine in the organization. By ensuring that LAIs are used appropriately, liability can be minimized by lowering potential malpractice risks, improving documentation, and enhancing the organization’s stance on the commitment to providing patients with safe, high-quality treatment and compliance with local regulations and laws. I hope the project will help the healthcare team adopt a culture of evidence-based practice. Successful execution of this project can serve as a foundation for future internal training initiatives. Limitations Small sample sizes limit the generalizability of findings, reduce the power of statistical tests, and lead to questions regarding the assumptions of t tests, making population estimates less reliable (Delacre et al., 2017). Voluntary participation can cause bias because those who choose to participate may be more interested in or more knowledgeable about the educational content, decreasing external validity. Concerns over the project's sustained efficacy beyond the initial postintervention period are further raised by the short-term evaluation's disregard for the project's long-term durability and impact on clinical practices. Impact Beyond Local Site The project's positive findings can address worldwide difficulties in schizophrenia management, which supports the project’s significance beyond the local site. With a 1% global prevalence, schizophrenia is a severe and persistent mental illness (Moreno-Küstner et al., 2018). Medication nonadherence is a major problem, which raises the risk of relapse, increases hospital stays, and has a negative impact on clinical outcomes. Reducing relapse rates, guaranteeing medication compliance, and enhancing patient outcomes are possible through LAI treatment. Misconceptions regarding side effects, complexity, and patient preference are among the obstacles to LAI adoption that can be addressed by improving provider expertise through organized education. Disseminating the project findings has the potential to positively impact worldwide optimal methodologies, assisting mental health practitioners in providing more efficient and customized treatment regimens to mitigate the public health impact of schizophrenia. Conclusion The project's organizational impact can include improved medication adherence, improved confidence in prescribing LAIs, reduced hospitalizations and healthcare costs, reduced relapses, crisis interventions, improved patient outcomes, effective use of hospital resources, patient-centered care, and improved healthcare quality. Further Recommendations Following the successful implementation of the project, it was imperative to include the following recommendations: • Consider LAI-focused training through mandatory educational programs for psychiatric providers to ensure sustained knowledge and enhance competency. • Encourage psychiatric practitioners to work with pharmacists, nurses, and case managers to improve LAI administration and follow-up care. • Education about the benefits of LAIs over oral drugs, especially in terms of enhancing adherence and lowering relapse rates, should be a part of future treatments for patients and caregivers. • To improve and customize therapies, regular evaluations of barriers—such as expense, stigma, and patient or provider opposition to LAIs—should be carried out. • Initiate future quality improvement projects or studies to assess the impact of expanding the use of LAI on hospitalization rates, relapse prevention, overall cost, and long-term staff knowledge retention. Implications for Nursing Practice Implications for nursing practice include better communication, more individualized care plans, increased patient participation and adherence to treatment, and greater engagement strategies catered to each patient's individual needs. The American Nurses Association's emphasis on holistic care is in line with the fundamental nursing ideal of patient-centered care, which is directly supported by this project. Implications for Positive Social Change The project's emphasis on educating healthcare professionals about the use of LAIs in managing schizophrenia fosters a culture of understanding, which is essential for creating an inclusive healthcare environment. Health inequalities can be decreased in psychiatric patients by comprehending the barriers that result in the underutilization of LAIs and the needs of underprivileged and minority populations. A more equitable care environment where all patients, regardless of their background, feel valued and understood can be achieved by lowering prejudices and presumptions about patient behavior through increased staff education. This project can potentially encourage similar initiatives in other mental health settings, which might lead to larger social change. By reducing obstacles to treatment and fostering broad adoption of educational initiatives on LAI use, we can support health equity, diversity, and inclusion.   References Blackwood, C., Sanga, P., Nuamah, I., Keenan, A., Singh, A., Mathews, M., & Gopal, S. (2020). Patients’ preference for long-acting injectable versus oral antipsychotics in schizophrenia: Results from the patient-reported Medication Preference Questionnaire. Patient Preference and Adherence, 2020(14), 1093–1102. Correll, C. U. (2020). Using patient-centered assessment in schizophrenia care: Defining recovery and discussing concerns and preferences. The Journal of Clinical Psychiatry, 81(3), Article 26418. https://doi.org/10.4088/jcp.ms19053br2c de Filippis, R., De Fazio, P., Gaetano, R., Steardo, L., Cedro, C., Bruno, A., Zoccali, R. A., & Muscatello, M. R. A. (2021). Current and emerging long-acting antipsychotics for the treatment of schizophrenia. Expert Opinion on Drug Safety, 20(7), 771–790. https://doi.org/10.1080/14740338.2021.1910674 Delacre, M., Lakens, D., & Leys, C. (2017). Why psychologists should by default use Welch's t-test instead of Student's t-test. International Review of Social Psychology, 30(1), 92–101. Haddad, P. M., & Correll, C. U. (2023). Long-acting antipsychotics in the treatment of schizophrenia: Opportunities and challenges. Expert Opinion on Pharmacotherapy, 24(4), 473–493. https://doi.org/10.1080/14656566.2023.2181073 Jin, L., Chen, Y., Zhu, J., Huang, Q., Li, B., Xu, Y., & Lu, W. (2021). The willingness of community psychiatric management physicians to preferentially recommend long-acting injections in Beijing. Frontiers in Public Health, 9, Article 779563. https://doi.org/10.3389/fpubh.2021.779563 Kane, J. M., McEvoy, J. P., Correll, C. U., & Llorca, P. M. (2021). Controversies surrounding the use of long-acting injectable antipsychotic medications for the treatment of patients with schizophrenia. CNS Drugs, 35(11), 1189–1205. https://doi.org/10.1007/s40263-021-00861-6 Keenan, A., Lin, D., Shepherd, J., Bailey, H., Benson, C., & Meakin, S. (2022). Patient-psychiatrist discordance and drivers of prescribing long-acting injectable antipsychotics for schizophrenia management in the real-world: A point-in-time survey. BMC Psychiatry, 22(1), Article 187. https://doi.org/10.1186/s12888-022-03846-x Kim, H. O., Seo, G. H., & Lee, B. C. (2020). Real-world effectiveness of long-acting injections for reducing recurrent hospitalizations in patients with schizophrenia. Annals of General Psychiatry, 19, Article 1. https://doi.org/10.1186/s12991-019-0254-2 Lewis, L., & Rodgers, J. (2022). Development and evaluation of a web-based educational toolkit on the knowledge, attitudes, and practices of psychiatric prescribers regarding long-acting injectable antipsychotics. Journal of the American Psychiatric Nurses Association, 28(2), 117–127. https://doi.org/10.1177/10783903221075651 Lin, Y. Y., Hou, W. L., & Lin, M. L. (2023). Psychiatric nurses’ knowledge and practice barriers to administering long-acting injectable (LAI) antipsychotics in Taiwan: A mixed-methods study. Healthcare, 11(12), Article 1670. https://doi.org/10.3390/healthcare11121670 Lindenmayer, J. P., Glick, I. D., Talreja, H., & Underriner, M. (2020). Persistent barriers to the use of long-acting injectable antipsychotics for the treatment of schizophrenia. Journal of Clinical Psychopharmacology, 40(4), 346–349. https://doi.org/10.1097/jcp.0000000000001225 Mahlich, J., Olbrich, K., Wilk, A., Wimmer, A., & Wolff-Menzler, C. (2021). Time to treatment discontinuation in German patients with schizophrenia: Long-acting injectables versus oral antipsychotics. Clinical Drug Investigation, 41, 99–113. https://doi.org/10.1007/s40261-020-00990-8 Milz, R., Benson, C., Knight, K., Antunes, J., Najarian, D., Lopez Rengel, P. M., Wang, S., Richarz, U., Gopal, S. & Kane, J. M. (2023). The effect of longer dosing intervals for long-acting injectable antipsychotics on outcomes in schizophrenia. Neuropsychiatric Disease and Treatment, 19, 531–545. Moreno-Küstner, B., Martín, C., & Pastor, L. (2018). Prevalence of schizophrenia and psychotic disorders in Europe. International Journal of Social Psychiatry, 64(5), 407–418. Ozguven, H. D., & Kir, Y. (2021). Long-acting injectable antipsychotics in the treatment of schizophrenia and bipolar disorder. Archives of Neuropsychiatry, 58(Suppl. 1), 47–53. https://doi.org/10.29399/npa.27480 Ratna, L. (2021). Knowledge and attitudes to relapse prevention in schizophrenia among clinical staff—A limiting factor in care delivery. IOSR Journal of Dental and Medical Sciences, 20(11). Schwartz, S., Carilli, C., Mian, T., Ruekert, L., & Kumar, A. (2022). Attitudes and perceptions about the use of long-acting injectable antipsychotics among behavioral health practitioners. Mental Health Clinician, 12(4), 232–240. https://doi.org/10.9740/mhc.2022.08.232 Sreeraj, V. S., Shivakumar, V., Rao, N. P., & Venkatasubramanian, G. (2022). Long-acting drug delivery systems for schizophrenia treatment. In E. Larrañeta, T. R. R. Singh, & R. F. Donnelly (Eds.), Long-acting drug delivery systems (pp. 203–222). Woodhead. https://doi.org/10.1016/B978-0-12-821749-8.00009-4 Yu, W., Tong, J., Sun, X., Chen, F., Zhang, J., Pei, Y., Zhang, T., Zhang, J. Zhang, T., Zhang, J. & Zhu, B. (2021). Analysis of medication adherence and its influencing factors in patients with schizophrenia in the Chinese institutional environment. International Journal of Environmental Research and Public Health, 18(9), Article 4746. https://doi.org/10.3390/ijerph18094746   Appendix A: Pretest/Posttest Questionnaire To support confidentiality, please do not write your name on the document. A unique identifier (UI) will be provided to ensure that your pretest and post-test are aligned. Thank you again for agreeing to participate in this educational intervention. ID: ___________________ Date: ____________________ 1. What are some advantages of long-acting injectable antipsychotics (LAIs) over oral medications? A) Increased risk of relapse B) Higher bioavailability C) Improved taste D) Greater risk of adverse events 2. Which generation of long-acting injectable antipsychotics (LAIs) is associated with movement-related side effects and long-term cognitive impairment? A) First generation B) Second generation C) Third generation D) Fourth generation 3. According to professional guidelines, who are the ideal candidates for LAIs? A) Patients with mild symptoms B) Patients with low risk of relapse C) Young patients with recent-onset schizophrenia D) Patients with a history of medication adherence 4. What is a common challenge associated with the administration of LAIs? A) Limited availability of injection sites B) Requirement for daily dosing C) Potential for oral supplementation D) Injection site pain and discomfort 5. What is the primary criterion for selecting candidates for LAIs? A) History of medication adherence B) High risk of extrapyramidal side effects C) History of non-adherence to oral medications D) Low risk of relapse or hospitalization 6. Among the listed second-generation LAIs, which one is available in a 6-month formulation? A) Aripiprazole at 1 month B) Paliperidone palmitate (PP6M) C) Risperidone RBP-7000 D) Aripiprazole lauroxil (AL) 7. What advantage do LAIs offer over oral medications in schizophrenia management? A) Higher bioavailability B) Lower cost C) Improved adherence rates D) Faster onset of action 8. Proper administration procedures for LAIs involve: A) Oral supplementation B) Injection into the intravenous (IV) line C) Meticulous injection site selection and rotation D) Administration without training for healthcare providers 9. Which of the following is NOT a potential barrier to the use of LAIs in schizophrenia management? A) Limited availability B) History of oral anti-psychotics C) Socioeconomic factors D) Cultural beliefs 10. What role does communication play in LAI treatment? A) To increase medication costs B) To reinforce stigma C) To address treatment-related concerns and foster adherence D) To discourage patient engagement   Appendix B: PowerPoint Presentation Please click on the picture above to open the whole file   Appendix C: Program Evaluation On a scale of one to seven, with 1 = “strongly agree” and 5 = “don’t agree”, please indicate your level of awareness of: 1= strongly agree, 2= agree, 3= neural, 4- disagree, 5= strongly disagree. 1. The objectives of the program were met. 2. The speaker was knowledgeable about the topic 3. My knowledge of Generations of Long-Acting Injections has been increased 4. My knowledge about the Rationale for using Long-Acting Injections has improved 5. I have a better understanding of Who is a potential candidate for getting LAIs 6. I understand the Potential side effects of LAIs. 7. I know the Sites of administration for LAIs 1. Additional comments? _________________________________________________________________ 2. Additional comments?

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