Theses and Dissertations at Montana State University (MSU)
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Item Implementation of a mental health pre-visit process in a rural primary care clinic: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kaufman, Tori Rae; Chairperson, Graduate Committee: Jamie M. Besel; This is a manuscript style paper that includes co-authored chapters.Background: United States rural residents have limited access to mental healthcare. Nearly half of Montana's population is designated rural. Maximizing resources in resource-deficient regions requires creative strategies and process implementation to streamline workflow to achieve sufficient care. Local Problem: A rural Eastern Montana primary clinic has attempted to address its rural community's limited mental health resources by employing a psychologist. There is no new mental health patient pre-visit process at the project site. The purpose of the project was to implement a pre-visit process to improve the psychologist's ability to effectively care for the patient population. Methods: The Iowa Model Revised guided this quality improvement (QI) project. Process changes evaluations occurred at week three, week six, and postintervention. Interventions: A new mental health patient pre-visit process and packet were created, including a standardized Mental Health History Questionnaire (MHHQ). Educational in-services and staff completion checklists were performed to promote adherence to the process change. Results: The project goals were achieved: 95% of the new mental health patient pre-visit packets were mailed within two days of referral acceptance, 75% of new mental health patients returned their MHHQs, and 100% of staff reviewed and signed the new mental health patient pre-visit process. Conclusion: The project improved the psychologist and staff's new mental health patient workflow process. The psychologist noted an increase in patient preparedness and satisfaction, a decrease in time to diagnosis/treatment, and a slight decrease in the initial mental health evaluation duration.Item Implementation of a school nurse-led anxiety screening protocol within an elementary school: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Sanders, Donna Ruth; Chairperson, Graduate Committee: Margaret Hammersla; This is a manuscript style paper that includes co-authored chapters.Childhood anxiety disorders are becoming increasingly prevalent in the US, with reported cases rising from 7.1% in 2016 to over 9.2% by 2020. This increase is often manifested through somatic symptoms in children, highlighting the urgent need for early detection and intervention, particularly in school settings where these symptoms frequently result in visits to school nurses. In a rural elementary school in Montana, there was a lack of systematic screening for anxiety among students aged 8-12. These students often present with somatic complaints that lack a clear medical diagnosis, leading to under-identification and inconsistent referral practices. The Plan-Do-Study-Act (PDSA) framework guided the implementation of a school nurse-led anxiety screening initiative using the SCARED tool. This project focused on systematic screening of English-speaking students who exhibited recurrent, unexplained somatic symptoms. Key interventions included training the school nurse on the SCARED tool, the establishment of structured screening protocols, and improved communication with parents to meet legislative consent requirements. The initiative was highly successful, achieving a 100% identification rate for students meeting the anxiety criteria, with all positively screened students referred for further support. These results demonstrate a significant enhancement in schools' capacity to manage childhood anxiety. This quality improvement project effectively addressed the rising prevalence of anxiety disorders in elementary students, emphasizing the value of structured, nurse-led screening processes. It successfully met and exceeded the set SMART goals, offering a replicable model for early detection and management of anxiety in schools. This model also highlights the importance of considering somatic complaints as potential indicators of anxiety disorders.Item Implementing peer conducted mental health and wellness checks in rural law enforcement: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2023) Feltz, Cheyenne Jae; Chairperson, Graduate Committee: Molly SecorBackground and purpose: Law enforcement officers in the United States are at a significantly increased risk of suicide and mental health challenges, accompanied with increased perceptions of stigma that limits mental health resource utilization. These trends are even more prominent among rural law enforcement officers compared to their urban counterparts. The purpose of this quality improvement project was to assist a rural law enforcement detachment in decreasing mental health stigma through implementation of peer conducted mental health and wellness check-ins. Methods: Baseline and progressive trends of stigma were assessed through the Attitudes About Mental Illness and its Treatment Scale (AMIS) following implementation of peer conducted proactive mental health support check-ins in the detachment. Intervention: This project utilized peer support law enforcement members to facilitate scheduled check-in's and discuss predetermined mental health topics while facilitating access of additional resources and education that could improve health outcomes. Results: A small rural law enforcement detachment conducted peer facilitated mental health and wellness checks with its full team of six team members. Evaluation of the AMIS assessments and personal feedback indicated that these meetings decreased reports of stigma and increased open discussion of mental health issues. Conclusion: Conclusive support for this intervention cannot be ascertained due to the small sample size and short duration of evaluation. However, this initiative indicates a framework for initiating similar processes in other areas and reveals a promising acceptance and trend of utilization and support by involved law enforcement members.Item Implementation of measurement based care for bipolar disorder: systematic symptom assessment to improve patient care(Montana State University - Bozeman, College of Nursing, 2021) Linster, Rachel Corey; Chairperson, Graduate Committee: Margaret HammerslaMeasurement-based care (MBC) in psychiatry facilitates greater recognition and communication of problematic symptoms. MBC is not commonly utilized in the routine care of individuals with bipolar disorder, resulting in failure to recognize treatment failure or subsyndromal symptoms. The purpose of this project was to improve patient outcomes through implementation of the Altman Self-Rating Mania Scale and Quick Inventory of Depression-Self Report as way to incorporate MBC at a community mental health center. Paper and pencil copies of assessment tools were utilized by clinicians with individuals aged 18 and over with a diagnosis of bipolar 1 or 2 disorder at the beginning of their appointments. Information about assessment tool use was collected via a tracking sheet and reviewed weekly. Of the 11 patients with bipolar disorder seen during the project timeframe, seven completed one or more assessment tool, one patient presentation was not clinically appropriate for assessment tool use, one patient preferred not to respond, and in two instances the provider forgot to use the tools. Utilization of both tools is indicated in order to assess both manic and depressive symptoms. Results support the integration of MBC into the EMR in order to reinforce the process of care. The relatively high use of one tool (5 of 11 times) supports the switch to a single tool to assess both manic and depressive symptoms. The Internal States Scale was identified as the tool that best fits the identified clinical and patient needs.Item Improving treatment of metabolic side effects from atypical antipsychotics(Montana State University - Bozeman, College of Nursing, 2021) Galahan, Alicia Marie; Chairperson, Graduate Committee: Margaret HammerslaAtypical antipsychotics are commonly used to treat a variety of mental health disorders in children and adolescents. Prescribing atypical antipsychotics is not without risk as the development of metabolic side effects can lead to reduced life expectancy from chronic metabolic diseases. The metabolic side effects from atypical antipsychotics are considered treatable medical conditions requiring appropriate screening and intervention. Despite recommendations, psychiatric providers do not consistently screen and treat metabolic abnormalities, creating a gap in care for these individuals. This quality improvement project took place on an adolescent inpatient residential unit. This project focused on incorporating recommendations from clinical practice guidelines by focusing on improving rates of metabolic screening and utilization of treatment interventions when metabolic abnormalities are identified to reduce the burden of metabolic side effects for patients. The Plan-Do-Study-Act framework was used to guide this quality improvement project over six weeks with four separate cycles varying in duration from one to two weeks each. A metabolic screening bundle for psychiatric provider notes was created within the electronic health record to improve ease of interpreting metabolic screening values and identifying need for further intervention. At the end of the quality improvement project, rates of metabolic screening remained unchanged. The rate of patients receiving treatment interventions increased and multiple patients received more than one treatment intervention. Treatment modalities studied included metformin, individual physical activity, and nutritionist consult. This quality improvement project sought to decrease patients experiencing metabolic abnormalities after treatment with atypical antipsychotic medication, but effectiveness was unable to be measured due to the short time frame. Metabolic screening is a necessary part of atypical antipsychotic treatment that needs to be completed upon initiation of medication and at future appointments. Once metabolic screening is completed, further education on potential treatment interventions for metabolic abnormalities needs to be discussed with the patient and other professionals involved in their care to improve patient outcomes.Item Telemental health care: provider's knowledge and beliefs(Montana State University - Bozeman, College of Nursing, 2018) Damberger, Kathleen Gail; Chairperson, Graduate Committee: Susan LuparellUniversity X, a state university in a northwestern state, offers a wide range of health care services for its students, one of which is mental health care. For students living on or near the university's main campus, access to care is generally not a problem. However a majority of nursing students are located on its distant satellite campuses 200 miles or more away, and distance serves as a barrier to access. This barrier to services is especially concerning when a student is experiencing an emergency or crisis, and it could potentially be mitigated by the use of telemental health. The purpose of this DNP project was to explore University X mental health care providers' knowledge and beliefs regarding telemental health. Providers were recruited from the counseling center (CC) and the student health center (SHC) on the University X campus. Providers completed an online survey that examined self-assessed knowledge and beliefs regarding telemental health. Fourteen providers completed the survey; two that identified as previous or current users of telemental health and 12 as nonusers of telemental health. The survey results highlighted the knowledge and beliefs regarding telemental health of both users and nonusers regarding quality of interactions with clients, inconveniences, and licensure. Baseline survey results were presented to the staffs of both agencies, accompanied by a presentation of literature that addressed these concerns and supported the use of telemental health. A follow up survey demonstrated some change in select attitudes.Item Implementation of a quality-improvement project to improve identification of patients at high risk for psychiatric hospitalization(Montana State University - Bozeman, College of Nursing, 2018) Shomate, Heath; Chairperson, Graduate Committee: Susan LuparellReadmission to a psychiatric hospital within 30 days is a common problem. Worldwide, nearly one in seven individuals hospitalized for psychiatric reasons are readmitted within 30 days of discharge. Frequent readmissions in individuals with a psychiatric cause are also problematic in the Western United States. The aim of this DNP project was to use the READMIT tool to determine if it can predict psychiatric readmission within 30 days of hospital discharge. The cohort included in the project were adults 18-years-old and older diagnosed as having a psychiatric disorder that caused them to be admitted to an inpatient psychiatric treatment unit. Data were collected from a 'healthcare organization in a western state' using a retrospective chart review of 50 electronic medical records (EMRs) that were at least one year old. The data were collected on the retrospective dates of 06/24/17, 7/01/17, and 7/08/17. The dates were selected close together so that treatments, providers, and cares would be relatively similar, thus having less of a chance to skew the data. Each of the 50 patient charts was examined and each was given its own separate score generated by the READMIT tool. The READMIT tool's scores ranged from 0 to 41, with higher scores indicating an increased probability for readmission. The mean READMIT score for patients that were readmitted was 23.21 compared with a mean of 17.78 for the group of patients that were not readmitted. Of the charts examined for this study, 14 (28%) of them were readmitted within 30 days. The READMIT index did show that the higher an individual scores, the more likely he or she would be readmitted. The READMIT tool has the potential to enhance psychiatric treatment as it can identify individuals more likely to be readmitted.Item Consumer's knowledge of energy drink ingredient interaction with their prescribed psychotropic medications(Montana State University - Bozeman, College of Nursing, 2017) McRae, Anne Evelyn; Chairperson, Graduate Committee: Donna A. WilliamsEach of the 300+ energy drinks currently on the market has a unique mixture of ingredients. Little is known whether consumers know what ingredients are in their drinks, especially those consumers who also take medications. Particularly consumers who take psychiatric medication can be at risk for adverse events due to potential drug/ingredient interactions. The purpose of this study was to examine energy drink consumer's knowledge of potential ingredient interactions with their mental health medications. In this study, 67% of respondents (n=6) stated they were not aware of any interactions be-tween their psychiatric medications and the ingredients of their energy drinks. An unexpected finding emerged when all respondents made unsolicited comments about their energy drinks being 'bad', although this did not deter them from consumption. If these results are replicated in further studies with larger and more diverse samples, a targeted education initiative for consumer safety could be developed.Item Development of an employer-sponsored health and wellness program(Montana State University - Bozeman, College of Nursing, 2016) Manion, Brenna Christine; Chairperson, Graduate Committee: Teresa Seright; Deanna Babb (co-chair)Obesity is affecting Americans at a higher rate and cost than ever before. This disparity does not evade those who work in hospitals or health professions, as the nursing profession is routinely statistically ranked in the top ten most obese occupations in the United States. Obesity, and its co-morbidities, such as depression, Type 2 diabetes, heart disease, sleep apnea, and chronic joint pain, are associated with higher rates of injury, absenteeism, and poor job performance. The purpose of this project was to analyze the current overall health status of the employees at a community hospital in Western Montana and to use this statistical information to develop a health and wellness program tailored to the identified deficiencies and problem areas. A total of 403 employees, 32% of the total population, participated in voluntary free health screenings. Results of the screenings indicated that 32.3% (n=130) of staff were overweight (BMI 25-29.9), and 25.6% (n=103) were obese (BMI >30). Additionally, 77.4% (n=312) of the screened population reported exercising less than five days per week, while 13.4% (n=54) reported not exercising at all. In regards to daily caloric intake, 63.3% (n=255) of employees are at increased risk for health issues related to poor food choices, while 28% (n=113) are at very high risk. Furthermore, when analyzing mental health, 31.3% (n=126) of employees indicated high levels of stress at work, 20.1% (n=81) indicated they are experiencing two or more major life events that were causing stress, and 16.4% (n=66) reported having a depressed mood, or feeling down, unhappy, and hopeless. These findings demonstrated that this setting is in need of overall health improvement. Through this project, a multifaceted health and wellness program was established to target the identified risk areas, as well as promote overall wellbeing at no cost to the employee. The conclusion of this project is that through the identification of problem areas and creation of the associated interventions, a health conscious work environment that promotes average BMI, healthy eating, balanced mental health, and physical activity provides multiple incentives and benefits to both the individual and the employer (CDC, 2014).Item Determinging support for the HNAP model : an integrative review of the literature(Montana State University - Bozeman, College of Nursing, 2014) Rasmussen, Andrea Dugan; Chairperson, Graduate Committee: Charlene WintersIn 1998 Buehler, Malone, and Majerus used grounded theory to derive the Symptom Action Time-Line (SATL), a linear process involving self-care, lay care, and professional resources used by rural Montana women to respond to physical illness symptoms. In 2010 (O'Lynn), a literature review to determine the level of support for the SATL process resulted in a more circular model called the Symptom Action Process (SAP). An integrative literature review in 2012 was conducted to determine the level of support for the SATL and SAP models, resulting in a revision, named the Health Needs Action Process (HNAP) (Rasmussen, Winters, & O'Lynn, 2013). The HNAP differed from the SATL and SAP in that the term 'symptom' was replaced with 'health need' to reflect a broader spectrum of health demands including psychological needs. All three models, SATL, SAP, and HNAP, were based on studies in the United States (U.S.). The HNAP included studies with women-only and mixed gender samples. The lack of international and male-only samples in the previous work prompted this integrative literature review to determine support for the HNAP model. Key words from the models (rural, rural health, self-care, health needs, health/illness behavior, attitudes/beliefs about self-care, decision-making, self-assessment, alternative therapies, complimentary medicine, and home remedies) were used to search the literature published from 2004-2013 using CINAHL, MedLine, and Psych Info. International studies and those involving men only were included in the new search. Case studies, dissertations, and anecdotal reports were excluded from the integrative review. Inductive and deductive coding was used to identify existing and new concepts/themes. The sample consisted of 17 studies: 29% were from the U.S. (17 states); 71% were conducted outside the U.S. (10 countries). Study samples included 23.5% women, 11.5% men, 65% mixed gender; 29% elderly, 71% adult, 0% children/youth; 71% rural; and 29% compared rural with urban samples. This integrative review provides support for the HNAP model regarding the use of self-care, lay resources, and professional resources when responding to both physical and psychological health needs. Health care providers can use this knowledge to assist rural persons to successfully manage health needs both domestically and internationally.