A QUALITY IMPROVEMENT PROJECT TO BOLSTER PSYCHIATRIC ADVANCE DIRECTIVE UTILIZATION IN COMMUNITY MENTAL HEALTH by Laira Lee Fonner A scholarly project submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice in Psychiatric Mental Health MONTANA STATE UNIVERSITY Bozeman, Montana May 2024 ©COPYRIGHT by Laira Lee Fonner 2024 All Rights Reserved ii ACKNOWLEDGEMENTS I'd like to thank the Pitman family: Doug, Carolyn, Elizabeth, and my husband, Adam, for their unwavering love and support. I'd like to thank Dr. Shannon Scally, my mentor, friend, and colleague, who guided me to the finish line with compassion and generosity beyond measure. I'd like to thank my instructors and faculty who worked tirelessly to promote my intellectual growth and development, and my peers who inspired me to achieve excellence while providing friendship and support. I am deeply grateful to Drs. Lindsay Benes and Carrie Miller, my project team members, for their guidance throughout the development and implementation of my DNP project and paper this past year. I felt fortunate to collaborate with scholars possessing equal parts kindness, wisdom, and knowledge. Finally, I'd like to acknowledge my mom, Suzanne Perkins Miller, for instilling in my sister and me a commitment to applying ethics and compassion in all interactions, an understanding of the equal values of science, knowledge, and wisdom, and the ability to live with gratitude. iii TABLE OF CONTENTS 1. INTRODUCTION .......................................................................................................................1 Review of the Literature ..............................................................................................................3 Search Strategy ...............................................................................................................4 Eligibility Inclusion and Exclusion Criteria .................................................................. 4 Results ............................................................................................................................ 4 Discussion and Conclusion ......................................................................................................... 8 2. QUALITY IMPROVEMENT PROPOSAL ................................................................................9 Problem Statement .....................................................................................................................10 Organizational Microsystem Assessment .................................................................................. 11 Quality Improvement Model/Framework ..................................................................................12 Project Purpose and Aims ..........................................................................................................13 Methods......................................................................................................................................13 Interventions and Implementation ...............................................................................14 Evaluation and Analysis ...............................................................................................16 Safety and Confidentiality .........................................................................................................16 3. A QUALITY IMPROVEMENT PROJECT TO BOLSTER PSYCHIATRIC ADVANCED DIRECTIVE UTILIZATION IN COMMUNITY MENTAL HEALTH ..........................................................18 Contribution of authors and co-authors .....................................................................................18 Manuscript information .............................................................................................................19 Introduction ................................................................................................................................20 Clinical Problem .........................................................................................................20 Review of Literature ..................................................................................................................20 Conceptual Framework ..............................................................................................................21 Aims ...........................................................................................................................22 Methods......................................................................................................................................23 Project Team ..............................................................................................................23 Interventions ..............................................................................................................23 PSS Training .....................................................................................................23 Peer-facilitated Events ......................................................................................23 Measures ....................................................................................................................................23 Ethical Considerations ...............................................................................................................26 Results ........................................................................................................................................26 Discussion ..................................................................................................................................27 Limitations .................................................................................................................28 Recommendations ......................................................................................................29 Conclusions ................................................................................................................................32 iv TABLE OF CONTENTS CONTINUED 4. HOW THE DNP PROGRAM ALLOWED ME TO MEET DNP ESSENTIALS .........................................................................................33 Scientific Underpinnings for Practice .......................................................................................33 Organizational and Systems Leadership for Quality Improvement and Systems Thinking ...........................................................................34 Clinical Scholarship and Analytical Methods for Evidence-Based Practice ......................................................................................36 Information Systems and Patient Care for the Improvement and Transformation of Healthcare ......................................................................37 Health Care Policy for Advocacy in Healthcare .......................................................................37 Conclusion ................................................................................................................................38 REFERENCES CITED ..................................................................................................................40 APPENDIX: EVENT OUTCOMES ..............................................................................................45 v LIST OF TABLES Table Page 1. Event Outcomes ................................................................................................................ 45 vi ABSTRACT Background: This quality improvement (QI) project aimed to increase Psychiatric Advance Directive (PAD) use in a community mental health organization serving clients with severe mental illness (SMI). PAD utilization has been shown to decrease involuntary hospitalization rates and associated coercive treatments, such as forced medication and seclusion and restraint for this vulnerable patient population. Local Problem: In Montana, busy clinicians rarely offer PAD education and assistance to clients with SMI. However, studies have demonstrated increased PAD utilization followed by reduced involuntary hospitalization rates for clients receiving these services from Peer Support Specialists (PSSs). PSSs are trusted employees with SMI working in outpatient mental health facilities. Methods: This quality improvement project established a repeatable PAD implementation workflow in an outpatient mental health care organization where PSSs were trained to facilitate PAD support events. Interventions: Interventions included hosting three online training workshops for PSSs followed by peer- facilitated events to offer client education and assistance in PAD completion. Event attendees were asked to complete event feedback surveys. Results: All invited PSSs attended one of the three online training workshops (n=X). X clients attended peer-facilitated events of X invited. Only two clients completed documents during the peer- facilitated events. Five clients started documents and wished to complete them later. None of the attendees completed event feedback surveys. Conclusions: The project successfully increased PAD awareness and utilization for PSSs and clients with SMI. The project team successfully established a repeatable workflow to bolster PAD use and generated organizational enthusiasm to continue utilization efforts. 1 INTRODUCTION The National Institute on Mental Health (NIMH) (2023) estimates that 14.1 million adults in the United States have a serious mental illness (SMI). SMI is a mental, behavioral, or emotional disorder causing serious functional impairment and alternating periods of symptom severity and stability (Avila & Leeper, 2022). Individuals with SMI are at high risk of involuntary hospitalizations and associated coercive treatments such as forced medications and seclusion and restraint (Wasserman et al., 2020). Involuntary hospitalizations and coercive treatments are trauma-inducing and pose ethical dilemmas related to patient autonomy, beneficence, and non-maleficence (Haddad & Geiger, 2023). Furthermore, mental health hospitalizations in the United States cost more than 5.6 billion dollars annually and represent more than 7 percent of total emergency department visits (Karaca & Moore, 2020). The utilization of psychiatric advance directives (PADs) has been shown to reduce involuntary hospitalization rates by up to 25% (Molyneaux, 2019) and decrease the incidence of coercive treatments (Easter et al., 2020; Tinland et al., 2022). The Patient Self-Determination Act of 1990 mandated that hospitals receiving federal funding inform patients about medical advance directives (ADs) which allow individuals to document end-of-life treatment preferences (Teoli & Ghassemzadeh, 2022). Shortly after that, PADs were developed, allowing individuals with SMI the ability to express preferences for treatment in the event of a mental health crisis. PAD utilization increases autonomy and empowerment and motivates treatment adherence (Joint Commission, 2020; Stephenson et al., 2020; Tinland et al., 2022). The use of PADs in community mental health facilities supports a commitment to patient-centered care and improves therapeutic alliances between providers and patients (American Psychiatric Association, 2023). 2 PADs are endorsed by organizations such as the National Alliance on Mental Illness (NAMI), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the American Psychiatric Association (APA) (APA, 2023; NAMI, 2023; SAMHSA, 2019). In 2006, the Centers for Medicaid and Medicare (CMS) mandated that facilities receiving CMS reimbursements for psychiatric services offer patients information on PADs and assistance completing them (CMS, 2006). Despite this mandate, PADs remain underutilized. Also referred to as mental health advanced directives, behavioral health advanced directives, and joint crisis plans (JCPs), efforts to bolster PAD use are ongoing in several countries, including India, England, New Zealand, Germany, the Netherlands, and Australia. In the United States, 27 states have developed specific legislation regarding PAD use (National Resource Center on Psychiatric Advance Directives, 2023). However, despite known benefits, several barriers continue to prevent widespread utilization, such as poor awareness and education for stakeholders, the lack of a clearly defined process for PAD utilization, and skepticism regarding benefits (Lenagh et al., 2021). PADs are not easy to complete, and most individuals require assistance due to document lengthiness and confusing medical and legal jargon. Psychiatric providers often lack the time and resources to offer PAD education or assist in documentation (Easter et al., 2017). Peer support specialist (PSS) facilitation has been shown to overcome most barriers to PAD implementation (Easter et al., 2017). PSSs are community mental health care workers in recovery from SMI. Due to lived experience and established therapeutic alliances within the outpatient mental health community, PSSs are well-equipped to facilitate PAD utilization efforts (Easter et al., 2017). PADs completed with the assistance of PSSs receive higher expert ratings 3 measuring feasibility and consistency (Belden et al., 2022). Moreover, recipients of peer- facilitated PAD support report improvements in autonomy and empowerment, improved therapeutic alliances, and improved recovery with fewer mental health symptoms (Stephenson et al., 2020; Tinland et al., 2022). Review of the Literature A search for peer-reviewed literature was conducted in September 2023 in four databases--Google Scholar, PsycInfo, PubMed, and CINAHL. A health sciences librarian assisted with establishing the keywords and constructing Boolean operators. The keywords used for the search included “psychiatric advance directives'' OR “behavioral health advance directives”, “mental health directives” OR “crisis planning” OR “self-binding directive” OR “Ulysses contract,” mental healthcare, crisis interventions, psychiatric crisis, shared decision- making, psychiatric disability, mental incapacity, and mental illness recovery. The search aimed to discover the most efficacious evidence-based interventions to increase PAD utilization for adults with SMI. Items included were published within the last 5 years, written in English, peer-reviewed, in full text, and with study participants aged 18 and older at risk of involuntary hospitalization. Items were excluded if they only discussed problems, barriers, or the history of PADs without a discussion on implementation strategies. Items discussing medical advance directives (ADs) were also excluded due to different targeted patient populations (end-of-life care versus mental health crisis care). 4 Search Strategy A search for peer-reviewed literature was conducted in September 2023 in four databases--Google Scholar, PsycInfo, PubMed, and CINAHL. A health sciences librarian assisted with establishing the keywords and constructing Boolean operators. The keywords used for the search included “psychiatric advance directives'' OR “behavioral health advance directives”, “mental health directives” OR “crisis planning” OR “self-binding directive” OR “Ulysses contract,” mental healthcare, crisis interventions, psychiatric crisis, shared decision- making, psychiatric disability, mental incapacity, and mental illness recovery. The search aimed to discover the most efficacious evidence-based interventions to increase PAD utilization for adults with SMI. Eligibility–Inclusion and Exclusion Criteria Items included were published within the last 5 years, written in English, peer-reviewed, in full text, and with study participants aged 18 and older at risk of involuntary hospitalization. Items were excluded if they only discussed problems, barriers, or the history of PADs without a discussion on implementation strategies. Items discussing medical advance directives (ADs) were also excluded due to different targeted patient populations (end-of-life care versus mental health crisis care). Results The database search resulted in 3,425 items. After inclusion and exclusion filters were applied, 90 items remained. The remaining items were manually searched, and duplicates were removed. Eight items meeting the criteria for this review remained (see Figure 1). The reviewed items included four randomized controlled trials (Easter et al., 2017; Easter et al., 2021; Rixe et 5 al., 2023; Tinland et al., 2022; Tinland et al., 2023), a mixed methods pilot study (Stephenson et al., 2022), and two systematic reviews (Braun et al., 2023; Stephenson et al., 2020). All study participants were adults (18 and older) with SMI (schizophrenia, schizoaffective disorder, or bipolar disorder) receiving psychiatric care services in inpatient or outpatient mental health facilities. Four studies reported positive consumer perceptions of PAD utilization, including improved autonomy and empowerment, and strengthened therapeutic alliances (Tinland et al., 2022; Easter et al., Stephenson et al., 2020; & Braun et al., 2023). Rixe et al., 2023 compared hospital admission rates (involuntary and voluntary) and hospital length of stay (LOS) between a group of individuals utilizing Joint Crisis Plans (JCPs) (Germany’s version of PADs) and a group utilizing only crisis cards (CCs). CCs are credit card- sized, laminated documents containing contact information of designated agents or trusted providers and preferences for treatment during a psychiatric crisis (SAMHSA, 2023). While no current evidence supports the effectiveness of CCs in improving outcomes for individuals with SMI, CCs are considered a practical communication tool. No change in hospital admission rates, LOS, or coercive treatments was found between groups. However, improved treatment team confidence and increased participation in treatment procedures were observed in the JCP group. Tinland et al., 2022 also compared involuntary and voluntary hospitalization rates in participants with SMI receiving assistance completing PADs by peer support specialists (PSSs) versus participants receiving no support (as usual care). The supported group experienced decreased involuntary admission rates and LOS but no change was observed in overall hospitalization rates (involuntary and voluntary admission rates combined and compared to the previous year). Supported participants also experienced higher recovery scores marked by fewer mental health 6 symptoms and improved empowerment but no significant differences were observed in therapeutic alliance or quality of life after 12 months. The same group of researchers compared treatment costs between the two groups at 12 months post-intervention and observed reduced annual costs for the supported group (Tinland et al., 2023). A systematic review of 13 articles demonstrated high consumer interest in PADs (Braun et al., 2023; Stephenson et al, 2022). Ninety-four percent of participants with bipolar disorder expressed interest in PADs and while seventy percent wished for provider collaboration with PAD completion, only 14% were able to achieve this goal (Stephenson et al., 2020) demonstrating an unmet need for clinician support. Preferences for assistance in PAD documentation by clinicians or PSSs were mixed in an RCT with 145 participants receiving psychiatric services in community mental health centers (Easter et al., 2017; Easter 2021). Participants identified the pros and cons of either choice, i.e., concerns that providers may encourage the selection of treatment options preferred from a clinical standpoint but not necessarily by patients themselves while peers with histories of involuntary hospitalization may better understand participants’ unique concerns. Conversely, patients recognized the benefits of clinician support, e.g., the clinical expertise peer facilitators may lack. In a systematic review of 53 studies, trust emerged as a key trait required of PAD facilitators; overriding the facilitator role (Braun et al., 2023). Easter et al., 2021 also noted the importance of trust. Participants were unbiased toward clinicians or peers as facilitators but expressed the need for established trust to feel at ease with the PAD documentation process. Stephenson et al, 2020 demonstrated a preference for legally binding PADs in study participants with bipolar disorder. Participants also expressed a preference for PAD content 7 containing both proscriptive (refusal of care) and prescriptive (the choice between one care option over another) treatment electives. Consumers also expressed a preference for self-binding PADs. Self-binding PADs allow users to agree to inpatient hospitalization in the event of a mental health crisis while acknowledging the likelihood of not wishing to comply with this option during the crisis. Events hosted by community mental health treatment facilities to provide education and assistance with PAD documentation resulted in the highest number of PADs completed (Easter et al., 2021; Tinland et al., 2022). No studies found during the literature search involved participants with suicidal depression, traumatic brain injuries, dementias, homelessness, or personality disorders. Research observing the benefits of PAD utilization for these populations is lacking, likely due to several factors. For example, individuals with intact decision-making capacity (e.g., suicidal depression without psychosis, personality disorders) may not require PADs, and individuals with dementia are advised by primary care advisors to include psychiatric decision-making in medical ADs (Porteri, 2018). Study participants in this review received inpatient or outpatient community mental health care services. All participants were adults with SMI and histories of involuntary hospitalizations, the two highest risk factors for involuntary hospitalizations (Walker et al., 2019). Planning events for consumers of community mental health services to receive education and support in completing documents is the best method to bolster PAD utilization. However, outreach to clinicians in private practice could increase PAD awareness for all community members at risk of involuntary psychiatric treatment. 8 Discussion and Conclusion The studies reviewed offer evidence-based methods to support autonomy for individuals with SMI and decrease involuntary hospitalization rates and the incidence of coercive treatments. The patient populations of focus are individuals with SMI at risk for psychiatric inpatient hospitalization. However, facilities offering inpatient psychiatric care increasingly serve individuals admitted involuntarily with diagnoses such as dementia and other cognitive disorders, traumatic brain injuries, and substance use disorders. The approaches to PAD implementation described in this review could benefit all individuals at risk for involuntary hospitalization. This review emphasizes the importance of trust in motivating patients to complete PADs. Trusting relationships are most likely established in community mental health centers, outpatient clinics serving patients with mental illnesses, and private practices. Through these community settings, individuals should be offered information on PADs, and support in completing them, as mandated by the CMS (CMS, 2023). New CMS billing codes allow clinicians to bill for time spent assisting patients with the completion of advance directives, which may help overcome the barrier related to clinician time limitations. Seeking the best methods to bolster PAD use and creating a plan to implement these methods fosters improved quality of care for the psychiatric patient population, which prompted the decision to include articles specifying implementation methods in this review. 9 QUALITY IMPROVEMENT PROPOSAL Despite the association with trauma and poor treatment outcomes, involuntary psychiatric hospitalizations continue to rise in all high-income countries (Tinland et al., 2023; Wasserman et al., 2020). Involuntary treatments are costly and raise ethical concerns related to autonomy, beneficence, and non-maleficence (Morris & Kleinman, 2020) and psychiatric facilities are notoriously understaffed and overburdened (American Hospital Association, 2022). Utilizing Psychiatric Advance Directives (PADs) has been shown to reduce involuntary hospitalizations, mitigating these problems (Barbui et al., 2021; Bone et al, 2019; DeJong et al., 2016; Tinland et al., 2023). Internationally, agreements such as the Ottawa Charter and the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) mandate the protection of human autonomy for all acutely ill patients (Callus & Camilleri-Zahra, 2019; Rixe et al., 2023). In the US, the Centers for Medicare, and Medicaid Services (CMS) requires facilities seeking Medicare and Medicaid reimbursements for psychiatric services to provide education and assistance in completing PADs (CMS, 2006). The Joint Commission (JC), CMS, the National Alliance on Mental Illness (NAMI), and the Substance Abuse and Mental Health Services Administration (SAMHSA), all recommend PAD document use for patients at risk of involuntary psychiatric hospitalization (CMS, 2006; JC, 2023; NAMI, 2023; SAMHSA, 2019). Efforts to increase PAD utilization are ongoing in many countries, including Germany, India, New Zealand, the Netherlands, and the UK. PAD content and legislation differ everywhere, and in the US, content and legislation vary from state to state. Some states require notarization and witnessing, while others do not. Some states offer PAD templates or sample 10 forms (accessible through the NRC PAD website), and some accept handwritten documents expressing treatment preferences. The myriad differences in PAD content and legislation contribute to stakeholder confusion. Problem Statement Despite evidence-based consensus supporting the need for PADs, these documents remain underutilized. Implementing a practical, replicable workflow to provide PAD education and assistance can bolster use. Interventions shown to be most effective and practical to support PAD utilization include: recruiting and educating peer support specialists (PSSs) on PAD facilitation; developing community programs and events to provide stakeholder education and assistance with PAD completion; ensuring primary providers, designated agents, and other clinicians receive copies of completed PADs and know how to access PAD documents filed on state registration sites, if available; and providing wallet or crisis cards to individuals with SMl to alert emergency workers of designated agent contact information and where a PAD is stored. This quality improvement (QI) project will establish a multi-factorial PAD implementation process aiming to reduce involuntary hospitalization rates and incidence of coercive treatments and patient-centered care in a community mental health setting. Organizational Microsystem Assessment The QI project setting is an outpatient community mental health treatment facility in an urban Montana town. The facility provides psychiatric services, including medication management, substance use disorder treatment, counseling/therapy, and crisis intervention and stabilization to an estimated 3-4,000 individuals of all ages (L. Mathias, personal 11 communication, November 1, 2023). Grants from the Substance Abuse and Mental Health Services (SAMHSA) organization supported the facility’s transition into a Certified Community Behavioral Health Center (CCBHC), allowing the facility to provide primary care in addition to psychiatric services (Hoscheid, 2021). The organization offers Telehealth services to expand behavioral health access in Montana, the fifth most rural state in the US (Rural Population Review, 2023). The two highest risk factors for involuntary hospitalization are the diagnosis of a disabling psychotic or bipolar illness and a history of previous involuntary hospitalization (Karasch et al., 2020). The facility serves approximately 500 individuals meeting these criteria (L. Mathias, personal communication, November 1, 2023). Already aware of studies demonstrating positive outcomes for PAD consumers, the facility director expressed high interest in this QI project from inception. The facility employs nearly 20 peer support specialists (PSSs) working on a Program of Assertive Community Treatment (PACT) team led by a licensed peer support specialist (LPSS). PACT programs provide outpatient treatment, rehabilitation, and support services to individuals with SMI at risk of involuntary psychiatric hospitalization (Gandy-Guedes et al., 2018). Based on lived experience and already established therapeutic alliances with consumers, PSSs are equipped to support PAD education and documentation efforts in community mental health facilities (Easter et al., 2021; Tinland et al., 2022). Engaging PSSs in this pilot study is key to establishing a sustainable, pragmatic workflow for PAD implementation at the community level of patient care. 12 Quality Improvement Model/Framework The Model for Improvement (MFI) and the Plan, Do, Study, Act (PDSA) framework was chosen to support the planning and development of this QI project (Langley, 2009). This framework allows project team members to plan activities, enact the plan, analyze the effects of interventions enacted, and adapt the plan between PDSA cycles, improving the process and workflow. The MFI asks three questions of QI project developers: (1) What are we trying to accomplish? (2) How will we know that a change is an improvement? and (3) What change can we make that will result in improvement? These questions are revisited following each PDSA cycle to review progress. The steps in the PDSA cycles include: (1) Plan–establishing steps to achieve goals, (2) Do– enacting the plan, (3) Study–reviewing data, and (4) (A)ct–the team chooses to Adapt (modify the process before another PDSA cycle), Adopt (approve the process and trial it on a larger scale), or Abandon (throw out the process after deciding it cannot be remedied). The project team will undergo the PDSA steps, beginning with planning during the first scheduled meeting. Planned activities will be carried out during each of the 3 events. The first 2 events will involve PSS training and provide PSSs with the opportunity to complete PADs with assistance if desired. The PSSs will facilitate the third event, attended by patients referred by facility providers to learn about and receive assistance completing PADs. Event outcomes, analyzed and interpreted by the graduate student, will provide the project team direction for facility workflow and event improvements. The number of invited event participants achieving event goals (PAD completion, receiving wallet cards) will be compared to the number of invitees unable to achieve goals. Event feedback, and unexpected occurrences such as poor attendance, 13 will be discussed during project team meetings, and interventions created to support improved success at the next event. The event itinerary will be adapted to improve outcomes. For example, more PSS training time may be required, or more time to complete documents. Adaptations will lead to establishing an efficacious PAD implementation workflow. Project Purpose and Aims The purpose of this QI project is to bolster the completion and utilization of PADs by combining strategies implemented in similar projects in the US and abroad. Short-term project outcomes include heightening stakeholder awareness and education regarding PADs, increasing the number of individuals at risk for involuntary hospitalization possessing completed PAD documents and wallet cards, and preparing peer specialists (PSSs) to assist consumers with PAD documentation. The long-term outcome is increased PAD utilization at statewide facilities providing mental health services, resulting in reduced involuntary hospitalization rates and incidence of coercive treatments. Methods This QI project combines evidence-based strategies to bolster PAD use at a community mental healthcare facility. The patient population targeted are individuals at risk of involuntary hospitalization due to diagnoses of schizophrenia, schizoaffective, or bipolar disorder and histories of previous psychiatric hospitalizations. This pilot study will allow staff members to participate in a practical PAD implementation process, melding PAD utilization strategies into the already established workflow. Feasible workflow adaptations will increase staff buy-in and reduce stress associated with change. The first change will be the expectation of providers (MDs 14 and NPs) to refer clients interested in PADs to a licensed peer support specialist (LPSS). The LPSS and her team of peer specialist workers (PSSs) will invite referred patients to a peer- facilitated PAD event (the third planned event). This QI project involves planning 3 PAD facilitation events. During the first two events, PSSs will undergo training to prepare to facilitate the third event. During the first two events, the graduate student and LPSS will distribute wallet cards, provide PAD education, view a training video with PSSs, and assist participants in PAD completion if desired. PSSs will receive information on the PAD notarization and state-registry filing process. Finally, the PSSs will complete an event satisfaction survey. The third event, facilitated by the trained PSSs, will be attended by clients referred by facility providers, and invited to the event by the LPSS. The event activities and goals will mirror those of the first two events. The survey will provide the team with event improvement feedback. This pilot study will occur within a 5-month timeline. Interventions and Implementation During an initial staff meeting, attendees will receive evidence-based information supporting PAD utilization provided by the graduate student and an invitation to participate in this pilot study. Four staff meetings will transpire to discuss event outcomes and survey content and make adaptations as necessary. The LPSS will invite PSSs to the first 2 PAD training events. The first event will be the first PSS training/PAD implementation event The second event will be the second PSS training/PAD implementation event. At the first and second events, PSSs will observe a training video provided by the NRC PAD organization and be offered help by the graduate student and the LPSS with PAD completion. They will receive information on the notarization and state registry process, receive wallet cards, and be invited to provide event 15 feedback via a satisfaction survey. The LPSS will invite clients referred by providers to the PSS- facilitated PAD event. At the third and final event, facilitated by trained PSSs, the event itinerary will be the same as the PSS training event itinerary but facilitated by PSSs. All PAD events will occur during facility working hours to support good attendance and provide a comfortable, familiar environment. The events will occur two weeks apart, allowing time to analyze data and determine required adaptations before the next event. The graduate student will record the number of participants invited versus the number attending events, the number of participants completing PADs versus the number of participants not completing PADs, and the number of participants receiving wallet cards. The Event Satisfaction survey will measure event satisfaction and provide feedback to consider during the Study phase of each PDSA cycle. Staff education on the QI project aims, goals, and structure will occur during staff meetings and via project team group emails. The project will take place between November 2023 and April 2024. Evaluation and Analysis The graduate student constructing this project will use the Event Outcomes template (see Table 2.) to document the number of participants attending events, the number of participants with completed documents before and after events, and the number of participants possessing wallet cards before and after events. A modified version of the Subjective Assessment of the Intervention survey (Rixe et al., 2023) will measure event satisfaction (see Table 4.). The survey 16 will inform the project team of participants’ event experiences and why or why not they were able to complete PAD documents during the event. Safety and Confidentiality During this project, the LPSS will collect referral names and invite participants to scheduled events using preferred contact methods (via email, phone, or in-person appointments). The LPSS will access patient contact information through the electronic health record (EHR). Only the LPSS will access personal health information and documents containing PPI will not be removed from the facility. Data collected at events will not contain PPI. The event outcome template (Table 2) will only contain participant numbers, and the survey form will instruct participants not to include names, and to anonymously hand in forms in a box provided by the LPSS. Survey data will be reported in aggregate, decreasing the chances of identifying any one person’s feedback. The risks associated with this QI project are no greater than those encountered in the organization’s standard care. Events will commence during typical working hours to support the facility's goal of integrating the PAD implementation process with the current workflow and to provide participants the comfort and convenience of attending events at a familiar location. 18 A QUALITY IMPROVEMENT PROJECT TO BOLSTER PSYCHIATRIC ADVANCE DIRECTIVE UTILIZATION IN COMMUNITY MENTAL HEALTH Contribution of Authors and Co-Authors Manuscript in Chapter 3 Author: Laira Lee Fonner, RN, BSN Contributions: Conception of the project idea, engagement with organization and staff, implementation of the evidence-based practice, data collection and analysis, interpretation of the findings, drafting and revising all components of the paper. Co-author: Dr. Lindsey Benes, PhD, RN Contributions: Critical review of the content, recommendations to align with scholarly project standards, editing for clarity and consistency, final approval of version to be published. Co-Author: Dr. Carrie Miller, PhD, RN, CNE, CHSE, IBCLC Contributions: Review of content for consistency and clarity. 19 Manuscript Information Laira Lee Fonner, Dr. Lindsay Benes, Dr. Carrie Miller Journal of the American Psychiatric Nurses Association Status of Manuscript:  Prepared for submission to a peer-reviewed journal ☐ Officially submitted to a peer-reviewed journal ☐ Accepted by a peer-reviewed journal ☐ Published in a peer-reviewed journal Journal of the American Psychiatric Nurses Association SAGE Publications https://journals.sagepub.com/author-instructions/JAP 20 Introduction Individuals with severe mental illness (SMI) experience an increased risk of involuntary hospitalization and associated coercive treatments such as seclusion and restraint and forced medication. In Montana, the state's largest mental health hospital lost federal funding in 2022 due to failed health and safety inspections, numerous episodes of violence, staffing shortages, and death, demonstrating such risks (Bauer, 2024). Clinical Problem In 2006, the Centers for Medicare and Medicaid Services (CMS) mandated that facilities seeking CMS reimbursements for mental health services provide clients with PAD education and support. Despite this, usage rates for individuals with SMI remain low at an estimated 4-13% (Joint Commission, 2024). Research suggests that approximately two-thirds of patients with SMI would utilize a PAD if provided with necessary assistance. Gaps in PAD knowledge, skepticism surrounding efficacy, and busy clinician schedules perpetuate low utilization rates. However, studies have demonstrated successful PAD utilization in mental health facilities offering peer- facilitated support services (Gaillard, 2022). Peer Support Specialists (PSSs) are trusted employees working in outpatient mental health facilities on teams that provide client services and support. PSSs are in recovery from SMI, and due to lived experience and established client trust, are well equipped to provide peer support services for clients interested in utilizing PADs. Review of Literature When comparing PAD users to non-users, Tinland et al., 2022 and Stephenson et al., 2020 saw fewer involuntary hospitalizations and improved recovery marked by fewer mental 21 health symptoms. Tinland et al., 2022, reported lowered treatment costs for PAD users due to fewer involuntary hospitalizations which are associated with higher costs due to longer length of stay (LOS) and costlier treatments (e.g., increased staffing requirements, emergency medications, and security services). Rixe et al., 2023, did not see a change in hospitalization rates for PAD uses, but advocated for PAD use nonetheless due to increased patient autonomy. Stephenson et al., Easter et al., 2017, and Braun et al., 2023, all found consumer interest in accessing PAD documents, with most consumers reporting a desire for assistance navigating the process. Braun et al., 2023, Easter et al., 2020, Stephenson et al., 2020, Rixe et al., 2020, and Tinland et al., 2022 all reported increased feelings of empowerment and autonomy for patients utilizing PAD documents. Tinland et al., 2022, did not find improved therapeutic alliances for PAD users, but Braun et al., 2023 reported mixed results, with some users reporting increased therapeutic alliances, while others did not. Both studies reported better outcomes when clients received assistance with PAD documents from a peer support specialist (PSS) compared to those receiving help from a clinician. However, Easter et al., 2020 saw no difference in outcomes between peer-assisted and clinician-assisted groups. While clients did not have a preference between peers and clinicians for PAD support, trust was identified as a critical element when receiving support from either clinicians or peers. Conceptual Framework The Plan-Do-Study-Act (PDSA) framework is an effective approach identifying change in small-scale QI projects (Melnyk & Fineout-Overholt, 2019). The project team (PT) followed the PDSA cycle steps during planning and implementation of this QI project. 22 The first step, 'Plan', was enacted during the project design. The PT planned online PSS training workshops to allow PSSs living in various communities the convenience of attending events while avoiding travel time and expense. Additional planning occurred as the team decided upon workshop training content and schedule. The second step, 'Do', transpired as the PT hosted the three online training workshops, followed by the three peer-facilitated events. Workshops and peer-facilitated events were scheduled throughout a month-long timeframe. The peer-facilitated events were held in person at three different facilities where PSSs worked. The third step, 'Study', involved the PT observing attendance rates for workshop training and peer-facilitated events, and the number of clients who were able to complete PADs during each peer-facilitated event. The final step of the PDSA cycles, 'Act' transpired as the PT discussed ideas to improve attendance rates at training workshops and peer-facilitated events. For example, after the first online training workshop, the PT hosted two additional training workshops to maximize PSS attendance. Another example of project adaptation occurred when no clients completed PADs at the first peer-facilitated event. A free notary service was available at this event, but as this service was not utilized, the PT determined that notary services were unnecessary at the second and third peer- facilitated events. Instead, the PT encouraged PSS facilitators to inform clients of local notary service availability. Aims The aim of this QI project was to strengthen autonomy and reduce involuntary hospitalization rates for individuals with SMI by bolstering the utilization of PAD documents. To achieve this aim, a peer-facilitated program was developed to provide on-going PAD education, assistance, and support. 23 Methods The project setting, a multifacility organization, provides outpatient community mental health and addiction services. Psychiatric nurses, psychiatrists, PSSs, addictions counselors, and therapists, collaborate in multidisciplinary care provision. The organization has received grants to enhance mental health services for individuals with SMI, the population at highest risk for involuntary hospitalizations during mental health emergencies. Project Team The project team (PT) consisted of the doctorate student, a university faculty member, the Chief Program Officer (CPO) of the mental health organization, and the Licensed Peer Support Specialist (LPSS) who supervises PSSs at all locations. The PT corresponded via weekly emails, texts, phone calls, and Zoom meetings to discuss project goals, delegate responsibilities, and contemplate the next steps. The doctorate student, the CPO, and the LPSS introduced the QI project to clinicians employed by the facility via a Zoom. They requested referrals of clients interested in attending peer-facilitated events to learn more about PADs and receive assistance with documents. Interventions Project interventions included hosting three online training workshops to prepare PSS employees to lead peer-facilitated PAD events, followed by hosting three consecutive peer- facilitated PAD events where trained PSSs could practice leading the events. At the conclusion of each peer-facilitated event, PSSs invited clients to complete event feedback surveys. 24 PSS Training Workshops. Three online training workshops scheduled within a two-week timeframe prepared PSSs to lead peer-facilitated events. PSSs viewed a short film describing PAD benefits and the impact of utilization, then carefully reviewed a PAD document to ensure understanding of content. For this QI project, the PT used a PAD provided by the Montana Disability Rights organization (Disability Rights Montana, n.d.). Notably, Montana does not require a specific document for advance planning use, and even a hand-written letter expressing treatment wishes suffices if notarized and signed by two witnesses. The PAD document is lengthy and contains confusing legal jargon. While some sections contain straight-forward content, such as preferred medications for use during a crisis, others evoke confusion and require careful consideration. For example, a section requiring consumers to choose a document expiration date or to opt out and leave this section blank can elicit confusion. Clients should understand that once a legal, notarized PAD expires, a new document must be completed, notarized, witnessed, and signed to replace the expired version. Some topics a client will address in the PAD require complex decision-making. For example, one section of the PAD asks users to select a preference between maintaining the ability to revoke the PAD at any time during a mental health crisis, or to waive this right. If choosing to waive the right to revoke the PAD during times of mental incapacitation, the preferences and wishes expressed in the PAD would remain valid despite the users wishes. There are no right or wrong answers, however, PSSs must be prepared to explain why one option may be preferred over another. Peer-facilitated Events. During peer-facilitated events, clients viewed the PAD informational film. PSSs then led a discussion. Clients were invited to ask questions and express concerns. Copies of PAD documents were available for clients wishing to begin filling out a 25 PAD, and to access as-needed peer-facilitated support during the event. Lunch was provided. At the end of the event, clients were invited to complete an event feedback survey. Measures The number of PSSs invited and the number able to attend training workshops was recorded. The number of clients invited and the number able to attend peer-facilitated events was recorded. The number of attendees completing PADs at the peer-facilitated events was recorded. The number of attendees receiving wallet cards was recorded. Clients at all three events were asked to complete an event feedback survey. The seven-question survey, created by the PT during project planning, served as a tool to help the PT understand how clients viewed the event experience, and allowed the clients the opportunity to provide feedback. The survey asked clients to rate the event experience by selecting the following answers to seven questions using a 5-point Likert scale: I strongly disagree, I disagree, I don't disagree or agree, I strongly agree, and I agree. The six questions were 1. The event enabled me to take part actively in decisions about my treatment. 2. The event will have a positive effect on the course of my mental illness. 3. This event gave me more confidence in my mental health treatment team. 4. This event enabled me to have a positive effect on my recovery process. 5. Overall, this event helped me. 6. I would recommend this event to others. The seventh question was open-ended, and asked clients to share any feedback they would like regarding the event experience. 26 Ethical Considerations This project was reviewed by the Montana State University's Institutional Review Board (IRB). Given the project's focus on implementing an evidence-based practice improvement to enhance clinical quality, it was deemed not human subject research. Results One hundred percent of PSSs expected to attend online training workshops (9/9) were able to attend an online training workshop. Only 50% (2/4) of PSSs trained and expected to facilitate the first event were unable due to work absence. However, at the second and third peer- facilitated events, 100% of trained PSSs attended and led the events as planned (3/3 PSSs at Event 2, and 2/2 PSSs at Event 3). Therefore, 78% (7/9) of all trained PSSs led peer-facilitated events as planned. At all three peer-facilitated events, 100% (21/21) of invited clients were in attendance. However, only four clients (19%) completed PADs at a peer-facilitated event (n=4/21). At the first event, all five clients invited were able to attend and 20% (1/5) completed PADs. At the second event, 25% of attendees completed PADs (2/8), and at the third event, 12.5% (1/8) completed PADs. Wallet cards were unavailable for distribution. Clients at all three peer- facilitated events bypassed the event feedback survey (see Table 1). 27 Table 1. Event Outcomes key: CI/CA=Number of Clients Invited/Clients Attending CCP/NCP=Number of Clients who Completed PADs/Not Completed Pads PRWC/NWC=Number of Participants receiving wallet cards/Not receiving cards PCS/PNCS=PSSs or Clients who Completed Survey/Not Completed Survey PSST/PSSF=Peer Support Specialists Trained/Peer Support Specialists Facilitating Discussion While the PT had anticipated a higher PAD completion rate at peer-facilitated events, the percentage of clients completing a PAD (19%) was higher than the estimated national average (4-13%) of people with SMI utilizing PADs (Joint Commission, 2020). Attendees at all three peer-facilitated events shared in meaningful discussions involving PAD documents, implications for use, and concerns. At the first event, a client who had utilized PADs in the past, advocated for their use. Event CI/CA % CCP/NCP % PRWC/NWC PCS/PNCS PSST/PSSF % 1 5/5= 100% 1/5= 20% 0 0 4/2= 50% 2 8/8= 100% 2/8= 25% 0 0 3/3= 100% 3 8/8= 100% 1/8= 12.5% 0 0 2/2= 100% Note: The number of PSSs who attended a training, then facilitated an event at their location of employment was calculated for each event. 28 PSSs and other staff members received PAD education and training and 78% (7/9) attended and led peer-facilitated events. PSSs facilitating events demonstrated good rapport with clients, and invited clients to schedule one-on-one time to complete documents. Some event attendees demonstrated little interest in PADs and seemed only interested in lunch, while others seemed hesitant to complete PAD documents. However, a few clients completed PADs and several opted to take the documents home to complete them with the support of a family member. At all peer-facilitated events, the PSSs announced on-going support for clients wanting assistance with PADs and disclosed available meeting times during the work week. The PT discussed the clients' disinterest in completing the event feedback survey. The peer-facilitated events were enjoyable but hectic. A 7-question survey was likely undesirable due to information overload. Limitations The project was limited by the small sample size, the low capacity of some attendees to comprehend PAD content, and the lack of staff knowledge of PADs, requiring the PT to provide a large amount of information in a short amount of time. Study strengths include efficacy of online training workshops, and project generalizability. PSSs are employed at several affiliated facilities statewide. Therefore, the PT expects the knowledge shared during this QI project will be shared in several locations, leading to an expansion of awareness. This is important, as poor clinician awareness of PADs has been identified as a barrier to utilization (Joint Commission, 2020). Organizations wishing to implement peer-facilitated PAD events can offer online trainings with relative ease and low cost. Time spent and employee wages are the only output 29 required for training as a plethora of free training material is accessible online. For example, multiple PAD tutorials and other resources (including the film the PT showed PSSs and clients) are available free of charge on the National Resource Center for Psychiatric Advance Directives website (National Resource Center for Psychiatric Advance Directives, n.d.) The short project timeframe prohibited the ability to maximize efficacy. However, each training workshop and peer-facilitated event allowed the PT to consider implementation strategies to improve outcomes. For example, increasing the number of online training workshops from one to three resulted in successful training for all PSSs expected to lead peer- facilitated events. Recommendations Hosting small, peer-facilitated events provided newly trained PSSs the opportunity to trial event facilitation in a manageable setting. To increase future event attendance, fliers containing event dates and times could be posted in clinics, day treatment centers, and group homes, and shared with clinicians. Alerting collaborating clinicians well ahead of planned events would allow time to receive event referrals. Emailing event reminders to clinicians could also boost event referral rates. Maintaining flexibility to meet facility staff training needs resulted in the ability to train all designated support staff. Likewise, planning enough peer-facilitated events to allow all trained staff to facilitate events allowed PSSs to demonstrate skills. The document chosen for this project was lengthy and contained detailed and confusing sections. While appropriate for individuals wishing to address varied and complex issues in a PAD, many event attendees were overwhelmed. A revised version, or a new document 30 addressing fewer items would be a beneficial option. Likewise, the event feedback survey may have been unappealing due to lengthiness. The PT recommends obtaining client feedback via a shorter survey, or a survey containing one or two open-ended questions requesting feedback. Also, the survey could be delivered to attendees at another time, allowing clients time to consider survey answers and to not feel overburdened by answering more questions. The short project timeframe resulted in a lack of provider referrals. Providers can refer clients screened for capacity and interest level to peer-facilitated events. Clients demonstrating readiness to participate in PAD utilization efforts would be more likely to complete documents. Clients receiving services through this state-funded organization would benefit from PAD utilization but may require longer timeframes to attain readiness for change. Clients with SMI often have histories of trauma and abuse and may require more time to gain trust, or overcome skepticism related to the merit of PADs. Long travel distances and transportation insecurity are common barriers for rural Montanans. Offering online peer-facilitated PAD events could overcome this barrier for many clients, and some PAD consumers may prefer this option. However, in-person events, such as those held during this project, increase community engagement and connectiveness, and allow clients to act as witnesses for one another during document notarization. Due to the many steps required to document, notarize, and register PADs, providing clients the opportunity to complete the process during events was lofty. The Stages of Resistance, otherwise known as the Transtheoretical Model of Change, describes resistance to change as a normal first step (Prochaska et al., 2009). According to this model, the first stage of change, the Pre-contemplation Stage, involves no intention to act. Behavioral change does not occur until the 31 fourth stage of change, the Action Stage, and actions or behaviors are short-lived until the Maintenance Stage, where long-term change finally occurs. Notarization fees may be an insurmountable barrier for low-income clients, especially those living on disability funds. To overcome this barrier, notary services could be provided at peer-facilitated events. Funding the notary certification process for a PSS would ensure client access to notary services. Providing refreshments or a meal at PAD events may inspire clients to attend even if uninterested in completing documents at the time. Facilitators should clarify that PAD information and education is provided without obligation to complete documents. Often, education dispels misinformation underlying any hesitation to utilize a PAD. Clients should share copies of PADs with support persons or agents and trusted providers to ensure PAD utilization during a mental health crisis. Also, clients should be advised to ask trusted providers to scan and upload notarized PADs to their electronic health records for safekeeping. PAD completion and notarization may be the most important step in utilization. Mailing notarized documents to the state advanced directive registry may be most beneficial to patients at risk of hospitalization in unfamiliar settings. When traveling outside of the county of residence or the state, PADs can be accessed via the registry. However, clinicians must notify the state registry and provide the client registration number to access a file. Time factors may prohibit a clinician overseeing emergency care from accessing state-registered documents. Finally, despite limited evidence supporting improved treatment outcomes for individuals utilizing wallet cards, these tools increase the likelihood that emergency clinicians will receive 32 information regarding treatment preferences. Studies observing improved outcomes with wallet cards use remain limited. Further research may provide evidence supporting increased benefits of their use. Conclusion Despite well-established benefits for patients with SMI who utilize PAD documents, barriers prevail. PSSs are well equipped to provide support and encouragement to clients with SMI who wish to utilize these documents, and typically have already established trusting relationships with clients. This QI project successfully bolstered education and utilization in three separate facilities providing services for patients with SMI. The organization plans to continue providing peer- facilitated support services for patients wishing to utilize PADs as a tool to support improved long-term treatment outcomes. 33 HOW THE DNP PROGRAM ALLOWED ME TO MEET DNP ESSENTIALS Introduction Nine essentials developed by the American Association of Colleges of Nursing describe the foundational competencies expected of a Doctor of Nursing Practice (DNP) graduate (American Association of Colleges of Nursing, 2006). In this paper, I will reflect on how my coursework and clinical experiences supported my competency development. Scientific Underpinnings for Practice The scientific foundation required of the doctorate level nurse arises from fields of human biology, genomics, and psychosocial sciences. Advanced health assessment studies provided me with the ability to perform an advanced physical assessment and detect abnormal physiological signs and symptoms during a comprehensive health examination. Advanced Physiology/Pathology coursework established my ability to establish connections between health assessment findings and human biology, anatomy, and physiology. I began to recognize hallmark signs and symptoms of physiologic conditions linked to mental health conditions. For example, neurologic manifestations associated with hypothyroidism include confusion, memory loss, slowed thinking and speech (McCance & Huether, 2019). A patient experiencing these symptoms may present for a psychiatric evaluation, seeking help to manage depression. Likewise, restlessness, short attention span, insomnia, and emotional lability manifesting in hyperthyroidism could be mistaken for depression, anxiety, or attention deficit disorder (ADD). Understanding connections between physiological and 34 psychological health motivated my practice of obtaining thorough medical histories during initial, comprehensive assessments. I've request copies of recent lab work for review, consider the requirement to rule out physiological underlying causes of symptoms before establishing mental health diagnoses (American Psychiatric Association, 2013). Advanced pharmacology coursework delved into pharmacokinetics and pharmacodynamics, allowing me to discuss biochemical, physiologic, and molecular drug effects on the body, and how drugs bind to receptors. This knowledge helps me provide patient education when recommending new medications. I can explain how the response of a new medication varies based on factors such as the types of drugs and supplements a patient takes, nutrition, age, and genetics. I can describe how the slowed absorption rate of extended-release drugs provides a more stable plasma drug concentration, decreasing the incidence of side effects (Woo et al., 2019). I can explain to older patients how drugs metabolized by the cytochrome P450 enzyme in the liver, such as tricyclic antidepressants and selective serotonin receptor inhibitors (SSRIs), do not break down as efficiently as the liver loses capacity, resulting in higher circulating drug concentrations and the need for lower drug doses. Organizational and Systems Leadership for Quality for Quality Improvement and Systems Thinking The DNP coursework instilled in me an understanding of how nurse leaders incorporate evidence-based practice (EBP) into clinical settings. EBP involves merging current best practice guidelines and methods with clinical wisdom, and patient preferences, values, and beliefs (Melnyk & Overholt, 2019). EBP leads to the best quality provision of care, explaining the importance of maintaining an EBP culture. Designing and implementing quality improvement (QI) projects to improve care outcomes allows the nurse leader to demonstrate EBP. 35 I studied the steps required to formulate a QI project in the Evidence-Based Practice (NRSG 604) course. The first step is to cultivate a spirit of inquiry to prepare project stakeholders for change, and ideally inspire enthusiasm and support. A thorough literature review informs project develop, aims and goals. I've emerged from my DNP coursework with the ability to perform thorough database searches and distinguish between levels of evidence in scholarly works. I know how to question the validity, reliability, and applicability of studies, and to know which study outcomes to integrate into my project design. Implementing a quality improvement (QI) project allowed me to demonstrate my scholarly achievements and nursing leadership. I understood the responsibility of the nurse leader to identify vulnerable populations and implement projects to improve quality care, a fundamental element of nursing leadership and advanced nursing practice. I've learned how vulnerability arises from issues such as low socioeconomic status, lack of health insurance, and minority ethnic backgrounds, resulting in greater health risks and needs (Shi & Stevens, 2021). Vulnerable populations experience a greater risk of poor physical, mental, and social health and higher rates of morbidity and mortality, and achieve poorer access to health care, poorer quality of health care received, and increased rates of diabetes, heart and lung disease, and other morbidities. My project involved implementing interventions to improve health outcomes for individuals with severe mental illnesses (SMI), a vulnerable population that experiences low socioeconomic status due to disabling mental illness. In addition to increased health risks, individuals with SMI experience a high risk of experiencing involuntary hospitalization and 36 associated coercive treatments. My project aimed to reduce involuntary hospitalization rates over time and improve autonomy for this population by promoting the utilization of psychiatric advance directives (PADs) in outpatient mental health facilities. My coursework prepared me to not only carry out the design and implementation of a QI project, but to embrace my responsibility as a nurse with advanced training, to enact change for my vulnerable community members. Clinical Scholarship and Analytical Methods for Evidence-Based Practice The commitment to EBP involves on-going knowledge of current literature and clinical practice guidelines. The DNP program prepared me to critically appraise literature and examine validity, reliability, and applicability of items before considering implementing recommendations into practice. A literature search identifies gaps in literature, indicating the need for more research. Conducting a small pilot study or carrying out a QI project strengthens the literature, helping to close gaps. I learned the value of both quantitative and qualitative measures. For my QI project, I collected quantitative data to measure the success of the interventions applied and considered participant feedback to understand the participant’s experience. This feedback provided me with an understanding of how the organization could improve intervention to better serve participant need. For example, participants attending an event to learn about psychiatric advance directives expressed the desire for a larger space allowing for quiet and privacy while working on directives. This feedback allowed the project team to consider holding the next event in more spacious area with access to private areas to draft documents. 37 Information Systems and Patient Care for the Improvement and Transformation of Healthcare The DNP coursework illuminated the potential of information systems technology and patient care technology to improve and transform healthcare. As a nurse leader, I know how to gather and analyze data, visualize patient care outcomes, and consider treatment efficacy and costs of care delivery. I can offer input into design features of an electronic health record (EHR) that impacts care delivery. While implementing my QI project, the lack of a simple technological system created a barrier for my patient population. Registering advance directive documents with the state registry allows providers to access document from any treatment facility. However, many individuals expressed discomfort mailing legal documents to the state. They expressed concern that making even minor changes to their documents would be time-consuming and force them to abide by outdated treatment preferences. If patients were provided the ability to upload documents to the state registry and access documents electronically to alter content, this convenience could improve utilization of medical and psychiatric advance directives. Utilization of advance directives (medical and mental health types) allows clinicians to consider treatment preferences during hospitalizations, which often results in shortened time for stabilization. When hospital length of stay (LOS) decreases, medical costs are also reduced. Health Care Policy for Advocacy in Healthcare Participation in health policy measures improves healthcare services and access for vulnerable groups. A deeper understanding of health policy developed through my DNP coursework inspires me to advocate for expanded Medicaid services and continued coverage 38 through the Affordable Care Act (ACA) to ensure improved access to quality healthcare for the millions of Americans insured through these programs. Supporting legislation allowing APRNs to practice and prescribe independently is another way I support efforts to expand access to care for vulnerable populations. Montana is among only 30 states in the US that allow APRNs to practice independently despite reports from trusted organizations such as the Institute of Medicine demonstrating that physicians and APRNs provide equal quality care, based on care outcomes. Patients often prefer APRNs for care delivery, and patient preference is a key element of EBP. Medical organizations such as the American Medical Association (AMA) fail to acknowledge these findings and continue to denounce independent practice rights for APRNs. I've learned that nursing organizations such as the American Nurses Association spend less than $1 million dollars annually for lobbying as compared to the $15 million spent annually by AMA (Goudreau & Smolenski, 2018). This illuminates the importance of increased nurse involvement in policy. Conclusion The DNP coursework instilled in me the foundational skills, knowledge, and concomitant ethical responsibilities I will require as I assume the role of an advanced practice nurse. The DNP program endowed me with the ability to interweave knowledge and skillsets described in the DNP Essentials with the ANA's Code of Ethics for Nurses, which will guide my clinical decision-making and practice. Reviewing the DNP competencies allowed me to appreciate the rigorous coursework I've completed. I feel proud of these accomplishments, and excited to put my knowledge into 39 practice. However, instead of feeling as if my education is complete, I know I will maintain the intellectual curiosity required to evolve and grow along with the nursing field. 40 REFERENCES CITED 41 American Hospital Association. (2022). AHA house statement: America’s mental health crisis. February 2, 2022. AHA. aha.org/2022-02-03-aha-house-statement-americas-mental- health-crisis-february-2-2022 American Nurses Association. (2015). Code of ethics for nurses. American Nurses Publishing. American Psychiatric Association (2023). Psychiatric Advance Directives. https://www.psychiatry.org/patients- families/psychiatric-advance-directives-1 Avila, A., & Leeper, E. (2022). Assessment of barriers to effective use of psychiatric advance directives: Providers' knowledge and attitudes. Psychological services, 19(2), 271–282. https://doi.org/10.1037/ser0000525 state psychiatric hospital to reapply for federal assistance. Local Multimedia Journalist. https://www.montanarightnow.com/butte/montana-state- psychiatric-hospital-to-reapply-for- federal-assistance/video_c6e7920c-bb16-11ee-a 1709c798d14f.html Bjerke, M.B. & Renger, R. (2017). Being smart about writing SMART objectives. Evaluation Program Planning. Elsevier. https://doi.org/10.1016j.evalprogplan.2016.12. 009. Braun, E., Gaillard, A. S., Vollmann, J., Gather, J., & Scholten, M. (2023). Mental health service users’ perspectives on psychiatric advance directives: A systematic review. Psychiatric Services, 74(4), 381-392. Centers for Medicare & Medicaid Services (CMS), DHHS (2006). Medicare and Medicaid programs; hospital conditions of participation: patients' rights. Final rule. Federal Register, 71(236), 71377–71428. Disability Rights Montana. (n.d.). Mental Health Advance Directive. https://www.disabilityrightsmt.org/wp-content/uploa.ds/2018/06/Montana-Mental- Health-Care-Advance-Directive-Disclaimer-Form-Instructions_1498236117-1.pdf Easter, M. M., Swanson, J. W., Robertson, A. G., Moser, L. L., & Swartz, M. S. (2017). Facilitation of psychiatric advance directives by peers and clinicians on assertive community treatment teams. Psychiatric Services, 68(7), 717-723. https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600423 Easter, M. M., Swanson, J. W., Robertson, A. G., Moser, L. L., & Swartz, M. S. (2021). Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists. Journal of Mental Health (Abingdon, England), 30(5), 585–593. https://doi.org/10.1080/09638237.2020.1714008 Fowler, M.D.M. (2015). Code of ethics for nurses with interpretive statements (2nd ed.). American Nurses Association. Gaillard, A. S., Braun, E., Vollmann, J., Gather, J., & Scholten, M. (2022). The content of https://www.psychiatry.org/patients-%09families/psychiatric-advance-directives-1 https://doi.org/10.1037/ser0000525 https://doi.org/10.1016j.evalprogplan.2016.12 https://doi.org/10.1080/09638237.2020.1714008 42 psychiatric advance directives: a systematic review. Psychiatric Services, 74(1), 44-55. https://doi.org/10.1176/appi.ps.202200002 Gandy-Guedes, M. E., Manuel, J. I., George, M., McCray, S., & Negatu, D. (2018). Understanding engagement in the Program of Assertive Community Treatment (PACT) from the perspectives of individuals receiving treatment. Social Work in Mental Health, 16(4), 400–418. https://doi.org/10.1080/15332985.2017.1399194 Haddad, L.M. & Geiger, R.A. (2023). Nursing ethical considerations. StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054/ Healthcare Cost & Utilization Project: User Report. (2020). Costs of emergency department visits for mental and substance use disorders. http://Hcup-us.ahrq.gov Hem M.H., Gjerberg, E., Husum, T.L, & Pedersen, R. (2018). Ethical challenges when using coercion in mental healthcare: a systematic literature review. Nursing Ethics. 25(1), pp. 92-110. http://doi:10.1177/0969733016629770 Hischeid, J. (2021). Western Montana Mental Health Center: Site inspection conducted by the mental disabilities board of visitors. https://boardofvisitors.mt.gov/_docs/WMMHC- Missoula-Report.pdf Hinkle, J. S. (2014). Population-Based Mental Health Facilitation (MHF): A Grassroots Strategy That Works. Professional Counselor, 4(1). http://doi:10.1097/NNA.0000000000000723. Hong, Q., Pluye, P., Fàbregues ,S. (2018). Mixed Methods Appraisal Tool (MMAT), Version 2018. Registration of Copyright (#1148552). Ot- tawa, Industry Canada, 2018 Joint Commission. (2022). Quick Safety 53: Improving care with psychiatric advance directives. https://www.jointcommission.org/resources/news-and- multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-53/quick-safety-53- improving-care-with-pads/ Karaca, Z., Moore, B.J. (2020). Costs of emergency department visits for mental and substance use disorders in the United States, 2017. Healthcare Cost and Utilization Project (HCUP)Statistical Briefs. Agency for Healthcare Research and Quality (US). Rockville (MD); 2006. PMID: 32550678. Karasch, O., Schmitz-Buhl, M., Mennicken, R., Zielasek, J., & Gouzoulis-Mayfrank, E. (2020). Identification of risk factors for involuntary psychiatric hospitalization: using environmental socioeconomic data and methods of machine learning to improve prediction. BMC Psychiatry. https://doi.org/10.1186/s12888-020-02803-w Langley, G.L., Moen, R., Nolan, K.M., Nolan, T.W., Norman, C.L., Provost, L.P. (2009). The https://doi.org/10.1176/appi.ps.202200002 https://boardofvisitors.mt.gov/_docs/WMMHC-Missoula-Report.pdf https://boardofvisitors.mt.gov/_docs/WMMHC-Missoula-Report.pdf https://www.jointcommission.org/resources/news-and- 43 improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco: Jossey-Bass Publishers. Lenagh-Glue, J., Potiki, J., O'Brien, A., Dawson, J., Thom, K., Casey, H., & Glue, P. (2021). Help and Hindrances to Completion of Psychiatric Advance Directives. Psychiatric challenges, and future directions. Journal of Psychiatric Practice®, 25(4), 303-307. Molyneaux, E., Turner, A., Candy, B., Landau, S., Johnson, S., & Lloyd-Evans, B. (2019). Crisis-planning interventions for people with psychotic illness or bipolar disorder: systematic review and meta-analyses. BJPsych Open, 5(4), e53. National Alliance on Mental Illness (2023). Psychiatric advance directives: Where we stand. https://www.nami.org/Advocacy/Policy-Priorities/Responding-to-Crises/Psychiatric- Advance-Directives#: ~:text=Many%20people%20with%20mental%20 illness s, care%20directives%20or%20living%20wills. National Institute of Mental Health (NIH) (2023). Mental Illness. https://www.nimh.nih.gov/health/statistics/mental-illness National Resource Center for Psychiatric Advance Directives. (2017). Introduction to Psychiatric Advance Directives: How to be your own advocate. [Video]. YouTube. https://www.youtube.com/watch?v=Pvue34Mm4QM Nelson-Brantley, H. V., David Bailey, K., Batcheller, J., Bernard, N., Caramanica, L., & Snow, F. (2019). Grassroots to Global: The Future of Nursing Leadership. The Journal of Nursing Administration, 49(3), 118–120. https://doi.org/10.1097/NNA.0000000000000723 Penzenstadler, L., Gentil, L., Grenier, G., Khazaal, Y., & Fleury, M. J. (2020). Risk factors of hospitalization for any medical condition among patients with prior emergency department visits for mental health conditions. BMC psychiatry, 20(1), 431. https://doi.org/10.1186/s12888-020-02835-2 Prochaska, J. O., Johnson, S., & Lee, P. (2009). The Transtheoretical Model of behavior change. In S. A. Shumaker, J. K. Ockene, & K. A. Riekert (Eds.), The handbook of health behavior change (3rd ed., pp. 59–83). Springer Publishing Company. Rixe, J., Neumann, E., Moller, J., Macdonald, L., Wrona, E., Bender, S., Schormann, M., Juckel, G., Driessen, M. (2023). Joint crisis plans and crisis cards in inpatient psychiatric treatment: A multicenter randomized controlled trial. http: doi:10. l3238/arztebl.m2022.038 Ruston, D. (Director). (2015). Crisis in Control: A Film about Psychiatric Advance Directives. https://www.youtube.com/watch?v=-QUi2QGodI4Rural Population Review. (2023). https://www.nami.org/Advocacy/Policy-Priorities/Responding-to-Crises/Psychiatric- https://doi.org/10.1097/NNA.0000000000000723 44 Silvers, M. (2022, April 11). State psychiatric hospital will lose Medicaid funding: federal agency pulls contract over unaddressed patient safety issues. Montana Free Press. Stephenson, L. A., Gergel, T., Ruck Keene, A., Rifkin, L., & Owen, G. (2022). Preparing for Mental Health Act reform: Pilot study of co-produced implementation strategies for Advance Choice Documents. Wellcome open research, 7, 182. https://doi.org/10.12688/wellcomeopenres.17947.1 Substance Abuse and Mental Health Services Administration (SAMHSA): A Practical Guide to Psychiatric Advance Directives. Rockville, MD: Center for Mental Health Services Substance Abuse and Mental Health Services Administration, 2019. Teoli D, Ghassemzadeh S. Patient Self-Determination Act. [Updated 2022 Aug 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538297/ Tinland, A., Loubière, S., Mougeot, F., Jouet, E., Pontier, M., Baumstarck, K., Loundou, A., Franck, N., Lançon, C., & Auquier, P. (2022). Effect of psychiatric advance directives facilitated by peer workers on compulsory admission among people with mental illness: A randomized clinical trial. JAMA Psychiatry, 79(8), 752-759. http://doi.org/10.1001/jamapsychiatry.2022.1627 Walker, S., Mackay, E., Barnett, P., Sheridan Rains, L., Leverton, M., Dalton-Locke, C., Trevillion, K., Lloyd-Evans, B., & Johnson, S. (2019). Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: A systematic review, meta-analysis, and narrative synthesis. The Llancet Psychiatry, 6(12), 1039– 1053. https://doi.org/10.1016/S2215-0366(19)30406-7CopyDownload .nbib Wasserman, D., Apter, G., Baeken, C., Bailey, S., Balazs, J., Bec, C., ... & Vahip, S. (2020). Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries. European psychiatry, 63(1), e82. https://www.cambridge.org/core/journals/european-psychiatry/article/compulsory- admissions-of-patients-with-mental-disorders-state-of-the-art-on-ethical-and-legislative- aspects-in-40-european-countries/C298EEFC767611182CF5F2B6EA228568 Western Montana Mental Health Center (n.d). Who we are. Retrieved October 29, 2023, from https://www.wmmhc.org/who-we-are World Population Review. (2024). Most Rural States. https://worldpopulationreview.com/state- rankings/most-rural-states https://doi.org/10.12688/wellcomeopenres.17947.1 https://doi.org/10.12688/wellcomeopenres.17947.1 https://www.ncbi.nlm.nih.gov/books/NBK538297/ https://doi.org/10.1016/S2215-0366(19)30406-7 https://www.ncbi.nlm.nih.gov/pmc/resources/citations/7029280/export/ 45 APPENDIX EVENT OUTCOMES 46 Table 1. Event Outcomes key: CI/CA=Number of Clients Invited/Clients Attending CCP/NCP=Number of Clients who Completed PADs/Not Completed Pads PRWC/NWC=Number of Participants receiving wallet cards/Not receiving cards PCS/PNCS=PSSs or Clients who Completed Survey/Not Completed Survey PSST/PSSF=Peer Support Specialists Trained/Peer Support Specialists Facilitating Event CI/CA % CCP/NCP % PRWC/NWC PCS/PNCS PSST/PSSF % 1 5/5= 100% 1/5= 20% 0 0 4/2= 50% 2 8/8= 100% 2/8= 25% 0 0 3/3= 100% 3 8/8= 100% 1/8= 12.5% 0 0 2/2= 100% Note: The number of PSSs who attended a training, then facilitated an event at their location of employment was calculated for each event. ©COPYRIGHT ACKNOWLEDGEMENTS TABLE OF CONTENTS TABLE OF CONTENTS CONTINUED LIST OF TABLES ABSTRACT INTRODUCTION Review of the Literature Search Strategy Eligibility–Inclusion and Exclusion Criteria Results Discussion and Conclusion QUALITY IMPROVEMENT PROPOSAL Problem Statement Organizational Microsystem Assessment Quality Improvement Model/Framework Project Purpose and Aims Methods Interventions and Implementation Evaluation and Analysis Safety and Confidentiality A QUALITY IMPROVEMENT PROJECT TO BOLSTER PSYCHIATRIC ADVANCE DIRECTIVE UTILIZATION IN COMMUNITY MENTAL HEALTH Contribution of Authors and Co-Authors Manuscript Information Introduction Clinical Problem Review of Literature Conceptual Framework Aims Methods Project Team Interventions PSS Training Workshops. Three online training workshops scheduled within a two-week timeframe prepared PSSs to lead peer-facilitated events. PSSs viewed a short film describing PAD benefits and the impact of utilization, then carefully reviewed a PAD... Peer-facilitated Events. During peer-facilitated events, clients viewed the PAD informational film. PSSs then led a discussion. Clients were invited to ask questions and express concerns. Copies of PAD documents were available for clients wishing to ... Measures Ethical Considerations Results Discussion Limitations Recommendations Conclusion HOW THE DNP PROGRAM ALLOWED ME TO MEET DNP ESSENTIALS Introduction Scientific Underpinnings for Practice Organizational and Systems Leadership for Quality for Quality Improvement and Systems Thinking Clinical Scholarship and Analytical Methods for Evidence-Based Practice Information Systems and Patient Care for the Improvement and Transformation of Healthcare Health Care Policy for Advocacy in Healthcare Conclusion REFERENCES CITED APPENDIX