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Depression is a severe condition that decreases patients quality of life and tends to be rather challenging to manage. As a result, it is crucial to equip healthcare workers with tools to help them in depression management. The present proposal describes a project that offers the VEGA medical center, which currently lacks any consistent guidelines on the topic, to implement the guidelines for depression management developed by the National Institute for Health and Care Excellence [NICE] (2016a). The paper contains a description of the problem, the key features of the project, including the PICOT question, theoretical framework, settings, and evaluation plans, and a review of the relevant literature to demonstrate that the practice recommendation is evidence-based.
Significance of the Practice Problem
Depression is a significant and rather prevalent health concern (Duhoux, Fournier, Gauvin, & Roberge, 2012; Petrosyan et al., 2017). It tends to cause suffering and decrease the quality of life in patients and the members of their families; also, it can be related to increased mortality in patients and is typically associated with lower general health and income when compared to the non-affected population (Duhoux et al., 2012; Petrosyan et al., 2017; Taylor, 2014).
Moreover, healthcare costs are also affected by depression, which is also related to increased healthcare services (Petrosyan et al., 2017). As for the prevalence, up to 16% of the US population aged 18 or older are reported to have experienced at least one major depressive episode (Center for Behavioral Health Statistics and Quality [CBHSQ], 2016, p. 3054). Overall, it is apparent that depression is a national concern for the US.
Among other populations, depression occurs in the elderly: it can be a recurrent or chronic condition, but a late-life onset is also a possibility. In the US, the percentage of adults older than 50 years who have been diagnosed with a major depressive episode amounted to 4.8% in 2015 (CBHSQ, 2016, p. 3055). Depression in the elderly is incredibly tricky to manage due to the specifics of the population: older people are more vulnerable and exceedingly likely to experience various medical conditions in addition to depression (Taylor, 2014). Thus, appropriate management of depression is crucial for the elderly population.
Unfortunately, depression management is not always efficient, and it is a superior quality of care problem. The recent studies by Petrosyan et al. (2017) and Straten, Hill, Richards, and Cuijpers (2015) describe this fact as a macro-level issue: they state that the detection and management of depression are currently not very useful throughout the world. In their consideration of the problem, Straten et al. (2015) focus on the inefficiencies in treatment, especially when some patients receive excessive services while others are under-treated. This inefficiency may affect patient outcomes in the latter case, leading to less effective depression management (Belsher et al., 2016; Straten et al., 2015), a significant care quality issue.
On the other hand, the former case (excessive treatment) is not economically feasible (Aa et al., 2015). The latter issue is especially crucial for the US due to its continuously growing healthcare expenditures. Indeed, US healthcare spending is currently more remarkable than that of any other country, which does not necessarily reflect patient outcomes (Woolf & Aron, 2013). However, multiple researchers agree that the problem can be resolved by introducing clear guidelines and a practical framework for depression management (Aa et al., 2015; Belsher et al., 2016; Straten et al., 2015; Petrosyan et al., 2017).
Thus, the critical problem that will be considered in the proposed research is inefficient depression management, predominantly related to the quality of provided care. The significance of the issue is apparent due to how it affects the lives of the patients, including the vulnerable elderly population, and the financial strain on healthcare that it causes, which the US should not have to afford. Given the prevalence of depression in the US, the introduction of appropriate interventions in its healthcare facilities is of notable importance.
PICOT Question
The following PICOT question has been formulated for the project: in community clinic nursing staff, how does the introduction of NICE (2016a) guidelines within ten weeks affect the accuracy of diagnosing and managing depression in the older population compared to the staffs performance before the intervention?
The population in question includes the nurses of the VEGA medical center. The expected sample is ten nurses. The participants will be included regardless of their gender, ethnic backgrounds, and age. Their experience and education are not going to affect recruitment either. Technically, the inclusion criteria are the profession and the place of work of the potential participants.
The proposed intervention is a NICE (2016a) guidelines. They are evidence-based and updated; according to the AORN model for evidence rating, such policies can be viewed as sufficient evidence for a practice to be recommended (Spruce, Wicklin, Hicks, Conner, & Dunn, 2014, p. 253). The guidelines are very comprehensive, but they focus on the stepped care model, discuss the critical aspects of caring for people with depression, and recommend specific evidence-based interventions.
In general, the guidelines describe working with patients with depression from the diagnosing process to their recovery. There are not enough articles that offer research on the implementation of NICE (2016a) guidelines, but extensive evidence shows that various aspects of the practice are appropriate. The intervention is not yet implemented at the VEGA medical center, but a nurse leader supported by the organizations management can organize its introduction into practice.
The current project does not have a comparison group; it is a test of change. As a result, the project is going to consider the pre- and post-intervention performance of the VEGA center nurses. The changes in the quality of depression management are viewed as the outcome of this project; the desired result is its improvement. The effects (as well as the pre-intervention quality of depression management) are going to be assessed with the help of the National Institute for Health and Care Excellence [NICE] (2016b) quality standards for depression management.
They are very comprehensive and include multiple quality indices, the majority of which are presented in the form of a percentage (for instance, the rate of recommended decisions on patient care). The indices are organized with the help of thirteen statements. The National Institute for Health and Care Excellence (n.d.) claims that the standards are valid, making them an appropriate tool for the project. The assessment is also in line with the NICE (2016a) guidelines for depression treatment; all the NICE (2016a) tools, which are included in the guidelines, refer to these standards.
The expected timing of the project is between eight and ten weeks, which should be enough for the key activities, including the introduction of the change, major assessments (pre- and post-intervention), and the measurement of the short-term outcomes. A longitudinal study could naturally provide some information on the long-term effects and sustainability, but the proposed research will focus on the short-term ones. If deemed feasible by the organization, a follow-up project can be carried out in the future.
Theoretical Framework
The intervention is a notable evidence-based change for the settings, so the use of change or evidence-based practice models is required for the project. The Iowa Model of Evidence-Based Practice (IMEBP) is a well-established model that guides the process of translating evidence and guidelines to practice (White & Spruce, 2015). As summarized by White and Spruce (2015), several key steps constitute the model. First, it is necessary to determine the problem and review it to establish if it is a priority for the organization. After that, the evidence pertinent to the issue is assembled and critiqued to determine the possible solution, which is sufficiently rooted in research.
The choice of the solution is followed by its pilot launch, which is evaluated to determine its appropriateness. It is possible to adjust the change to the organizations needs until it is suitable, after which it is routinized, and the results of the shift are disseminated. The figure that depicts IMEBP can be found in the article by White and Spruce (2015) or Brown (2014); its reprinting has to be authorized by the University of Iowa Hospitals and Clinics (n.d.).
IMEBP can guide every element of the project from needs assessment to evaluation. Some of the parts have already been carried out, including the determination of the issue and its priority and research and change choice. IMEBP can also help in the processes of implementation, evaluation, and dissemination. One of the strengths of the model is the fact that it is not linear; specific steps can be repeated multiple times to ensure that the proposed change is indeed necessary and capable of satisfying the needs of the organization. Due to its merits and ability to guide the interventions implementation, IMEBP is appropriate for the proposed project.
Other models will be used to enhance the process. For instance, Rogers (2010) Innovation Diffusion Theory would help during the implementation. In particular, the characteristics of innovation are a beneficial framework that can help modify the nurses perceptions of the innovation to enable them to routinize it faster and more effectively (Hanrahan et al., 2015). However, IMEBP is the theoretical core of the project.
Synthesis of the Literature
The search that was performed for this project could not locate any articles that would specifically test the NICE (2016a) guidelines. However, the fact that the guidelines are rooted in evidence can be proven. First of all, NICE (2016b) states that all of its standards and guidelines result from a collaborative effort (shared by nursing colleges and organizations of the UK) that aims to synthesize available evidence through research, discussion, revision, and validity checks.
Thus, NICE (2016b) works to make its guidelines evidence-based. In turn, such guidelines are viewed by the nursing community as evidence of a very high level; such guidelines are sufficient for a practice to be viewed as recommended (Spruce et al., 2014, p. 253). Thus, it can be suggested that NICE (2016a) guidelines are evidence-based by being high-quality guidelines developed by the healthcare community of the UK.
However, additional evidence can also be provided. In particular, the specific aspects of the guidelines can be supported by modern literature. The NICE (2016a) guidelines are very comprehensive, so it would be challenging to review all the evidence on every recommendation that it provides. As a result, for the current proposal, several aspects of the guidelines have been chosen to be considered from the perspective of the currently available literature.
An example of interventions that are recommended by NICE (2016a) is stepped care, which is an approach to care that prioritizes the employment of the most influential and evidence-based, as well as the least intrusive, intervention as the initial treatment and its substitution in the cases when it is not practical, or the patient does not want to use it. Straten, Hill, Richards, and Cuijpers (2015) point out that this approach is supposed to be more effective and cost-efficient; technically, its development responds to the existing problem of excessive and insufficient treatment that affects patients with depression nowadays.
Trials indicate that stepped care can indeed resolve the issue of inadequate treatment in various populations, including older adults (Aa et al., 2015; Belsher et al., 2016), although there is not sufficient evidence to claim that it tends to improve the cost-efficiency of treatment (Straten et al., 2015). In their systematic review, Straten et al. (2015) point out that there is not much high-quality evidence on the use of stepped care in depression management. Still, the present information does suggest that it is beneficial for patient outcomes. Thus, stepped care can be viewed as a reasonable recommendation. It is also noteworthy that the articles mentioned above support the idea that clear and effective frameworks and guidelines can improve depression management.
Another recommendation that NICE (2016a) suggests is cognitive-behavioral therapy (CBT), including cognitive therapy (CT). This approach to depression treatment is relatively well-researched (Naeem et al., 2015), and finding high-quality articles on the topic is not difficult. For instance, Naeem et al. (2015) conduct an RCT to test the effectiveness of culturally adapted CBT and show that it is more effective than usual treatment and results in sustainable improvement in patients with depression.
Also, Hollon et al. (2014) show that CBT enhances pharmacotherapy, increasing the recovery rates for depressed patients, which is the goal of depression treatment. Driessen et al. (2013) also test CBT with the help of an RCT and show that it effectively attains remission and reduces symptoms. Thus, the existing evidence supports the approach.
Moreover, NICE (2016a) also recommends using intrapersonal therapy (IPT), and this approach is also sufficiently researched. For instance, Cuijpers, Donker, Weissman, Ravitz, and Cristea (2016) offer a systematic review and meta-analysis of RCTs on the topic and demonstrate that IPTs effectiveness in depression treatment is notable; for example, when employed in subthreshold depression, it is capable of preventing major depression.
The authors also highlight the fact that IPT is more effective when combined with other treatments (for instance, pharmacotherapy). Finally, IPT is shown to be more effective than treatment as usual in specific populations (for example, women with chronic pain or earthquake survivors) (Jiang et al., 2014; Poleshuck et al., 2014). Thus, sufficient evidence supports this intervention, as well.
Multiple trials compare CBT or CT to IPT. The majority finds that the two are more or less similar in their effectiveness, which makes them interchangeable and appropriate alternatives that can depend entirely on patients preferences. Lemmens et al. (2015) compare the clinical effectiveness of the two approaches and find that they effectively reduce the severity of depression. Lemmens, DeRubeis, Arntz, Peeters, and Huibers (2016) discover that the sudden gains prompted by the two approaches are comparable; in fact, CBT seems to have greater rates of sudden gains, but controlling for individual factors like the between-session intervals makes this change statistically insignificant. Thus, the evidence appears to predominantly suggest that IPT and CBT are more or less interchangeable.
However, Donker et al. (2013) compare specific interventions based on Internet platforms and find slightly different results. The authors demonstrate that two recently developed interventions (one based on CBT and one based on IPT), which are meant for self-treatment, can reduce the symptoms of depression in patients, but CBT shows better results. It is noteworthy that this outcome is only applicable to self-guided and Internet-based specific interventions, which is why the results may be not very generalizable. Therefore, it is difficult to state that the article directly challenges the outcomes found in the works by Lemmens et al. (2015) and Lemmens et al. (2016). Still, it can be suggested that there is some contradicting evidence on the relative effectiveness of IPT and CBT, but both are proven to be effective in depression management.
A problem encountered during the search is that few sources review the specifics of treating depression in the elderly population. The majority of sources specifically target the population between 18 and 65 years old, which may be prompted by ethical considerations. Still, the RCT by Aa et al. (2015) specifically targets older adults; the systematic review by Straten et al. (2015) includes four studies that target older populations, but they are not very recent.
Also, Hollon et al. (2014) and Jiang et al. (2014) do not specify the age of the participants of their RCTs beyond stating that they are older than 18, and Cuijpers et al. (2016) report that their review focused on any age groups. Thus, there is some evidence that supports the employment of all the mentioned interventions in older populations, but this group of patients does not seem to be very well-researched.
Except for the systematic reviews and meta-analyses by Straten et al. (2015) and Cuijpers et al. (2016), the sources mentioned above present the results of RCTs. As can be seen in Appendices A and B, most of the sources also have relatively large samples, employ well-established methods of data collection and analysis, and introduce ways of bias reduction like triangulation. It is also noteworthy that smaller samples are characteristic of the sources that review specific populations; for instance, Jiang et al. (2014) consider particular patients, earthquake survivors with depression. Mostly, the samples exceed one hundred people.
Both systematic reviews diligently describe their methodology, highlighting their triangulation procedures and the methods of determining the quality of studies. Thus, it can be suggested that the presented evidence is high-quality. As for the level of evidence, using the evidence pyramid described by Polit and Beck (2017), RCTs should be viewed as evidence of the second level. The systematic reviews are evidence of the highest level. Therefore, the NICE (2016a) guidelines interventions are supported by the highest-level evidence.
In summary, no recent articles appear to test the NICE (2016) guidelines, but their elements are supported by high-quality recent evidence, including RCTs and systematic reviews. Some inconsistent results also suggest that specific interventions may be more effective than other options, as can be seen in CBT and IPT: the former may be more effective than the latter. However, this evidence is inconsistent and appears to apply to specific interventions; CBT and IPT are mostly shown to be interchangeable and effective.
Also, there seems to be a shortage of studies that would consider the elderly as their primary population. Still, a few studies do include some information on this group of patients. Finally, some of the studies demonstrate that the introduction of clear frameworks and guidelines like stepped care, which is supported by NICE (2016a), can be beneficial for depression management. Thus, it can be suggested that modern literature supports the interventions proposed by the NICE (2016a) guidelines.
Practice Recommendations
The evidence provides some indirect support to the idea that the introduction of evidence-based guidelines can affect community clinic nursing staff, improving the accuracy of diagnosing and managing depression in the older population, which is an answer to the PICOT question. No discovered evidence directly discusses the NICE (2016a) guidelines, but there is sufficient evidence that supports its interventions. The interventions appear to be relatively well-researched. The studies that provide this support include RCTs and systematic reviews with decent samples and consistent methodology. This evidence can be viewed as high-level and high-quality information, which implies that it is capable of supporting practice (Spruce et al., 2014, p. 253).
The majority of the statements produced by the evidence can be described as consistent. A minor discrepancy appears with respect to the comparative advantages of the two of the proposed interventions. It is not apparent which one of them is more effective: CBT or IPT. However, the idea that both are roughly equal in their effectiveness appears to be dominant.
The majority of the studies, especially RCTs, purposefully avoid the elderly population, which slightly limits the applicability of the research to the patient population of interest. In general, when compared to the population aged 18-65, the elderly population appears to be understudied. Still, all the mentioned interventions are shown to benefit the elderly population in at least one study.
It is also noteworthy that several studies (those devoted to stepped care) comment that the presence of a clear framework for depression management is expected to be beneficial both for the patients and the organization. Thus, the practice recommendation for modern healthcare organizations would be to adopt appropriate guidelines that promote evidence-based practice. NICE (2016a) guidelines correspond to these requirements, which means that the evidence supports the proposed intervention.
Project Setting
The proposed project is going to take place at the VEGA medical center, which is located in Miami, IL. It is a primary care center that focuses on Family Medicine and Internal Medicine provided in various settings, from offices to hospitals. The organizations vision is to build healthier communities, and its mission is to provide high-quality and affordable care. The companys fundamental values include innovation, which is in line with the proposed project; the project is also aligned with the mission and vision because all of them aim to improve the quality of care.
The center celebrates diversity and promotes culturally competent care because VEGA serves a culturally and economically diverse community. The elderly population of both genders may be prevalent among the patients because of various chronic illnesses treated by the center, but other age groups are also served by it. As a result, the proposed project targets the population that is relatively prevalent among the centers patients.
The institutions key decision-makers include the owner, medical director, and the administrator and manager, who comprise the bulk of the centers organizational structure. The support of the administration has already been received in the letter of support. However, no financial aid will be provided for the project. The center nurses are included in decision-making, which is shared, and this factor facilitates nurse-led change. In general, the organization welcomes change due to its innovation value. However, it is possible that a significant innovation might meet some resistance due to the specifics of the change process (Hanrahan et al., 2015).
The process of needs assessment has been carried out with the help of a discussion with the administration and the staff of the center. In particular, the administrator and manager of the center and two of the nurses have agreed that the absence of straightforward guidelines on depression diagnosis may have detrimental effects on the quality of care. Also, one nurse suggested that it would be more convenient for the staff to have direct guidelines. Thus, the need for policies is recognized by the organization. Using the Iowa model terminology, this trigger is related to a problem (an absence of practice) (Brown, 2014), which can be resolved with the help of the NICE (2016a) guidelines.
The projects primary stakeholders are the nurses of the VEGA medical center, their patients, and the organization itself. The absence of the standardized guidelines may complicate the treatment of patients with depression (Petrosyan et al., 2017), which is especially problematic for vulnerable populations like older adults (Taylor, 2014). Moreover, the nurse advisor from the VEGA center suggests that the existence of clear guidelines will make the process of depression management more comfortable for the staff.
Both these outcomes would be expected to lead to increased satisfaction in nurses and patients and better results, which is beneficial for the company and its reputation. Finally, the standardization of the guidelines improves the cost-effectiveness of service, which is useful for the organization (Duhoux et al., 2012). Thus, multiple stakeholders will benefit from the change.
The innovation is expected to be sustainable since it presupposes the change of the centers policy with respect to depression management. The adaptation of the change to the needs of the organization and the routinization of the guidelines will be supported by the tools suggested by the theoretical frameworks. After the project, the nursing leaders and the administration will ensure the sustainability of the change. No unexpected consequences are likely to occur because of the implementation of an EBP guideline, and it poses no danger. The only possible risks may be connected to the resistance to change or ineffective use of the policies, which might affect the outcomes.
A SWOT analysis of the project is presented in the form of a table in Appendix C. It demonstrates that the projects key strength is the evidence-based intervention that can address the organizations problem, and the weaknesses are related to the restricted time and budget. Still, the timeline should be sufficient for gathering baseline data, introducing new guidelines and providing training on their use, and collecting data on the outcomes.
The budget will be managed carefully. The organization offers the opportunities which the project intends to employ, including the support of the stakeholders. However, the project also recognizes that there is a possibility of resistance to change and inefficient employment of the guidelines. The former issue is going to be addressed with the help of the theoretical frameworks (especially Rogers (2010) theory), and the latter will be mitigated with the help of formative assessments.
Project Vision, Mission, and Objectives
The vision of the project is to achieve the optimal quality of the management of depression in the older patients of the VEGA medical center. Its mission is to improve the quality of depression management of the VEGA center by promoting evidence-based practices with the help of standardized guidelines provided by the National Institute for Health and Care Excellence [NICE] (2016a). The project is in line with VEGAs vision and mission.
As it was mentioned, VEGA aspires to improve the health of the community, and its mission is high-quality and affordable care. The promotion of evidence-based practice is likely to improve the quality of depression management. Therefore, the health of the community and the employment of care standards can positively impact the costs of care (Petrosyan et al., 2017).
For the projects objectives, the SMART framework is used: it involves the consideration of the specific, measurable, achievable, realistic, and timely objectives (Murray, 2017, p. 347). Two long-term objectives are proposed to prove the adoption of the guidelines and measure their effects.
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At the completion of the project (week ten, timeframe), all the adopted quality indicators suggested by the National Institute for Health and Care Excellence [NICE] (2016b) will experience at least a twenty-percent improvement (specific, realistic, achievable) as evidenced by the depression case management documentation (measurable).
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At the completion of the project (week ten, timeframe), all the participants will report being able to apply the new guidelines as evidenced by the documentation of the final discussion with them (specific, realistic, achievable, and measurable).
The first objective can be supplemented by the following long-term objective.
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At the completion of the project (week ten, timeframe), the must-do quality indicators suggested by NICE (2016b) will achieve 100% (specific, realistic, achievable), as evidenced by the depression case management documentation (measurable).
The must-do aspects include, for instance, proper assessment procedures, the revision of treatment for resistant cases, and so on.
Short-term objectives are the following ones.
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During the first week of the project (timeframe), 100% of the nurses will review and understand the new guidelines, as evidenced by their reports during the discussion of the first week (specific, realistic, achievable, and measurable).
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At the beginning of the second week of the project (timeframe), 100% of the nurses will be using the new standards (specific, realistic, achievable), as evidenced by their use of depression case management documentation (measurable).
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By the fifth week of the project (timeframe), at least 50% of the nurses reported concerns and difficulties would be addressed (specific, realistic, achievable), as evidenced by the discussion documentation (measurable).
Additional goals may be introduced by the principal investigator in collaboration with the nurses.
The project aims to improve the quality of care, but it is acknowledged that this outcome may not be achieved. Thus, the unintended consequence of the project is the lack of improvement. Moreover, the change is a complex process that might cause short-term confusion and a decrease in care quality. Also, the change might put additional pressure on nurses, which may also negatively affect their productivity and, possibly, discourage them from employing the new methods. All the stress-related risks and unintended consequences are going to be mitigated with the help of active communication and the projects theoretical and practical change models.
Project Plan
The project will employ the change model by Rogers (2010). The theory suggests that a change includes five stages; knowledge, persuasion, and decision (p. 193), followed by the implementation and confirmation stages. The first three stages include the exposure to the information about the innovation, the understanding of its perceived value, and the decision to adopt. The two remaining steps describe the process of adoption and the reinforcement of the need for innovation. The model is going to guide managing the nurses decision to adopt, which will affect the sustainability of the change.
Indeed, the five stages of the approach are focused on the engagement of individual stakeholders, which is an essential basis for organizational change: technically, the latter depends on the former (Pashaeypoor, Ashktorab, Rassouli, & Alavi-Majd, 2016). Moreover, the theory also discusses the innovation properties, determination, and management of which can help the stakeholders in adopting (Hanrahan et al., 2015).
For instance, determining that a change is viewed as too complicated should prompt additional educational efforts, changing this perception. Overall, the theory promotes sustainable change, and its emphasis on the individual adoption processes will help address nurses concerns and difficulties.
As an individual change model, Rogers (2010) theory can be viewed as a complementary one to IMEBP, which is more organization-focused, at least within the proposed project. Hanrahan et al. (2015) demonstrate that both models can be successfully merged for improved outcomes. Rogers (2010) theory is incredibly valuable in this respect since it provides the project with multiple tools for individual and group motivation, which will help the nurses to adapt to the change and make the latter sustainable.
Project Schedule
Since both the theoretical and change model are instrumental for the process of change, the project plan should be considered from the perspective of their merger, as presented by Hanrahan et al. (2015). Thus, the pre-intervention activities are supposed to include the organizational evaluation process and the research aimed at determining a solution to the issue discovered at t
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