Perspectives in Psychiatric Care
ISSN 0031-5990
Evaluation of an Innovative Late-Life Depression Training Program Marianne Smith, PhD, RN, Mary Ellen Stolder, PhD, RN, and Megan Fang Liu, PhD, RN Marianne Smith, PhD, RN, is Assistant Professor, College of Nursing, University of Iowa, Iowa City, Iowa, USA; Mary Ellen Stolder, PhD, RN, is Assistant Professor, School of Nursing, Viterbo University, La Crosse, Wisconsin; and Megan Fang Liu, PhD, RN, is Assistant Professor, College of Nursing, Taipei Medical University, Taipei, Taiwan.
Search terms: Depression, training nursing roles, behavioral activation, problem-solving methods, older adults Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors declare no actual or potential conflicts of interest.
PURPOSE: This paper describes evaluation findings associated with an innovative, CD-based, self-directed training program that was designed to improve general practice nurses’ abilities to identify and care for older adults with depression. DESIGN AND METHODS: A voluntary sample of nurses completed an evaluation that focused on participants’ perceptions of changes in their knowledge and skills and usefulness of the program. FINDINGS: Quantitative items received high ratings, and narrative responses to open-ended questions were largely positive. PRACTICE IMPLICATIONS: Many opportunities exist for psychiatric nurses to facilitate, support, and extend training principles to promote late-life depression recognition and treatment.
First Received August 29, 2012; Final Revision received January 19, 2013; Accepted for publication February 15, 2013. doi: 10.1111/ppc.12019
Depression is widely recognized as a major public health problem that is both prevalent and highly associated with disability among older adults (Chapman & Perry, 2008; Rogers et al., 2010; Strine et al., 2009). In late life, subsyndromal or “minor” depression is also associated with increased physical health burden and disability (Lyness, Chapman, McGriff, Drayer, & Duberstein, 2009; Watson et al., 2006), making it an equally important target of care and treatment. Rates of clinically significant depression increase with the need for healthrelated assistance support, affecting an estimated 14% of older adults in home care, 32% in residential care settings, 37% of those who are hospitalized, and 44% of nursing home residents (Anstey, von Sanden, Sargent-Cox, & Luszcz, 2007; Ciro et al., 2012; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2011). However, depression symptoms may be more challenging to recognize in older adults compared to younger ones for a variety of reasons. Overlapping chronic physical health conditions that may mask depression, loss and life changes that are considered “understandable causes” for depression, and the tendency of elders to attribute their depression symptoms to physical causes regularly interfere with recognizing depression symptoms as depression by older adults themselves, their family members, and health providPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
ers who provide regular care and treatment (National Institute of Mental Health [NIMH], 2007). The cycle of depression described in the highly successful depression treatment program, Improving Mood: Providing Access to Collaborative Treatment (IMPACT) (Unutzer et al., 2002), emphasizes the important interactions among thoughts and feelings,stressors,physical problems,and behaviors that interact to contribute to late-life depression. Effective treatment often relies on recognizing and addressing factors that cause, contribute to, and perpetuate late-life depression. Although designed for use in primary care settings, IMPACT principles and treatment approaches may be applied in diverse settings. Key components include regular depression screening; using standardized scales and systematic monitoring; treating problems that contribute to depression; and treatment that includes depression education, behavioral activation (i.e., increasing pleasant activities), problem-solving therapy and/or medication management, and relapse prevention plans (University of Washington, 2009). Outcomes associated with the IMPACT intervention included significant reduction of depression symptoms, more satisfaction with care, less functional impairment, and greater quality of life for those in the treatment group compared to 19
Evaluation of an Innovative Late-Life Depression Training Program
elders receiving usual primary care (Unutzer et al., 2002). These positive results have fueled the replication, adaptation, and extension of IMPACT in other settings and populations (Grypma, Haverkamp, Little, & Unutzer, 2005). One extension of IMPACT was the development of a CD-based depression training program that targeted nurses who come into regular contact with older adults who may have depression, but are not psychiatric-mental health specialists. The program, Depression Training to Promote Nurses as Advocates for Older Adults, was designed to assist nurses in community, long-term, and acute care settings to better identify, assess, refer, and provide direct nursing care to older adults with depression (Smith, Johnson, Seydel, & Buckwalter, 2010). The purpose of this paper is to describe evaluation results associated with statewide dissemination of the Nurses as Advocates depression training program. Background information, including the rationale for selecting content and teaching/learning approaches used in the training program, is briefly described to provide a framework for understanding evaluation findings. Results focus on nurse participants’ perceptions of how the training program changed their knowledge of depression and its treatment, and their views about the usefulness of the training program. Quantitative data and descriptive narrative answers to open-ended questions provide important perspectives that may be used by psychiatric mental health nurses (PMHNs) in general and advanced practice to facilitate collaboration with their nurse peers in other settings and areas of practice. The important roles of PMHNs in facilitating, supporting, and extending depression training to further advance identification, assessment, monitoring, referral, and daily management of older adults with depression are discussed. Training Background and Development The CD-based depression training program was developed collaboratively by geriatric education center (GEC) personnel and college of nursing faculty in a Midwestern university, with assistance from instructional design and technical experts. The IMPACT approach to depression care was selected as the foundation on which to build the Nurses as Advocates depression training program for a variety of reasons. The IMPACT study regularly utilized nurses as depression care managers, underscoring the important contributions that nurses can make to late-life depression treatment (Haverkamp, Arean, Hegel, & Unutzer, 2004). Many of the IMPACT treatment approaches were within the scope of professional nursing practice, offering a logical transfer of ideas to daily nursing care. In addition, the overall success of IMPACT approaches in reducing late-life depression and improving function and quality of life for elders was clearly a motivating factor. Furthermore, the IMPACT Training Center offered a variety of high-quality materials, examples, 20
and resources to develop the CD-based training program (University of Washington, 2009). Each section of the CD-based program followed the same basic format: print handouts, view the digitized presentation, work through the case-based learning, and apply the workplace exercise in practice. The program was divided into sections so that learners could start and stop easily, and work at their own pace. A short digitized presentation introduced the four-part program and provided guidance on how each part was organized and intended to be used. The introduction recommended that learners move sequentially from Part 1 to 4 as the content in each tended to build on earlier content. However, the format of the program also allowed learners to use any section or component of the training, in or out of sequence, to permit easy access to content that was considered most useful or needed. The four parts were organized by content and included (a) understanding depression in late life, (b) assessing depression, (c) depression care for older adults, and (d) collaborating to promote positive outcomes. Training Distribution and Evaluation The Nurses as Advocates training program addressed three main objectives: (a) improve access to depression education, (b) increase the skills and knowledge of providers who care for elders with depression, and (c) improve the provision of quality, evidence-based depression care. The program was advertised using the statewide GEC databases and provided at no cost, including free continuing education units (CEUs). A total of 513 training packets were mailed to healthcare providers and facilities located in 97 of 99 counties in Iowa. Additional details related to the development and dissemination of the Nurses as Advocates training program are described elsewhere in the literature (Smith et al., 2010). Key features of the evaluation and the respondents are provided here to frame findings associated with changes in knowledge and perceptions of the usefulness of the training program. Evaluation Format and Analysis Training and CEU evaluation forms were included in the CD mailing packet along with instructions to return the forms in the self-addressed and posted envelope provided. Perceptions of how the training program influenced knowledge and skills included 18 items that were rated from 1 (very little) to 6 (very much) that were followed by an open-ended question. Another section included items related to training topics, methods, and strategies that were rated from 1 (useless) to 6 (useful). Following this section, an open-ended question invited respondents to list the three least and most useful things about the training program. Two additional openended questions asked respondents to describe any difficulPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
Evaluation of an Innovative Late-Life Depression Training Program
ties encountered using the program, and add any other comments, suggestions, or feedback about the program. Other sections of the evaluation related to changes in practice and outcomes of care are described elsewhere in the literature (Smith et al., 2010). Returned evaluations were labeled using a unique identifying (ID) number.Quantitative data were entered into a spreadsheet then analyzed using PASW 18 Statistics software (SPSS, 2010). Narrative responses were entered into a word processing program by ID number. Content analysis was undertaken by a team guided by an expert qualitative researcher. Narrative answers for each question were de-identified, sorted alphabetically, and examined for common themes related to responses. Conceptual content analysis using inductive processes (Elo & Kyngas, 2007) guided the review of responses, identification of concepts (called themes in this paper), analysis and coding of text,and resolution of discrepancies related to placement of responses within themes.
Training Participants A total of 250 individuals returned evaluation forms, resulting in a response rate of 49%. Respondents were largely employed by nursing homes (40%), community/home health agencies (24%), and hospitals (17%), with smaller numbers reporting employment with other settings (19%) such as assisted living, public health, adult day health care, and private practice. Most were staff nurses (57%), followed by nurses in management roles
(18%), care coordinators (6%), educators (7%), and other positions (12%). Education included associate degrees in nursing (49%), licensed practical nurses (19%), bachelor’s in nursing (15%), 3-year diploma in nursing (13%), master’s degrees (3%), and other education (1%). Less than half of the group (40%) reported having received previous depression education or training beyond what was provided in their basic nursing education.
Evaluation Results Changes in Knowledge As shown in Table 1, nearly all of the 250 participants responded to the 18 items that followed the request “Rate the extent to which the training program increased your knowledge about depression and care you provide to older adults.” Individual scores ranged from 1 (very little) to 6 (very much). Average (mean) scores ranged from a high of 5.1 for administering and rating the PHQ-9 (the 9-item Patient Health Questionnaire) depression scale (Spitzer, Kroenke & Williams, 1999) to a low of 4.5 for communicating with physicians. A total of 54 of 250 participants (22%) responded to the request “Did the depression training program influence your knowledge or skills in other ways?” Four main themes included assessment methods and scales, awareness of depression, importance of individualized care, and nursing care and interventions. Table 2 provides definitions of knowledge-related themes and examples for each.
Table 1. Extent to Which Training Increased Knowledge Item
N
Min
Max
Mean (SD)
Administering and interpreting the PHQ-9 Nursing assessment of depression Diagnostic criteria for depression Using scale scores in decision-making Using other screening and rating scales Depression-related nursing interventions Importance of scheduling pleasant events Nursing roles in antidepressant management Using follow-up methods to improve outcomes Outcome monitoring methods Symptoms of depression in late life Identifying person-centered goals and outcomes Behavioral activation Factors that cause and contribute to depression Making referrals for depression evaluation Communicating with team members Nursing roles in psychotherapy management Communicating with physicians
249 247 249 249 249 249 249 249 249 249 249 249 249 249 249 249 248 249
2 1 1 2 2 1 1 2 1 2 1 2 1 1 1 1 1 1
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
5.1 4.9 4.9 4.8 4.8 4.8 4.8 4.8 4.7 4.7 4.7 4.7 4.7 4.6 4.6 4.6 4.5 4.5
(.9) (1.0) (.9) (.9) (.9) (.9) (1.1) (.9) (1.0) (1.0) (1.0) (1.0) (.9) (1.1) (1.0) (1.1) (1.0) (1.1)
Note: Min, minimum value; Max, maximum value; SD, standard deviation; PHQ-9, 9-item Patient Health Questionnaire. Items were rated on a scale where 1 = very little to 6 = very much.
Perspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
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Evaluation of an Innovative Late-Life Depression Training Program
Table 2. Other Ways the Training Influenced Knowledge Understanding and awareness of depressiona • Increase awareness to identify depression and symptoms of depression • It gave me a better understanding of the causes of depression in late life and things that you don’t always relate to depression, but are silent signs • Awareness of how depression/other illnesses coincide Assessment methods and scalesa • The PHQ-9 was new to me and very useful • Yes, to be more observant to other assessments • It is nice to be part of the diagnosis and fact-finding instead of just throwing pills at people • I think it just reminded me of how important the initial assessment is and the patient receiving help right away Nursing care and interventionsa • There are things we can do on a daily basis to help our residents get through their depression • It made me think about our residents and want to take a different approach on some of their behaviors/actions Importance of individualized carea • Looking at the whole person—physical, social, mental, spiritual, etc.—is important for well-rounded care • Each has their own unique circumstances a
Themes that were identified in the responses. Responses are provided as they were written by participants. PHQ-9, 9-item Patient Health Questionnaire.
Usefulness of Training The request to “rate the overall usefulness” of training components resulted in high overall scores. The main topics (Parts 1–4) were rated from 2 to 6, with mean scores of 5.0 or higher. See Table 3. Missing data were more common for application exercises, including case-based learning, workplace exercises, and appendix materials, suggesting that some participants may have failed to implement these components in practice. A total of 181 participants (72%) responded to the request to list the “three most useful things” about the training. Responses were largely composed of short answers and clustered into two main themes. The first theme, content addressed in the program, included 229 responses that clustered around the subthemes of assessment methods and scales, understanding and awareness of depression, nursing care and interventions, and communication methods. The second theme, format of the program, included 170 comments that clustered around the main teaching approaches: handouts, case-based learning, video presentations, workplace exercises, and appendix materials, as well as general appreciation for the program. See Table 4 for examples. A total 116 participants (46%) responded to the request to “list the three least useful things” about the training program. Of these, 22 (33%) offered positive comments, including “Everything was quite good,” “I found the entire program to
Table 3. Usefulness of the Training Program and Methods Component of Training
N
Min
Max
Mean (SD)
Part 1: Overview of depression reviews common signs and symptoms of depression in older adults, including diagnostic criteria, differences between major and minor depressions, and factors that may cause and contribute to depression in late life Part 2: Assessing depression encourages problem-solving approaches, provides instruction to use the PHQ-9 scale, and recommends scales to assess cognitive ability, pain, and anxiety that are common comorbid conditions with late-life depression Part 3: Depression care for older adults reviews independent nursing interventions to reduce and treat depression, focusing on behavioral activation (scheduling pleasant events), addressing related health problems, and monitoring outcomes. Part 4: Collaborating to promote positive outcomes emphasized the importance of teamwork and communication among care and treatment team members, including nurses and physicians who prescribe antidepressant and other medications Video training programs combine slides with a speaker to provide instruction for each of the four parts listed above Handouts accompany each of the four parts to support and extend information provided in the slide presentations that are part of the videos Case-based learning: Sandra Jo Green provides a video example of how to administer the PHQ-9 scale and a talk about scheduling pleasant events with older adults Workplace exercises are designed to apply principles of care, including administering the PHQ-9 scale, developing a depression-related care plan, and making referrals for assessment and treatment Appendix materials provided additional information about other resources related to late-life depression
245
2
6
5.0 (1.0)
246
2
6
5.2 (.9)
246
2
6
5.1 (.9)
245
2
6
5.0 (1.0)
245
1
6
5.0 (1.1)
241
1
6
5.0 (1.1)
232
1
6
4.8 (1.1)
230
1
6
4.7 (1.1)
230
2
6
4.9 (1.1)
Note: Items were scored from 1 (useless) to 6 (useful). Min, minimum value; Max, maximum value; SD, standard deviation; PHQ-9, 9-item Patient Health Questionnaire.
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Perspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
Evaluation of an Innovative Late-Life Depression Training Program
Table 4. Three Most Useful Things About the Training Program
Table 5. Three Least Useful Things About the Training Program
Content Addressed in the Training Program Assessment methods and scalesa • PHQ-9 depression assessment and scoring • Use and importance of using standardized scales • Recommendations regarding when to utilize different types of depression scales
Content of the Training Program Understanding and awareness of depressiona • Causes of depression
Understanding and awareness of depressiona • Better understanding of depression in older adults and how to recognize it • Elderly like to talk to someone—not be on medication • Reinforcement that depression is a disease and can be treated • The cycle of depression made it clearer for me to “get it” Nursing care and interventionsa • Education of patients and families • Incorporating pleasant activities • Listening to residents • Making simple adjustments • Non-medication interventions Communication methodsa • Communication tool to discuss depression cues • Nurse–physician communication info (information) • Communication techniques Format of the Training Program • Handouts were great to have and share with staff • Pleasant activity list • The case-based questions helped me see how to apply this • Easy-to-follow video presentation • Presenter’s voice and presence • Video: being able to see and hear the material at the same time • All of the exercises were useful • Excellent reference materials • All processes simple and direct—would not change a
Subtheme within the broad theme of program content. All comments are provided as they were written by participants. PHQ-9, 9-Item Patient Health Questionnaire.
be quite useful and user friendly,” and “The program was very useful to all aspects of my current work position.” The remaining individuals offered comments that clustered into two main themes, including 80 comments related to content and 58 comments related to format. Subthemes in these two areas were directly parallel to those identified as most useful aspects. That is, subthemes related to the most useful aspects were also identified as being the least useful. See Table 5 for examples. A total of 131 participants (52.4%) responded to the question “Did you have any other difficulties completing any part of the training program?” Of the 131 responses, 92 (70%) responded “no; no problems; or none,” and within that group 8 participants added a positive comment about the quality or usefulness of the training program (e.g., “No, this was a very user-friendly and comprehensive program,” “None, easy to use!”). Another eight participants responded with positive comments (e.g., “Very well explained and put together. DefiPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
Assessment methods and scalesa • Pain scale • PHQ-9 form • More explanation of tests Nursing care and interventionsa • Basic nursing interventions that are very common • Listing pleasant activities • Relapse plan Communication methodsa • Communicating with physicians • Referrals to care providers (do that now) Format of the Training Program • Speaker (too fast, too slow, monotone, singsong, distracting) • A lot of handouts • Patient exercises—Sandra Jo Green • Writing out plan/outcomes • Appendix materials • Noninteractive • Should have had a test • Would like to be in person • Would like it to be DVD compatible for staff • Too much information in a short time • No discussions a
Subtheme within the broad theme of program content. All comments are provided as they were written by participants. PHQ-9, 9-Item Patient Health Questionnaire.
nitely a lot of thought behind the information. Very useful in everyday situations”; “Yes, everything was useful. Could not think of least useful.”) The remaining 31 comments (24%) echoed problems and issues that were identified as the “least useful” aspects of the training program. In turn, the main themes clustered around format (n = 18) and function/ technical difficulties (n = 13). A total of 55 participants (22%) responded to the request “If you have other comments, suggestions, or feedback about the depression training program, please describe it in the space below.” Of those who replied, 12 were simple “no” replies and 24 provided general positive feedback and perspectives (e.g., “This is a great program on depression. Reminds you how big of a part of someone’s life depression can consume”; “Very useful! The PHQ-9 scale needs to be used universally for healthcare—not just for the elderly.”). The remaining comments echoed sentiments noted earlier in “least useful things” or “other difficulties.” Discussion Findings from this evaluation support the importance of depression training for nurses and allied health providers 23
Evaluation of an Innovative Late-Life Depression Training Program
who provide daily care and treatment to older adults, but are not specially trained in psychiatric-mental health nursing. The overall positive responses of nurses who participated in the Nurses as Advocates evaluation suggest that training improved their awareness and knowledge of late-life depression, particularly related to using standardized scales like the PHQ-9 to quantify and monitor symptoms and nursing roles in assessment and daily care interventions like scheduling pleasant events (behavioral activation). The narrative responses to open-ended questions were particularly informative both in terms of their quantity and quality. Twice as many participants (72.4%) provided “most useful” comments compared to those who provided “least useful” comments (35.6%). The number of individuals who took time to affirm that no problems were encountered and/or write positive responses to requests for least useful things, difficulties in completing training, and other comments similarly indicates that most learners benefited from the depression training program. An important trend in narrative responses is consistent with the adage that “strengths may also be weaknesses.” The themes and subthemes that emerged in the least and most useful things about training ran parallel to one another, indicating the things that some learners valued, other learners found unhelpful or even distasteful. For example, some learners expressed appreciation for the video (e.g., presenter’s voice and presence) while others listed it among the least useful aspects (e.g., speaker). Furthermore, the variability in comments all related to the speaker, who was too fast for some, too slow for others, and considered both monotone and singsong, points to individual preferences that are challenging to meet in a single approach. The Nurses as Advocates training program was designed to address a broad audience with varying levels of skill related to depression recognition and treatment. In order to assure that “basic” information was provided and reinforced, the program likely became too simple and/or redundant for those who already understood the content.The request to use all four parts of the program in sequence (which related to achieving a complete evaluation) likely deterred more experienced learners from viewing the product as a“menu”that could be used to best address their individualized training needs. Post-evaluation changes may address some criticisms. Instructions to complete the four program parts in full and sequentially have been removed. Since the evaluation is now completed,the five-page evaluation is no longer included.Free CEUs have been discontinued, and users now purchase the product and education credits for a modest fee. (Visit the Iowa Geriatric Education Center at http://www.healthcare. uiowa.edu/igec/ for additional information.) Together, these factors suggest that only those who wish to improve their depression care skills will acquire and use the product to meet their individualized needs. 24
Implications for Psychiatric Nursing Practice The outcomes associated with the Nurses as Advocates evaluation provide both generalist and advanced practice PMHNs with important information that may be used in a wide variety of roles, including but not limited to discharge planning in acute care settings, consultation and liaison roles within or between care settings, and both formal and informal education and/or training. Several key issues are salient to PMHNs and their practice. Understanding Depression. One of the most important themes that emerged in narrative comments related to gaining a greater understanding and awareness of late-life depression, which included responses both “other knowledge” and “most useful” aspects of training. A variety of comments suggested that nurses in general practice may benefit from formal and/or informal education related to late-life depression: “Depression is an illness on its own,”“Describing differences between major and minor depression,” “Leading cause of disability—ways to recognize and help patients,” “The cycle of depression made it clearer for me to ‘get it.’ ” PMHNs have many opportunities to educate their nurse colleagues during “informal” discussions of an older adult’s status, and through more traditional methods such as in-service programs, workshops, and other educational events. Whether formal or informal educational methods are used, narrative comments related to the format of the Nurses as Advocates training program may guide PMHNs to best help their peers. The emphases placed on training being “easy to follow,” “short,” and “understandable,” that “Handouts were great to have and share with staff,” and that “Case-based questions helped me see how to apply this” all provide direction for educational approaches. Some learners very much appreciated the CD-based format and the ability to work at their own pace, while others clearly would have preferred a live program that provided greater opportunities for questions and interaction. Educational approaches used by PMHNs may easily be designed to accommodate both needs, such as a “live” program followed by a self-directed learning assignment like the workplace exercises offered in the Nurses as Advocates program. Assessing Depression. The five most highly rated knowledge items all related to assessing depression: administering and interpreting the PHQ-9 depression scale,assessing depression, diagnostic criteria, using scale scores in decision-making, and using other screening and rating tools. The importance of assessment was further supported in narrative responses such as “Nursing assessment of depression,”“Importance and use of standardized assessment scales,” “PHQ-9 and other assessment forms,” and “Recommendations regarding when to utilize different types of depression scales.” Perspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
Evaluation of an Innovative Late-Life Depression Training Program
Gaining skills to quantify signs and symptoms using standardized rating scales for depression (e.g., PHQ-9) and common comorbid conditions such as anxiety and pain may also be facilitated by PMHNs. By introducing and explaining easy-to-use methods like the GAD-7 (Spitzer, Kroenke, Williams, & Lowe, 2006) or the Pain Thermometer (Herr, Spratt, Garand, & Li, 2007), PMHNs may improve both their nurse colleagues’ knowledge and the overall quality of care provided to older adults. As emphasized in the IMPACT approach, using standardized scales like the PHQ-9 to assess and monitor outcomes of treatment facilitates understanding of progress being made, and the possible need to adjust the course of treatment to achieve optimal outcomes. For example, preadmission or post-discharge discussion of an elder’s status may be greatly enhanced by reviewing changes based on a mutually understood scale. In other cases, quantifying comorbid conditions, such as anxiety, pain, or sleep disturbance, may facilitate both treatment and enhanced nursing care of contributing factors. Nursing Interventions. Another important area that PMHNs may address with their nurse peers involves the diverse array of “scope of nursing practice” interventions that do not rely on physician orders and may be used in daily care. Knowledge items related to nursing interventions were also given high ratings, including depression-related nursing interventions, importance of scheduling pleasant events, nursing roles in antidepressant medication management, using follow-up methods to improve outcomes, and outcome monitoring methods. These objectively rated items were supported with a variety of narrative comments, such as “Non-medication interventions,” “Providing depression education,” “Incorporating pleasant activities,” “Making simple adjustments,” “Response to a depressed person’s remarks,” and “Developing a plan for relapse.” As before, PMHNs may help their nurse peers to better understand and use a variety of approaches in daily care that are often, as the participants note, simple adjustments in how the nurse responds to older adult and depression-related behaviors or complaints. As emphasized in the IMPACT program and Nurses as Advocates training program, adapting daily routines to increase the frequency of pleasant events and activities (i.e., behavior activation) and physical activity (e.g., exercise) are effective interventions in depression treatment that nurses and allied health personnel may easily implement. Additional interventions, such as providing depression education to the older adult and his/her family, overseeing antidepressant medication use, measuring and reporting relevant outcomes to primary care providers, and assisting older adults to develop and use depression relapse plans, may be part of care or discharge plans developed by PMHNs and provided to other nurse providers. Of equal importance, nursing care approaches (and care plans) may target depressionPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
related problems such as difficulties in sleeping, anorexia, pain, anxiety, or other health concerns, as well as stress (loss, life change) that may be contributing to depression. In short, PMHNs may facilitate use of nursing interventions that may be used during psychiatric care, following discharge, and as part of care provided in other settings independent of hospitalization. Limitations and Next Steps This evaluation study has a number of limitations that warrant mention. First, the sample was composed of nurses from a single Midwestern state who requested the training program and voluntarily returned evaluations. Their perceptions may not be representative of the larger population of nonpsychiatric nurses or nurses in other parts of the country. Second, selfreported perceptions may not reflect actual changes in practice. We report only what nurses said they did/will do without verifying changes made. Furthermore, the written format may constrict the type or volume of information provided by participants. Finally, we did not use additional mailing or telephone calls to promote returning the evaluations to increase the response rate. These limitations reflect study constraints related to the time frame (1-year project) and funding level,and point to the need for further and more rigorous evaluation of the program and its use. Additional research is needed to further evaluate factors that may influence the use of recommended depression assessment and intervention approaches. Potential facilitating and impeding factors should be examined, including but not limited to (a) organizational support (e.g., setting or specialty-specific issues), (b) nurse-related characteristics (e.g., education or experience level, motivation), and (c) older adult characteristics (e.g., comorbidities; severity of illness; availability of support, assistance, treatment). The impact of nurse training on depressed older adults (and their families) should also be evaluated, including changes in level of depression and comorbid problems such as anxiety and pain, quality of life, and satisfaction with care and treatment. Summary and Conclusion The Nurses as Advocates evaluation findings provide important insights related to the value of depression training for nurses working in nonpsychiatric settings and an important foundation for future research. Responses to knowledge items and open-ended questions reinforce important roles that PMHNs may play in advancing knowledge and skills among their nurse peers who provide daily care to older adults with depression. Many opportunities exist to educate colleagues, both during informal conversations about patient care and through traditional educational formats, to enhance 25
Evaluation of an Innovative Late-Life Depression Training Program
understanding of depression, and to develop skills related to improving nursing assessment and interventions used in daily care. Acknowledgments The authors wish to thank The Wellmark Foundation of Iowa for their generous support of this training project. We also very much appreciate the assistance and support of Jurgen Unutzer, Diane Powers, and others at the IMPACT Coordinating Center for generously allowing the inclusion of IMPACT information throughout the depression training product. In addition, we extend our thanks to all personnel at the Iowa Geriatric Education Center for their assistance in developing the program and compiling evaluation results, to Dr. Toni Tripp-Reimer for oversight of the content analysis, and to Courtney Lee for her assistance in conducting content analysis. References Anstey, K. J., von Sanden, C., Sargent-Cox, K., & Luszcz, M. A. (2007). Prevalence and risk factors for depression in a longitudinal, population-based study including individuals in the community and residential care. American Journal of Geriatric Psychiatry, 15(6), 497–505. doi:10.1097/JGP.0b013e31802e21d8 Chapman, D. P., & Perry, G. S. (2008). Depression as a major component of public health for older adults. Preventing Chronic Disease, 5(1), A22. Ciro, C. A., Ottenbacher, K. J., Graham, J. E., Fisher, S., Berges, I., & Ostir, G. V. (2012). Patterns and correlates of depression in hospitalized older adults. Archive of Gerontolology and Geriatrics, 54(1), 202–205. doi:10.1016/j.archger.2011.04.001 Elo, S., & Kyngas, H. (2007). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. doi:10.1111/j.1365-2648.2007.04569.x Grypma, L., Haverkamp, R., Little, S., & Unutzer, J. (2005). Taking an evidence-based model of depression care from research to practice: Making lemonade out of depression. General Hospital Psychiatry, 28, 101–107. Haverkamp, R., Arean, P., Hegel, M. T., & Unutzer, J. (2004). Problem-solving treatment for complicated depression in late life: A case study in primary care. Perspectives in Psychiatric Care, 40(2), 45–52. doi:10.1111/j.1744-6163.2004.00045.x Herr, K. A., Spratt, K. F., Garand, L., & Li, L. (2007). Evaluation of the Iowa Pain Thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: A preliminary study. Pain Medicine, 8(7), 585–600. doi:10.1111/j.1526-4637.2007.00316.x Lyness, J. M., Chapman, B. P., McGriff, J., Drayer, R., & Duberstein, P. R. (2009). One-year outcomes of minor and
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subsyndromal depression in older primary care patients. International Psychogeriatrics, 21(1), 60–68. doi:10.1017/S1041610208007746 National Institute of Mental Health. (2007). Older adults: Depression and suicide facts (Fact Sheet). NIH Publication No. 4593. Retrieved from http://www.nimh.nih.gov/health/ publications/older-adults-depression-and-suicide-factsfact-sheet/index.shtml Rogers, J. C., Holm, M. B., Raina, K. D., Dew, M. A., Shih, M. M., Begley, A., . . . Reynolds, C. F., 3rd. (2010). Disability in late-life major depression: Patterns of self-reported task abilities, task habits, and observed task performance. Psychiatry Research, 178(3), 475–479. doi:10.1016/j.psychres.2009.11.002 Smith, M., Johnson, K. M., Seydel, L. L., & Buckwalter, K. C. (2010). Depression training for nurses: Evaluation of an innovative program. Research in Gerontological Nursing, 3(3), 162–175. Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. doi:10.1001/archinte.166.10.1092 Spitzer, R. L., Kronenke, K., & Williams, J. B. (1999). Validation and utility of a self-report version of the PRIME-MD: The PHQ primary care study. Journal of the American Medical Association, 282(18), 1737–1744. doi:org/10.1001/jama.282.18.1737 SPSS. (2010). PASW statistics 18. Chicago, IL: SPSS, Inc. Strine, T. W., Kroenke, K., Dhingra, S., Balluz, L. S., Gonzalez, O., Berry, J. T., & Mokdad, A. H. (2009). The associations between depression, health-related quality of life, social support, life satisfaction, and disability in community-dwelling US adults. Journal of Nervous and Mental Disorders, 197(1), 61–64. doi:org/10.1097/NMD.0b013e3181924ad8 Teresi, J., Abrams, R., Holmes, D., Ramirez, M., & Eimicke, J. (2001). Prevalence of depression and depression recognition in nursing homes. Social Psychiatry and Psychiatric Epidemiology, 36(12), 613–620. doi:org/10.1007/s127-001-8202-7 Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., . . . Langston, C.; IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288(22), 2836–2845. doi:org/10.1001/jama.288.22.2836 University of Washington. (2009). IMPACT Evidenced based depression care. Retrieved August 18, 2010, from http://impact-uw.org/. Watson, L. C., Lehmann, S., Mayer, L., Samus, Q., Baker, A., Brandt, J., . . . Lyketsos, C. (2006). Depression in assisted living is common and related to physical burden. American Journal of Geriatric Psychiatry, 14(10), 876–883. doi:org/10.1097/01.JGP.0000218698.80152.79
Perspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
ISSN 0031-5990
Evaluation of an Innovative Late-Life Depression Training Program Marianne Smith, PhD, RN, Mary Ellen Stolder, PhD, RN, and Megan Fang Liu, PhD, RN Marianne Smith, PhD, RN, is Assistant Professor, College of Nursing, University of Iowa, Iowa City, Iowa, USA; Mary Ellen Stolder, PhD, RN, is Assistant Professor, School of Nursing, Viterbo University, La Crosse, Wisconsin; and Megan Fang Liu, PhD, RN, is Assistant Professor, College of Nursing, Taipei Medical University, Taipei, Taiwan.
Search terms: Depression, training nursing roles, behavioral activation, problem-solving methods, older adults Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement The authors declare no actual or potential conflicts of interest.
PURPOSE: This paper describes evaluation findings associated with an innovative, CD-based, self-directed training program that was designed to improve general practice nurses’ abilities to identify and care for older adults with depression. DESIGN AND METHODS: A voluntary sample of nurses completed an evaluation that focused on participants’ perceptions of changes in their knowledge and skills and usefulness of the program. FINDINGS: Quantitative items received high ratings, and narrative responses to open-ended questions were largely positive. PRACTICE IMPLICATIONS: Many opportunities exist for psychiatric nurses to facilitate, support, and extend training principles to promote late-life depression recognition and treatment.
First Received August 29, 2012; Final Revision received January 19, 2013; Accepted for publication February 15, 2013. doi: 10.1111/ppc.12019
Depression is widely recognized as a major public health problem that is both prevalent and highly associated with disability among older adults (Chapman & Perry, 2008; Rogers et al., 2010; Strine et al., 2009). In late life, subsyndromal or “minor” depression is also associated with increased physical health burden and disability (Lyness, Chapman, McGriff, Drayer, & Duberstein, 2009; Watson et al., 2006), making it an equally important target of care and treatment. Rates of clinically significant depression increase with the need for healthrelated assistance support, affecting an estimated 14% of older adults in home care, 32% in residential care settings, 37% of those who are hospitalized, and 44% of nursing home residents (Anstey, von Sanden, Sargent-Cox, & Luszcz, 2007; Ciro et al., 2012; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2011). However, depression symptoms may be more challenging to recognize in older adults compared to younger ones for a variety of reasons. Overlapping chronic physical health conditions that may mask depression, loss and life changes that are considered “understandable causes” for depression, and the tendency of elders to attribute their depression symptoms to physical causes regularly interfere with recognizing depression symptoms as depression by older adults themselves, their family members, and health providPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
ers who provide regular care and treatment (National Institute of Mental Health [NIMH], 2007). The cycle of depression described in the highly successful depression treatment program, Improving Mood: Providing Access to Collaborative Treatment (IMPACT) (Unutzer et al., 2002), emphasizes the important interactions among thoughts and feelings,stressors,physical problems,and behaviors that interact to contribute to late-life depression. Effective treatment often relies on recognizing and addressing factors that cause, contribute to, and perpetuate late-life depression. Although designed for use in primary care settings, IMPACT principles and treatment approaches may be applied in diverse settings. Key components include regular depression screening; using standardized scales and systematic monitoring; treating problems that contribute to depression; and treatment that includes depression education, behavioral activation (i.e., increasing pleasant activities), problem-solving therapy and/or medication management, and relapse prevention plans (University of Washington, 2009). Outcomes associated with the IMPACT intervention included significant reduction of depression symptoms, more satisfaction with care, less functional impairment, and greater quality of life for those in the treatment group compared to 19
Evaluation of an Innovative Late-Life Depression Training Program
elders receiving usual primary care (Unutzer et al., 2002). These positive results have fueled the replication, adaptation, and extension of IMPACT in other settings and populations (Grypma, Haverkamp, Little, & Unutzer, 2005). One extension of IMPACT was the development of a CD-based depression training program that targeted nurses who come into regular contact with older adults who may have depression, but are not psychiatric-mental health specialists. The program, Depression Training to Promote Nurses as Advocates for Older Adults, was designed to assist nurses in community, long-term, and acute care settings to better identify, assess, refer, and provide direct nursing care to older adults with depression (Smith, Johnson, Seydel, & Buckwalter, 2010). The purpose of this paper is to describe evaluation results associated with statewide dissemination of the Nurses as Advocates depression training program. Background information, including the rationale for selecting content and teaching/learning approaches used in the training program, is briefly described to provide a framework for understanding evaluation findings. Results focus on nurse participants’ perceptions of how the training program changed their knowledge of depression and its treatment, and their views about the usefulness of the training program. Quantitative data and descriptive narrative answers to open-ended questions provide important perspectives that may be used by psychiatric mental health nurses (PMHNs) in general and advanced practice to facilitate collaboration with their nurse peers in other settings and areas of practice. The important roles of PMHNs in facilitating, supporting, and extending depression training to further advance identification, assessment, monitoring, referral, and daily management of older adults with depression are discussed. Training Background and Development The CD-based depression training program was developed collaboratively by geriatric education center (GEC) personnel and college of nursing faculty in a Midwestern university, with assistance from instructional design and technical experts. The IMPACT approach to depression care was selected as the foundation on which to build the Nurses as Advocates depression training program for a variety of reasons. The IMPACT study regularly utilized nurses as depression care managers, underscoring the important contributions that nurses can make to late-life depression treatment (Haverkamp, Arean, Hegel, & Unutzer, 2004). Many of the IMPACT treatment approaches were within the scope of professional nursing practice, offering a logical transfer of ideas to daily nursing care. In addition, the overall success of IMPACT approaches in reducing late-life depression and improving function and quality of life for elders was clearly a motivating factor. Furthermore, the IMPACT Training Center offered a variety of high-quality materials, examples, 20
and resources to develop the CD-based training program (University of Washington, 2009). Each section of the CD-based program followed the same basic format: print handouts, view the digitized presentation, work through the case-based learning, and apply the workplace exercise in practice. The program was divided into sections so that learners could start and stop easily, and work at their own pace. A short digitized presentation introduced the four-part program and provided guidance on how each part was organized and intended to be used. The introduction recommended that learners move sequentially from Part 1 to 4 as the content in each tended to build on earlier content. However, the format of the program also allowed learners to use any section or component of the training, in or out of sequence, to permit easy access to content that was considered most useful or needed. The four parts were organized by content and included (a) understanding depression in late life, (b) assessing depression, (c) depression care for older adults, and (d) collaborating to promote positive outcomes. Training Distribution and Evaluation The Nurses as Advocates training program addressed three main objectives: (a) improve access to depression education, (b) increase the skills and knowledge of providers who care for elders with depression, and (c) improve the provision of quality, evidence-based depression care. The program was advertised using the statewide GEC databases and provided at no cost, including free continuing education units (CEUs). A total of 513 training packets were mailed to healthcare providers and facilities located in 97 of 99 counties in Iowa. Additional details related to the development and dissemination of the Nurses as Advocates training program are described elsewhere in the literature (Smith et al., 2010). Key features of the evaluation and the respondents are provided here to frame findings associated with changes in knowledge and perceptions of the usefulness of the training program. Evaluation Format and Analysis Training and CEU evaluation forms were included in the CD mailing packet along with instructions to return the forms in the self-addressed and posted envelope provided. Perceptions of how the training program influenced knowledge and skills included 18 items that were rated from 1 (very little) to 6 (very much) that were followed by an open-ended question. Another section included items related to training topics, methods, and strategies that were rated from 1 (useless) to 6 (useful). Following this section, an open-ended question invited respondents to list the three least and most useful things about the training program. Two additional openended questions asked respondents to describe any difficulPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
Evaluation of an Innovative Late-Life Depression Training Program
ties encountered using the program, and add any other comments, suggestions, or feedback about the program. Other sections of the evaluation related to changes in practice and outcomes of care are described elsewhere in the literature (Smith et al., 2010). Returned evaluations were labeled using a unique identifying (ID) number.Quantitative data were entered into a spreadsheet then analyzed using PASW 18 Statistics software (SPSS, 2010). Narrative responses were entered into a word processing program by ID number. Content analysis was undertaken by a team guided by an expert qualitative researcher. Narrative answers for each question were de-identified, sorted alphabetically, and examined for common themes related to responses. Conceptual content analysis using inductive processes (Elo & Kyngas, 2007) guided the review of responses, identification of concepts (called themes in this paper), analysis and coding of text,and resolution of discrepancies related to placement of responses within themes.
Training Participants A total of 250 individuals returned evaluation forms, resulting in a response rate of 49%. Respondents were largely employed by nursing homes (40%), community/home health agencies (24%), and hospitals (17%), with smaller numbers reporting employment with other settings (19%) such as assisted living, public health, adult day health care, and private practice. Most were staff nurses (57%), followed by nurses in management roles
(18%), care coordinators (6%), educators (7%), and other positions (12%). Education included associate degrees in nursing (49%), licensed practical nurses (19%), bachelor’s in nursing (15%), 3-year diploma in nursing (13%), master’s degrees (3%), and other education (1%). Less than half of the group (40%) reported having received previous depression education or training beyond what was provided in their basic nursing education.
Evaluation Results Changes in Knowledge As shown in Table 1, nearly all of the 250 participants responded to the 18 items that followed the request “Rate the extent to which the training program increased your knowledge about depression and care you provide to older adults.” Individual scores ranged from 1 (very little) to 6 (very much). Average (mean) scores ranged from a high of 5.1 for administering and rating the PHQ-9 (the 9-item Patient Health Questionnaire) depression scale (Spitzer, Kroenke & Williams, 1999) to a low of 4.5 for communicating with physicians. A total of 54 of 250 participants (22%) responded to the request “Did the depression training program influence your knowledge or skills in other ways?” Four main themes included assessment methods and scales, awareness of depression, importance of individualized care, and nursing care and interventions. Table 2 provides definitions of knowledge-related themes and examples for each.
Table 1. Extent to Which Training Increased Knowledge Item
N
Min
Max
Mean (SD)
Administering and interpreting the PHQ-9 Nursing assessment of depression Diagnostic criteria for depression Using scale scores in decision-making Using other screening and rating scales Depression-related nursing interventions Importance of scheduling pleasant events Nursing roles in antidepressant management Using follow-up methods to improve outcomes Outcome monitoring methods Symptoms of depression in late life Identifying person-centered goals and outcomes Behavioral activation Factors that cause and contribute to depression Making referrals for depression evaluation Communicating with team members Nursing roles in psychotherapy management Communicating with physicians
249 247 249 249 249 249 249 249 249 249 249 249 249 249 249 249 248 249
2 1 1 2 2 1 1 2 1 2 1 2 1 1 1 1 1 1
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
5.1 4.9 4.9 4.8 4.8 4.8 4.8 4.8 4.7 4.7 4.7 4.7 4.7 4.6 4.6 4.6 4.5 4.5
(.9) (1.0) (.9) (.9) (.9) (.9) (1.1) (.9) (1.0) (1.0) (1.0) (1.0) (.9) (1.1) (1.0) (1.1) (1.0) (1.1)
Note: Min, minimum value; Max, maximum value; SD, standard deviation; PHQ-9, 9-item Patient Health Questionnaire. Items were rated on a scale where 1 = very little to 6 = very much.
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Evaluation of an Innovative Late-Life Depression Training Program
Table 2. Other Ways the Training Influenced Knowledge Understanding and awareness of depressiona • Increase awareness to identify depression and symptoms of depression • It gave me a better understanding of the causes of depression in late life and things that you don’t always relate to depression, but are silent signs • Awareness of how depression/other illnesses coincide Assessment methods and scalesa • The PHQ-9 was new to me and very useful • Yes, to be more observant to other assessments • It is nice to be part of the diagnosis and fact-finding instead of just throwing pills at people • I think it just reminded me of how important the initial assessment is and the patient receiving help right away Nursing care and interventionsa • There are things we can do on a daily basis to help our residents get through their depression • It made me think about our residents and want to take a different approach on some of their behaviors/actions Importance of individualized carea • Looking at the whole person—physical, social, mental, spiritual, etc.—is important for well-rounded care • Each has their own unique circumstances a
Themes that were identified in the responses. Responses are provided as they were written by participants. PHQ-9, 9-item Patient Health Questionnaire.
Usefulness of Training The request to “rate the overall usefulness” of training components resulted in high overall scores. The main topics (Parts 1–4) were rated from 2 to 6, with mean scores of 5.0 or higher. See Table 3. Missing data were more common for application exercises, including case-based learning, workplace exercises, and appendix materials, suggesting that some participants may have failed to implement these components in practice. A total of 181 participants (72%) responded to the request to list the “three most useful things” about the training. Responses were largely composed of short answers and clustered into two main themes. The first theme, content addressed in the program, included 229 responses that clustered around the subthemes of assessment methods and scales, understanding and awareness of depression, nursing care and interventions, and communication methods. The second theme, format of the program, included 170 comments that clustered around the main teaching approaches: handouts, case-based learning, video presentations, workplace exercises, and appendix materials, as well as general appreciation for the program. See Table 4 for examples. A total 116 participants (46%) responded to the request to “list the three least useful things” about the training program. Of these, 22 (33%) offered positive comments, including “Everything was quite good,” “I found the entire program to
Table 3. Usefulness of the Training Program and Methods Component of Training
N
Min
Max
Mean (SD)
Part 1: Overview of depression reviews common signs and symptoms of depression in older adults, including diagnostic criteria, differences between major and minor depressions, and factors that may cause and contribute to depression in late life Part 2: Assessing depression encourages problem-solving approaches, provides instruction to use the PHQ-9 scale, and recommends scales to assess cognitive ability, pain, and anxiety that are common comorbid conditions with late-life depression Part 3: Depression care for older adults reviews independent nursing interventions to reduce and treat depression, focusing on behavioral activation (scheduling pleasant events), addressing related health problems, and monitoring outcomes. Part 4: Collaborating to promote positive outcomes emphasized the importance of teamwork and communication among care and treatment team members, including nurses and physicians who prescribe antidepressant and other medications Video training programs combine slides with a speaker to provide instruction for each of the four parts listed above Handouts accompany each of the four parts to support and extend information provided in the slide presentations that are part of the videos Case-based learning: Sandra Jo Green provides a video example of how to administer the PHQ-9 scale and a talk about scheduling pleasant events with older adults Workplace exercises are designed to apply principles of care, including administering the PHQ-9 scale, developing a depression-related care plan, and making referrals for assessment and treatment Appendix materials provided additional information about other resources related to late-life depression
245
2
6
5.0 (1.0)
246
2
6
5.2 (.9)
246
2
6
5.1 (.9)
245
2
6
5.0 (1.0)
245
1
6
5.0 (1.1)
241
1
6
5.0 (1.1)
232
1
6
4.8 (1.1)
230
1
6
4.7 (1.1)
230
2
6
4.9 (1.1)
Note: Items were scored from 1 (useless) to 6 (useful). Min, minimum value; Max, maximum value; SD, standard deviation; PHQ-9, 9-item Patient Health Questionnaire.
22
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Evaluation of an Innovative Late-Life Depression Training Program
Table 4. Three Most Useful Things About the Training Program
Table 5. Three Least Useful Things About the Training Program
Content Addressed in the Training Program Assessment methods and scalesa • PHQ-9 depression assessment and scoring • Use and importance of using standardized scales • Recommendations regarding when to utilize different types of depression scales
Content of the Training Program Understanding and awareness of depressiona • Causes of depression
Understanding and awareness of depressiona • Better understanding of depression in older adults and how to recognize it • Elderly like to talk to someone—not be on medication • Reinforcement that depression is a disease and can be treated • The cycle of depression made it clearer for me to “get it” Nursing care and interventionsa • Education of patients and families • Incorporating pleasant activities • Listening to residents • Making simple adjustments • Non-medication interventions Communication methodsa • Communication tool to discuss depression cues • Nurse–physician communication info (information) • Communication techniques Format of the Training Program • Handouts were great to have and share with staff • Pleasant activity list • The case-based questions helped me see how to apply this • Easy-to-follow video presentation • Presenter’s voice and presence • Video: being able to see and hear the material at the same time • All of the exercises were useful • Excellent reference materials • All processes simple and direct—would not change a
Subtheme within the broad theme of program content. All comments are provided as they were written by participants. PHQ-9, 9-Item Patient Health Questionnaire.
be quite useful and user friendly,” and “The program was very useful to all aspects of my current work position.” The remaining individuals offered comments that clustered into two main themes, including 80 comments related to content and 58 comments related to format. Subthemes in these two areas were directly parallel to those identified as most useful aspects. That is, subthemes related to the most useful aspects were also identified as being the least useful. See Table 5 for examples. A total of 131 participants (52.4%) responded to the question “Did you have any other difficulties completing any part of the training program?” Of the 131 responses, 92 (70%) responded “no; no problems; or none,” and within that group 8 participants added a positive comment about the quality or usefulness of the training program (e.g., “No, this was a very user-friendly and comprehensive program,” “None, easy to use!”). Another eight participants responded with positive comments (e.g., “Very well explained and put together. DefiPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
Assessment methods and scalesa • Pain scale • PHQ-9 form • More explanation of tests Nursing care and interventionsa • Basic nursing interventions that are very common • Listing pleasant activities • Relapse plan Communication methodsa • Communicating with physicians • Referrals to care providers (do that now) Format of the Training Program • Speaker (too fast, too slow, monotone, singsong, distracting) • A lot of handouts • Patient exercises—Sandra Jo Green • Writing out plan/outcomes • Appendix materials • Noninteractive • Should have had a test • Would like to be in person • Would like it to be DVD compatible for staff • Too much information in a short time • No discussions a
Subtheme within the broad theme of program content. All comments are provided as they were written by participants. PHQ-9, 9-Item Patient Health Questionnaire.
nitely a lot of thought behind the information. Very useful in everyday situations”; “Yes, everything was useful. Could not think of least useful.”) The remaining 31 comments (24%) echoed problems and issues that were identified as the “least useful” aspects of the training program. In turn, the main themes clustered around format (n = 18) and function/ technical difficulties (n = 13). A total of 55 participants (22%) responded to the request “If you have other comments, suggestions, or feedback about the depression training program, please describe it in the space below.” Of those who replied, 12 were simple “no” replies and 24 provided general positive feedback and perspectives (e.g., “This is a great program on depression. Reminds you how big of a part of someone’s life depression can consume”; “Very useful! The PHQ-9 scale needs to be used universally for healthcare—not just for the elderly.”). The remaining comments echoed sentiments noted earlier in “least useful things” or “other difficulties.” Discussion Findings from this evaluation support the importance of depression training for nurses and allied health providers 23
Evaluation of an Innovative Late-Life Depression Training Program
who provide daily care and treatment to older adults, but are not specially trained in psychiatric-mental health nursing. The overall positive responses of nurses who participated in the Nurses as Advocates evaluation suggest that training improved their awareness and knowledge of late-life depression, particularly related to using standardized scales like the PHQ-9 to quantify and monitor symptoms and nursing roles in assessment and daily care interventions like scheduling pleasant events (behavioral activation). The narrative responses to open-ended questions were particularly informative both in terms of their quantity and quality. Twice as many participants (72.4%) provided “most useful” comments compared to those who provided “least useful” comments (35.6%). The number of individuals who took time to affirm that no problems were encountered and/or write positive responses to requests for least useful things, difficulties in completing training, and other comments similarly indicates that most learners benefited from the depression training program. An important trend in narrative responses is consistent with the adage that “strengths may also be weaknesses.” The themes and subthemes that emerged in the least and most useful things about training ran parallel to one another, indicating the things that some learners valued, other learners found unhelpful or even distasteful. For example, some learners expressed appreciation for the video (e.g., presenter’s voice and presence) while others listed it among the least useful aspects (e.g., speaker). Furthermore, the variability in comments all related to the speaker, who was too fast for some, too slow for others, and considered both monotone and singsong, points to individual preferences that are challenging to meet in a single approach. The Nurses as Advocates training program was designed to address a broad audience with varying levels of skill related to depression recognition and treatment. In order to assure that “basic” information was provided and reinforced, the program likely became too simple and/or redundant for those who already understood the content.The request to use all four parts of the program in sequence (which related to achieving a complete evaluation) likely deterred more experienced learners from viewing the product as a“menu”that could be used to best address their individualized training needs. Post-evaluation changes may address some criticisms. Instructions to complete the four program parts in full and sequentially have been removed. Since the evaluation is now completed,the five-page evaluation is no longer included.Free CEUs have been discontinued, and users now purchase the product and education credits for a modest fee. (Visit the Iowa Geriatric Education Center at http://www.healthcare. uiowa.edu/igec/ for additional information.) Together, these factors suggest that only those who wish to improve their depression care skills will acquire and use the product to meet their individualized needs. 24
Implications for Psychiatric Nursing Practice The outcomes associated with the Nurses as Advocates evaluation provide both generalist and advanced practice PMHNs with important information that may be used in a wide variety of roles, including but not limited to discharge planning in acute care settings, consultation and liaison roles within or between care settings, and both formal and informal education and/or training. Several key issues are salient to PMHNs and their practice. Understanding Depression. One of the most important themes that emerged in narrative comments related to gaining a greater understanding and awareness of late-life depression, which included responses both “other knowledge” and “most useful” aspects of training. A variety of comments suggested that nurses in general practice may benefit from formal and/or informal education related to late-life depression: “Depression is an illness on its own,”“Describing differences between major and minor depression,” “Leading cause of disability—ways to recognize and help patients,” “The cycle of depression made it clearer for me to ‘get it.’ ” PMHNs have many opportunities to educate their nurse colleagues during “informal” discussions of an older adult’s status, and through more traditional methods such as in-service programs, workshops, and other educational events. Whether formal or informal educational methods are used, narrative comments related to the format of the Nurses as Advocates training program may guide PMHNs to best help their peers. The emphases placed on training being “easy to follow,” “short,” and “understandable,” that “Handouts were great to have and share with staff,” and that “Case-based questions helped me see how to apply this” all provide direction for educational approaches. Some learners very much appreciated the CD-based format and the ability to work at their own pace, while others clearly would have preferred a live program that provided greater opportunities for questions and interaction. Educational approaches used by PMHNs may easily be designed to accommodate both needs, such as a “live” program followed by a self-directed learning assignment like the workplace exercises offered in the Nurses as Advocates program. Assessing Depression. The five most highly rated knowledge items all related to assessing depression: administering and interpreting the PHQ-9 depression scale,assessing depression, diagnostic criteria, using scale scores in decision-making, and using other screening and rating tools. The importance of assessment was further supported in narrative responses such as “Nursing assessment of depression,”“Importance and use of standardized assessment scales,” “PHQ-9 and other assessment forms,” and “Recommendations regarding when to utilize different types of depression scales.” Perspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
Evaluation of an Innovative Late-Life Depression Training Program
Gaining skills to quantify signs and symptoms using standardized rating scales for depression (e.g., PHQ-9) and common comorbid conditions such as anxiety and pain may also be facilitated by PMHNs. By introducing and explaining easy-to-use methods like the GAD-7 (Spitzer, Kroenke, Williams, & Lowe, 2006) or the Pain Thermometer (Herr, Spratt, Garand, & Li, 2007), PMHNs may improve both their nurse colleagues’ knowledge and the overall quality of care provided to older adults. As emphasized in the IMPACT approach, using standardized scales like the PHQ-9 to assess and monitor outcomes of treatment facilitates understanding of progress being made, and the possible need to adjust the course of treatment to achieve optimal outcomes. For example, preadmission or post-discharge discussion of an elder’s status may be greatly enhanced by reviewing changes based on a mutually understood scale. In other cases, quantifying comorbid conditions, such as anxiety, pain, or sleep disturbance, may facilitate both treatment and enhanced nursing care of contributing factors. Nursing Interventions. Another important area that PMHNs may address with their nurse peers involves the diverse array of “scope of nursing practice” interventions that do not rely on physician orders and may be used in daily care. Knowledge items related to nursing interventions were also given high ratings, including depression-related nursing interventions, importance of scheduling pleasant events, nursing roles in antidepressant medication management, using follow-up methods to improve outcomes, and outcome monitoring methods. These objectively rated items were supported with a variety of narrative comments, such as “Non-medication interventions,” “Providing depression education,” “Incorporating pleasant activities,” “Making simple adjustments,” “Response to a depressed person’s remarks,” and “Developing a plan for relapse.” As before, PMHNs may help their nurse peers to better understand and use a variety of approaches in daily care that are often, as the participants note, simple adjustments in how the nurse responds to older adult and depression-related behaviors or complaints. As emphasized in the IMPACT program and Nurses as Advocates training program, adapting daily routines to increase the frequency of pleasant events and activities (i.e., behavior activation) and physical activity (e.g., exercise) are effective interventions in depression treatment that nurses and allied health personnel may easily implement. Additional interventions, such as providing depression education to the older adult and his/her family, overseeing antidepressant medication use, measuring and reporting relevant outcomes to primary care providers, and assisting older adults to develop and use depression relapse plans, may be part of care or discharge plans developed by PMHNs and provided to other nurse providers. Of equal importance, nursing care approaches (and care plans) may target depressionPerspectives in Psychiatric Care 50 (2014) 19–26 © 2013 Wiley Periodicals, Inc.
related problems such as difficulties in sleeping, anorexia, pain, anxiety, or other health concerns, as well as stress (loss, life change) that may be contributing to depression. In short, PMHNs may facilitate use of nursing interventions that may be used during psychiatric care, following discharge, and as part of care provided in other settings independent of hospitalization. Limitations and Next Steps This evaluation study has a number of limitations that warrant mention. First, the sample was composed of nurses from a single Midwestern state who requested the training program and voluntarily returned evaluations. Their perceptions may not be representative of the larger population of nonpsychiatric nurses or nurses in other parts of the country. Second, selfreported perceptions may not reflect actual changes in practice. We report only what nurses said they did/will do without verifying changes made. Furthermore, the written format may constrict the type or volume of information provided by participants. Finally, we did not use additional mailing or telephone calls to promote returning the evaluations to increase the response rate. These limitations reflect study constraints related to the time frame (1-year project) and funding level,and point to the need for further and more rigorous evaluation of the program and its use. Additional research is needed to further evaluate factors that may influence the use of recommended depression assessment and intervention approaches. Potential facilitating and impeding factors should be examined, including but not limited to (a) organizational support (e.g., setting or specialty-specific issues), (b) nurse-related characteristics (e.g., education or experience level, motivation), and (c) older adult characteristics (e.g., comorbidities; severity of illness; availability of support, assistance, treatment). The impact of nurse training on depressed older adults (and their families) should also be evaluated, including changes in level of depression and comorbid problems such as anxiety and pain, quality of life, and satisfaction with care and treatment. Summary and Conclusion The Nurses as Advocates evaluation findings provide important insights related to the value of depression training for nurses working in nonpsychiatric settings and an important foundation for future research. Responses to knowledge items and open-ended questions reinforce important roles that PMHNs may play in advancing knowledge and skills among their nurse peers who provide daily care to older adults with depression. Many opportunities exist to educate colleagues, both during informal conversations about patient care and through traditional educational formats, to enhance 25
Evaluation of an Innovative Late-Life Depression Training Program
understanding of depression, and to develop skills related to improving nursing assessment and interventions used in daily care. Acknowledgments The authors wish to thank The Wellmark Foundation of Iowa for their generous support of this training project. We also very much appreciate the assistance and support of Jurgen Unutzer, Diane Powers, and others at the IMPACT Coordinating Center for generously allowing the inclusion of IMPACT information throughout the depression training product. In addition, we extend our thanks to all personnel at the Iowa Geriatric Education Center for their assistance in developing the program and compiling evaluation results, to Dr. Toni Tripp-Reimer for oversight of the content analysis, and to Courtney Lee for her assistance in conducting content analysis. References Anstey, K. J., von Sanden, C., Sargent-Cox, K., & Luszcz, M. A. (2007). Prevalence and risk factors for depression in a longitudinal, population-based study including individuals in the community and residential care. American Journal of Geriatric Psychiatry, 15(6), 497–505. doi:10.1097/JGP.0b013e31802e21d8 Chapman, D. P., & Perry, G. S. (2008). Depression as a major component of public health for older adults. Preventing Chronic Disease, 5(1), A22. Ciro, C. A., Ottenbacher, K. J., Graham, J. E., Fisher, S., Berges, I., & Ostir, G. V. (2012). Patterns and correlates of depression in hospitalized older adults. Archive of Gerontolology and Geriatrics, 54(1), 202–205. doi:10.1016/j.archger.2011.04.001 Elo, S., & Kyngas, H. (2007). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. doi:10.1111/j.1365-2648.2007.04569.x Grypma, L., Haverkamp, R., Little, S., & Unutzer, J. (2005). Taking an evidence-based model of depression care from research to practice: Making lemonade out of depression. General Hospital Psychiatry, 28, 101–107. Haverkamp, R., Arean, P., Hegel, M. T., & Unutzer, J. (2004). Problem-solving treatment for complicated depression in late life: A case study in primary care. Perspectives in Psychiatric Care, 40(2), 45–52. doi:10.1111/j.1744-6163.2004.00045.x Herr, K. A., Spratt, K. F., Garand, L., & Li, L. (2007). Evaluation of the Iowa Pain Thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: A preliminary study. Pain Medicine, 8(7), 585–600. doi:10.1111/j.1526-4637.2007.00316.x Lyness, J. M., Chapman, B. P., McGriff, J., Drayer, R., & Duberstein, P. R. (2009). One-year outcomes of minor and
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