Mental Health

Dear writer, please make a professional poster addressing following questions. I am attaching the manuscript content and template to help you with creating the points.
DNP project Education Plan
Purpose- The purpose of this activity is for students to create a professional poster to disseminate their DNP evidence-based practice change project through a poster presentation at a national conference. This progressive poster assignment.
Instruction

1. Create your poster using the Professional Poster Template located in the Project & Practicum Forms section of the DNP Resources page. Scroll down to select the right poster for this assignment titled: NR 707_DNP Professional Poster Template 6.24.22. (attaching below)
2. Insert your content into the text boxes for each section; make sure to remove the instructions on the template. The content should be well-developed, concisely conveyed, and supported by the evidence. Leave space between each section without words, so that there is a space break between sections.
3. Set up your poster using the following format and guidelines.
   • Layout & Organization
   • Your poster sections are required to have the exact sections and headers as the NR707 Poster template and in the same order. Use the following template headings
   o Practice Problem
   o Practice Question
   o Methodology
   o Results
   o Implications
   o Conclusions
   o References
   • The Results and Conclusion sections should be blank. (Case Study students also leave the Methodology section blank.)
   • The poster should convey the practice change project concisely and accurately to enhance reader comprehension.
   • Read the poster from another person’s point of view to ensure that the information you entered describes your practice change project concisely and flows logically.
   • Visual presentation
   Writing mechanics and word usage • No errors
   Poster title • 60-72 font size
   • Limited to 12 words or less; all words fully spelled out (no acronyms or abbreviations)
   • Title should be centered and capitalized
   Name and credentials • 32-36 font size
   • Should not contain “DNP” or “DNP student”
   • Name/credentials should be centered
   Headings • 32-40 font size
   • Location of headings needs to remain in the exact column of the template provided
   Text within each section • 24-32 font size; needs to be consistent across the entire poster (can be smaller in the Reference section)
   • Text should not be written outside the poster template
   Reference section • Font size can be smaller, but still needs to be legible
   Font type • Arial, Calibri, or Times New Roman (legible and consistent throughout each section of the poster)
   Spacing • Empty space between each section
   • There should be only one space between words
   Color • Adheres to template provided
   Clip art/pictures • None
   Bullets • For all data points in all sections
   • (Exception: No bullet needed for the Aim and the PICOT practice question)

Include the following in your poster:

1. Practice Problem
   a. Offer strong evidence-based statements for the significance data, including prevalence, and/or incidence, and/or mortality data at the national and state (or county or city) levels. If available, include data from the practicum site to support this is a priority problem for the organization.
   b. Include the project aim (main purpose or objective) at the end of this section.
   c. Include in-text citations.
   d. Use bullet points for practice problem data points. Bullet points are not required for project aim.
   e. Use concise and accurate statements.
2. Practice Question
   PICOT- In adult patients with mild to moderate depression at an outpatient mental health clinic, does implementing Mindfulness Based Stress Reduction (MBSR) compared to current practice improve depression symptoms in 8-10 weeks?
   4. Methodology (Part 1 and Part 2 in the Rubric)
      Methodology Part 1 (Implementation students only)
      Requirements:
3. Use the exact bulleted subheaders listed on the NR707 poster template. Complete the content with short, concise phrases.
4. State the translational science model or theory/change model.
5. State a short description of the setting.
6. Provide a short description of the population with an estimate of the number of participants.
7. Briefly state the inclusion and exclusion criteria.
8. Briefly describe the intervention (with primary citation).
   Methodology Part 2 (Implementation students only)
   Requirements:
9. Use the exact bulleted subheaders listed on the NR707 poster template. Complete the content with short, concise phrases.
10. Briefly state the formative evaluation plan.
11. Briefly state the summative evaluation plan.
12. Briefly state the main outcome from the PICOT practice question.
13. Briefly describe the data collection (e.g., pre-intervention and post-intervention data collection).
14. State the name of the data collection instrument (with primary citation) OR data source.
15. Briefly describe the data analysis plan.
16. State the exact timeframe for the total implementation and the intervention implementation.
17. Results: (LEAVE BLANK)
18. Conclusion: (LEAVE BLANK)
19. Implications for Nursing and Healthcare
    a. Briefly state your anticipated implications for changing patient, nursing practice, and organizational outcomes. The anticipated outcomes should be based on the research supporting your intervention. Implications should be explained for each system level below:
    i. Micro (patient or individual nurse outcomes)
    ii. Meso (unit or department collective nursing practice)
    iii. Macro (facility or healthcare system[s])
    b. Use a bullet point for each implication.
    c. Do not include the terms Micro, Meso, Macro in the bullet points (cover the concepts)
20. References: Use of Scientific Evidence
    a. Every reference is required to be associated with an in-text citation.
    b. The poster includes at least three (3) references; research articles (primary research or systematic reviews) or data from a government or nationally-recognized healthcare organization related to the DNP project in citations and references. Avoid secondary or summary sources.
    c. References must be published in the past 5 years.
    d. References and in-text citations are required to be in correct APA format, excluding the hanging indent (which PowerPoint may not enable).

Manuscript
Mindfulness-Based Stress Reduction as an Alternative Treatment for Depression
Depression is a prevalent mental health disorder, poses a significant health burden, and often requires multifaceted treatment approaches (World Health Organization, 2023). According to Centers for Disease Prevention and Control (CDC, 2023), depression is a leading cause of disability in the United States and a common cause of outpatient visits in acute care and psychiatry clinics. Major depressive disorder is a complex mental health problem associated with persistent sadness, loss of interest and abnormal tiredness, sleep disturbance, low or depressed mood, altered thinking, and suicidal ideation (Christensen et al., 2020). Traditional treatments such as psychotherapy and pharmacotherapy have been the cornerstone of depression management for many decades. However, there are gaps in managing this condition arising from expense and side effects in pharmacological treatments, cost and length of treatment in psychotherapy, and a shortage of mental health practitioners to support other behavioral interventions for major depressive disorders (MDD). The CDC estimates that 4.7% of the US adult population have regular depression, 15 million physician office visits identify depression as the primary diagnosis annually, 12.7% of emergency department (ED) visits due to depression, and 48,813 suicide deaths attributed to depression annually (CDC, 2023). Quality of care, safety, and effectiveness of depression treatment involves adherence to evidence-based guidelines and appropriate monitoring.
Integrating mindfulness-based stress reduction (MBSR) in the treatment recommendations for MDD will increase the options available to our patients, retaining patients who would previously drop out due to side effects of high-dose antidepressants and those unable to access standard psychotherapy, such as cognitive behavior therapy due to high cost and a high number of sessions required to achieve remission. Depression causes approximately $1 trillion per year in lost productivity and leads to a global economic burden necessitating cost-effective intervention (World Health Organization, 2023). MBSR is a structured program that combines mindfulness meditation and awareness techniques to cultivate non-judgmental attention to the present moment. The impact of this treatment approach is improving statistical aspects of treatment quality, safety, efficacy, patient-centeredness, timeliness, affordability, efficiency, and equality, which are essential for improving healthcare. This paper addresses the practice problem of adults with mild to moderate depression at an outpatient mental health clinic can benefit from the effectiveness of MBSR by significantly reducing symptoms of depression, improving overall well-being, and enhancing their emotional regulation.
Problem
Depression affects approximately 3.8 percent of the global population, translating to about 280 million people (World Health Organization, 2023). Depression is the most prevalent mental disorder, accounting for 99% of all disorders (Hope for Depression Research Foundation, n.d.). It affects 5% of adults, 4% of males, and 6% of females. It also affects 5.7% of individuals over 60 (World Health Organization, 2023). Pregnant women are also susceptible to depression, with more than 10% of women who give birth suffering from depression (World Health Organization, 2023). Overall, mental health problems increased during the COVID-19 pandemic, worsening a gradual increase in MDD by up to 28% and anxiety disorders by up to 26% (Penninx et al., 2022).
In America, depression affects more than 18 million people yearly (Hope for Depression Research Foundation, n.d.). Seven thousand people die by suicide related to depression in America every year. It is the fourth highest factor contributing to the death of young people between 15 and 25. A person commits suicide every 12 minutes because of depression, accounting for more than 41,000 people yearly (Hope for Depression Research Foundation, n.d.). The mortality rate from depression in the United States is even higher than from homicide, which kills less than 16,000 people annually (Hope for Depression Research Foundation, n.d.). According to the CDC (2023), over 20 percent of people experience clinically relevant mental health problems before age 25, whereby half of them are already symptomatic by age 14. Another indicator of a mental health crisis is a higher age-adjusted suicide death rate than the national average in 2021 (CDC, 2023). The prevalence of mental health problems varies across national contexts and local school settings. For example, for every 6 US children aged 2-8 years, one had been diagnosed with a mental, behavioral, or developmental disorder (Ghandour et al., 2019). According to the CDC (2022), the most common mental issues reported among US children aged 3-17 years in 2016-19 included ADHD (9.8 percent), anxiety (9.4 percent), and behavior problems (8.9 percent), and depression (4.4 percent). ADHD affected 6.0 million children, while anxiety, depression, and behavior problems affected 5.8 million, 2.7 million, and 5.5 million children, respectively (CDC, 2022).
A survey by the KFF (2023) showed that 36.8% of adults in Texas reported symptoms of anxiety and/or depressive disorder, slightly higher than the national average of 32%. However, Texas is recognized as a Health Professional Shortage Area (HPSA), with a shortage of 702 psychiatrists and a met need of 32.5%, higher than the national average of 27.7% (KFF, 2023). The state also reports shortages of other mental health practitioners: psychologists, psychiatric nurses, addiction counselors, and family and marriage counselors. While Texas is an undisputed poor performer in providing mental health services, the national average of unmet needs is even higher (KFF, 2023). However, there are gaps in managing this condition arising from expense and side effects in pharmacological treatments, cost and length of treatment in psychotherapy, and a shortage of mental health practitioners to support other behavioral interventions for MDD.
The two most common mental health illnesses cost the global economy $1 trillion annually and between $80 billion and $300 billion in America (Greenberg et al., 2021). The healthcare costs of depression and its ineffective treatment in the United States have increased significantly, from $US83.1 billion in 2000 to $US173.2 billion in 2005 and $US210.5 billion in 2010 (Greenberg et al., 2021).
More needs to be done to improve access, increase treatment options, and improve the effectiveness of mental health treatments. The deficiency in current treatment for depression leads to low work efficacy among nurses in providing care and treatment to patients. For example, pharmacotherapy is a treatment option for depression and patients are not experiencing efficacy due to tolerability, delayed onset of action and differences in individual response. In that case, nurses may have the faulty belief that depression is a natural part of life and that if a patient is on antidepressants, no additional care is required. Nurses become unsure of their sufficiency to treat depression among patients because of ineffective treatment approaches, which leave them unsure of what to do. The ineffective treatment approach reduces the quality of care and safety of patients, lowering healthcare organizations’ reliability and ability. In general, ineffective treatment of depression adds to the healthcare burden of the disease on society.
Recommended treatment for depressed patients includes psychotherapy and pharmacotherapy (Burgess et al., 2021). Several treatment options exist, such as Mindfulness-based stress reduction, acceptance and commitment counseling, cognitive behavioral therapies, and dialectic behavioral therapy. Still, there is more focus on antidepressant medication use, which has not been effective in treating depression (National Institute of Mental Health, 2021). At my practicum site, depressive patients tend to stop increased doses of pharmacotherapy due to the side effects and are not able to access standard psychotherapy, such as CBT due to the financial burden that tends to keep them in the continuous depressive stage. The practice problem is that mindfulness-based interventions (MBI), such as MBSR, are not routinely recommended as a first-line or adjunct treatment at my clinical site.
The practicum site problems lead to a lack of efficacy in treating depression due to inadequate knowledge, skills, and experience required to treat depression effectively. They promote a poor quality of depression treatment and care, reduce patient safety, and hinder the impact of efforts to promote social justice and the reliability of the healthcare organization (National Institute of Mental Health, 2021). Currently, there is no evidence that the problem in the practicum site has been addressed.
Project Aim and Supporting Objectives
People suffering from these mental disorders experience inadequate and lesser quality care, leading to high costs and lengthy treatments associated with adverse outcomes (National Institute of Mental Health, 2021). The project intervention enhances the everyday experience of people suffering from psychiatric mental illnesses such as significant depression or anxiety disorder by improving their quality of care. The proposed DNP project aims to decrease depression symptoms in mild to moderate depressive patients in an outpatient mental health setting by implementing an eight-week MBSR intervention administered through weekly lessons and self-directed daily sessions (Hoge et al., 2023). The following are the specific objectives associated with the project aim.
a) Reduction in depression symptoms, measured by using the standardized assessment tool PHQ-9 scale and comparing pre and post-intervention.
b) Improvement in emotional regulation and resilience by increasing emotional acceptance and decreasing emotional reactivity measured by using the Emotion Regulation Questionnaire.
c) Improved quality of life and well-being by decreasing depressive symptoms and promoting a positive outlook using a performance questionnaire.
d) Decrease relapse and recurrence rates of depression after MBSR intervention and able to cope with stressors through mindfulness practices. The experiences can be measured through questionnaires.
Practice Question
The following practice question will serve as the basis for the DNP practice change project. In adult patients with mild to moderate depression at an outpatient mental health clinic, does implementing Mindfulness-Based Stress Reduction compared to current practice improve depression symptoms in 8-10 weeks?
Research Synthesis and Evidence-Based Intervention (NR 702)
Evidence-Based Intervention
MBSR is a structured, evidence-based program that incorporates mindfulness meditation and stress reduction techniques to promote emotional well-being and alleviate symptoms of depression. It was developed in the late 1970s by Dr. Jon Kabat-Zinn, who originally designed it for stress management. However, mindfulness-based programs, such as MBSR, reduce stress, distress, and somatic complaints of depression and anxiety and improve well-being, compassion, and job satisfaction (Vonderlin et al., 2020). It is delivered through an eight-week course, which includes weekly group sessions lasting about two and a half hours, as well as daily home practice assignments. Even though the specific practices in MBSR may vary from program to program, the most common ones include body scan, mindful breath awareness, sitting meditation, yoga, and daily mindfulness practice. These basic practices combine mindfulness meditation and stress reduction exercises taught progressively over the eight-week MBSR course, with participants gradually building their mindfulness skills. After completing the course, participants are expected to demonstrate enhanced self-awareness, reduced reactivity to stressors, and improved overall well-being.
The MBSR program has developed a strong evidence base throughout the last four decades. Currently taught in every continent, MBSR has led to a new field of study and practice, enabling diverse populations to access mindfulness training (Crane et al., 2023). Its popularity has led several reputable organizations and government agencies to recognize its effectiveness as an intervention for various mental health conditions. In their publication from Autumn 2022, the WHO highlights five mindfulness-based interventions (MBIs) as potential effective approaches for enhancing mental health in the workplace (Bonde et al., 2023). MBSR is one of these MBIs. Similarly, the American Psychological Association (APA) acknowledges the benefits of mindfulness-based approaches, including MBSR, in managing depression and stress-related disorders. They have published research and guidelines supporting the integration of mindfulness into mental healthcare (APA, 2019). Even though these organizations have not explicitly endorsed MBSR as an alternative treatment for mild to moderate depression, their reviews and guidelines underscore its potency to improve the daily personal and professional functioning of patients with psychiatric mental illnesses such as major depressive disorder or anxiety disorder.
Evidence Synthesis
Eleven evidence-based, peer-reviewed research articles support the effectiveness of MBSR, an alternative treatment for depression among patients with psychiatric mental illnesses. The synthesis includes ten quantitative research studies and one qualitative study. Ten research articles are level I, and one article is level II. The quality of these articles is high since eight articles have a quality rating of A while three have a rating of B.
Main Themes in the Research
Eleven evidence-based, peer-reviewed research articles support the effectiveness of MBSR, an alternative treatment for depression among patients with psychiatric mental illnesses (Ding et al., 2023; Haller et al., 202; Hoge et al., 2023; Koszycki et al., 2021; Norouzi et al., 2020; Zhang et al., 2019 ;). The synthesis includes ten quantitative research studies and one qualitative study. Ten research articles are level I, and one article is level II. The quality of these articles is high since eight articles have a quality rating of A while three have a rating of B.
Comparative effectiveness. The comparative effectiveness of MBSR to standard care in addressing depression is the most prominent theme featured in the articles. In their findings, these articles maintain that the effectiveness of MBSR is comparable to that of other standard techniques. Its effectiveness is more pronounced for people with depression disorder (Ding et al., 2023). Its ability to reduce the severity of depression is comparable to standard medications like escitalopram (Hoge et al., 2023) and Cognitive Behavioral Therapy (CBT) (Sverre et al., 2023). Some studies reveal that combining MBSR with other standards of care, particularly CBT, enhances its effectiveness. For instance, different mindfulness-based approaches may have varying degrees of effectiveness, with Mindfulness-Based Cognitive therapy showing smaller differences compared to CBT than MBSR (Alsubaie et al., 2018; Ninomiya et al., 2020). MBSR effectively reduces depressive symptoms and anxiety with short-term anxiolytic effects (Haller et al., 2021; Koszycki et al., 2021).
Adaptability. At the same time, the adaptability of MBSR is also a notable theme across the studies. MBSR interventions are culturally adaptable and effective across diverse patient populations (Ding et al., 2023; Zhang et al., 2019) and are feasible and well-accepted among participants, including healthcare professionals and adolescents (Alsubaie et al., 2018). Their effects extend beyond the intervention period, with reductions in depression and anxiety persisting up to three months post-intervention (Santamaría-Peláez et al., 2021). It can also complement treatments like medication or psychotherapy, enhancing their effectiveness. Its adaptability ensures that individuals from diverse cultural and ethnic backgrounds can benefit from the program without encountering cultural barriers. Moreover, it addresses depression from a holistic perspective due to its adaptable nature. It does not focus solely on symptom reduction but also emphasizes overall well-being and quality of life. Participants learn mindfulness techniques that can be applied to various situations, helping them manage stress, negative emotions, and depressive tendencies in the long run. It encourages self-awareness and self-regulation, giving individuals a sense of control over their mental health.
Sustainability. Additionally, based on the first two themes, sustainability emerged as a notable theme. Positive effects on psychological health, including reduced stress, anxiety, and improved well-being, make MBSR a versatile and sustainable intervention (Norouzi et al., 2020). For instance, comorbid depression occurs when patients experience both depression and anxiety simultaneously (Sverre et al., 2023). This coexistence can create a more complex clinical picture as the two conditions can intensify each other’s symptoms. MBSR can be optimized to address such complexity by targeting the shared symptoms. For example, its ability to reduce depression and rumination (Zhang et al., 2019) by cultivating mindfulness would help alleviate the shared symptoms of depressive and anxiety disorders (Haller et al., 2021; Hoge et al., 2023). Moreover, MBSR is sustainable because it can be tailored to suit the needs of specific groups or individuals, such as parents of neonatal intensive care unit (NICU) patients (Ginsberg et al., 2023) as well as those with subthreshold depression.
Contrasting Elements in the Research
The research findings present contrasting elements by demonstrating the overall effectiveness and adaptability of MBSR while acknowledging variations in its effectiveness for different outcomes and populations. Even though MBSR effectively reduces depressive symptoms and anxiety, the research suggests that the effectiveness can vary depending on the specific outcome measures and populations. Despite being particularly effective for individuals with major depression disorder (Ding et al., 2023), its effectiveness in reducing social anxiety is less conclusive (Koszycki et al., 2021). Culture is also a contrasting element. The research indicates that MBSR interventions are culturally adaptable and effective across diverse cultural backgrounds (Alsubaie et al., 2018). it also suggests that neither cultural background nor sample origin had significant effects on the results of the intervention (Ding et al., 2023). Furthermore, another contrasting element entails its general and specific impacts. On the one hand, MBSR demonstrates general positive outcomes on psychological health, including reduced stress, anxiety, and improved well-being. On the other hand, it is particularly effective in secondary-care settings for individuals resistant to pharmacotherapy, showcasing its specific application in treating certain patient groups (Ninomiya et al., 2020). It is important to consider these contrasting elements when assessing the applicability of MBSR in different clinical contexts.
Research Support for the Evidence-Based Intervention
MBSR emerges as a compelling and evidence-based intervention for addressing depression. Supported by a substantial body of research comprising eleven peer-reviewed articles, including both quantitative and qualitative studies, MBSR has consistently demonstrated its effectiveness. Ten of these studies are classified as level I evidence, the highest tier, with the remaining one at level II, ensuring robust support. The quality of evidence is notably high, with eight articles rated as A and three as B. Key themes in this research underscore MBSR’s effectiveness. Most prominently, it compares favorably with standard care and other established techniques in treating depression, particularly for those with depression disorders. It exhibits adaptability, serving diverse patient populations and being well-accepted among participants. Additionally, its effects extend beyond the intervention period, fostering sustainability. MBSR’s holistic approach to well-being, encompassing stress and anxiety reduction, reinforces its versatility. Furthermore, it shows promise in addressing comorbid depression and anxiety, making it more sustainable and flexible. Although research findings reveal contrasting elements regarding its effectiveness in various outcomes and populations, the overall evidence strongly supports MBSR as a potent intervention for depression.
Methodology (NR 702)
The project methodology centers on a comprehensive and evidence-based approach to incorporate MBSR as an alternative treatment method for alleviating symptoms of mild to moderate depression and enhancing their overall well-being. The methodology involves organizational setting, participant population, coinciding translation science model into practice change project, practice change project implementation plan with time frame and plans for sustainability. The structured methodology provides a clear, organized, and systematic approach to achieving the project’s objectives effectively and efficiently.

Organizational Setting
The project setting is a psychiatric outpatient clinic in Houston, Texas. The organization is a premier psychiatry practice with experienced professionals providing care for anxiety, autism, attention deficit hyperactivity disorder (ADHD), depression, bipolar disorders, panic disorders, schizophrenia, and other mental and behavioral issues. They offer care in the upscale Vintage Park area in North Houston. The clinic is dedicated to providing homely and compassionate care with highly individualized and evidence-based interventions. The clinic’s mission is to create a supportive and inclusive environment to make patients feel heard, respected, and empowered to participate in their treatment journey. The providers are board-certified in different specialties and the clinic offers psychiatric interventions to people of all ages. The clinic also offers exceptional treatments like transcranial magnetic stimulation (TMS) for persistent depression. The interdisciplinary care team comprises four competent and certified practitioners in child, adolescent, adult psychiatry, brain injury medicine, mental health, and gerontology, including TMS coordinator, nurse supervisor, front office manager, and billing coordinator. This outpatient clinic operates from 8-5 on weekdays and closed on weekends. The clinic has an average of 130-150 clients aged 5 years to 90 years old monthly and this population of patients requires new psychiatric evaluation and others who often visit regularly for follow-ups and treatments.
Population
The DNP project focuses on adults 18-65 years experiencing mild to moderate depression. The patients will be included in the project based on age and diagnosis. A Patient Health Questionnaire (PHQ-9) score of 5-14 is the threshold for inclusion. Those with severe depression will be excluded from the study since they likely undergo TMS or more rigorous pharmacotherapy. Exclusion criteria for the proposed project include patients population with chronic depression (>2 years), mania, psychosis, and participants with physical, cognitive, and intellectual disabilities. PHQ-9 is a self-administered validated tool with high sensitivity, specificity, and reliability(Levis et al., 2019). Those meeting the inclusion criteria must give informed consent to the project and its requirements. A form showing the project details will be offered, including how it will benefit them and any risks involved. It is expected that the project will have about 20-25 participants.
Translation Science Model: Knowledge-to-Action and Project Management
Theoretical Framework
The project will apply the knowledge-to-action model (KTA) developed by the National Center for Chronic Disease Prevention and Health Promotion Work Group on Translation to close the knowledge-practice gap and is also defined as translating clinical evidence, knowledge, or science to improve health outcomes (Tem Ham-Baloyi, 2022). The KTA framework has two main components: knowledge creation and action cycle. It was designed to be nonlinear, applicable in all settings, for all conditions or diseases and interventions being implemented, and to support the involvement of all stakeholders (Steinskog et al., 2021).
Knowledge Creation. This phase is divided into three aspects. The first is knowledge inquiry, which involves generating knowledge through research. The research phase involves exploring discovery, efficacy, effectiveness, and implementation studies. Discovery studies are the original epidemiological, behavioral, or biomedical findings stimulating the development of an intervention. The project idea arose after analyzing service gaps at the practicum site, noting that depression is a common cause of outpatient visits and that available treatment options are either long and costly (in the case of psychotherapy) or expensive and fraught with adverse effects (in the case of antidepressants). At the same time, MBSR has not been incorporated into the care pathways as an alternative treatment for mild to moderate depression. In this project, the research focuses on all studies exploring MBSR as an alternative treatment for mild to moderate depression, including its implementation, efficacy, and effectiveness. After inquiry, the next step involves knowledge synthesis and developing a knowledge product before deciding to translate it into practice. There must be proven efficacy of the MBSR intervention and supporting structures for effective implementation to move to the action stage. The gap in current practice is the limited use of MBSR as a routine recommendation for mild to moderate depression despite the evidence of its effectiveness.
Action Cycle. The action cycle starts with problem identification, which involves identifying a problem in practice and determining what should be in place to close that gap. The organization implements evidence-based treatment for mental disorders in current practice, but there is limited recommendation of MBSR as an alternative. The barriers are limited evidence-based understanding, time constraints, access to qualified MBSR instructors, and the patient’s preferences. The next step in the action cycle is adapting knowledge to the local context, considering the specific needs and constraints of the mental health clinic. Adapting the MBSR intervention to the specific needs of the outpatient population at the clinic, ensuring it aligns with the clinic’s resources and patient needs. Here, the project will adapt the best knowledge from the previous phase. The next step is assessing the situation to determine the barriers and facilitators of knowledge translation. Interviews, surveys, and review of records with the professionals at the clinic can be used to explore other barriers and drivers to implementation.
This step is followed by selecting, tailoring, and implementing the evidence-based intervention. MBSR is selected as the best intervention after assessing barriers and drivers for adaptation at the clinic. Some considerations include the sustainability of the intervention and the engagement of stakeholders. The intervention is to be tailored to the specific population, considering any prior treatments and the receptiveness of patients to an alternative treatment for depression. Implementation follows proper consideration of the most effective delivery strategy. The MBSR intervention will be directly administered to the patients. This is followed by monitoring knowledge use, collecting data, and evaluating its impact. Any changes are made at this point, and the cycle continues. The project will then be evaluated, and if it meets the goals, planning for sustainability follows.
Project Implementation Plan
Trained mindfulness instructors will implement the MBSR intervention to participating 18-65-year-old patients with mild to moderate depression. Sessions will occur twice weekly, with 45-minute sessions and one whole day weekend class on the 6th week of the entire 8-week implementation period. The lessons on mindfulness meditation and MBSR activities will be conducted through in-person and Zoom meeting sessions. Daily self-directed activities can be done by participants at their own homes. Patients will engage with the intervention through active participation in group sessions, daily self-directed practice, and intensive whole-day weekend sessions. Instructors will guide participants through mindfulness exercises and offer necessary resources
Project outlines
Evidence based intervention- According to the Centers for Disease Control and Prevention (n.d), depression is a leading cause of mental health disability in the United States, often poses a significant health burden, and is a common cause of psychiatric outpatient visits. Recommended treatment for depression includes psychotherapy and pharmacotherapy (Haller et al., 2021). The identified practice gap is that mindfulness-based interventions (MBI), such as mindfulness-based stress reduction (MBSR), are not routinely recommended as a first-line or adjunct treatment at my clinical site. At my practicum site, depressive patients tend to stop increased doses of pharmacotherapy due to the side effects and are not able to access standard psychotherapy, such as Cognitive Behavioral Therapy (CBT) due to the financial burden that tends to keep them in the continuous depressive stage. The proposed DNP project intervention aims to decrease depression symptoms in mild to moderate depressive patients in an outpatient mental health setting by implementing an eight-week mindfulness-based stress reduction intervention administered through weekly lessons and self-directed daily sessions (Hoge et al., 2023). Mindfulness-Based Stress Reduction is a feasible and emerging non-pharmacologic treatment for depression, anxiety, and stress mitigation (Chi et al., 2018; Hoge et al., 2022). The intervention helps patients cultivate self-awareness, openness, and acceptance and assists individuals in making better decisions and enhancing their capacity for coping (Chi et al., 2018). The Mindfulness-Based Stress Reduction program helps individuals reduce their stress, distress, and somatic complaints of depression and anxiety and improves psychological well-being (Norouzi et al., 2020). With the explosion of self-help applications and telehealth interventions, Mindfulness Based Stress Reduction is available as self-administered or guided meditation and reflection exercises, providing a flexible and accessible treatment method (Chi et al., 2018; Hoge et al., 2022).

PICOT- In adult patients with mild to moderate depression at an outpatient mental health clinic, does implementing Mindfulness Based Stress Reduction (MBSR) compared to current practice improve depression symptoms in 8-10 weeks?

Population, inclusion and exclusion criteria- The patients will be included in the DNP project based on age and diagnosis. The project focuses on adults 18-65 years old experiencing mild to moderate depression. A Patient Health Questionnaire (PHQ-9) score of 5-14 is the threshold for inclusion. A consent form showing the project details will be offered, including how it will benefit them and any risks involved. Those meeting the inclusion criteria must give informed consent to the project and its requirements. Those with severe depression will be excluded from the study since they likely undergo more rigorous treatment methods. Exclusion criteria for the proposed project include patients’ population with chronic depression (>2 years), mania, psychosis, and participants with physical, cognitive, and intellectual disabilities. It is expected that the project will have about 20-25 participants.

Intervention Plan- I, along with trained mindfulness instructors, will implement the Mindfulness Based Stress Reduction intervention to participating 18-65-year-old patients diagnosed with mild to moderate depression. The group sessions will occur twice weekly (45-minute sessions) with one 8-hour weekend class during the 6th week of the implementation period. The lessons on mindfulness meditation and Mindfulness Based Stress Reduction activities will be conducted at the clinic location and the participants can access the sessions through a combination of in-person sessions and Zoom web-conferencing platform sessions. The recommended daily self-directed activities can be completed by participants at their own homes or other location of choice. Week 1: Project Implementation begins with Participant recruitment and staff training. I will begin reaching out to potential participants to explain the Mindfulness Based Stress Reduction program, benefits, structure of the program, explain the time commitment, and obtain informed consent. Appointments will be scheduled for the in-person and virtual sessions. Staff training will occur which will include details of the project, timeline, and outline of training sessions. Weeks 2-9: The Intervention Implementation Begins. In the first in-person meeting, I will introduce the instructors, provide program materials to participants for mindfulness stress reduction activities are breathing exercises, meditation sessions, sleep support, mindful walking, and journaling. A baseline assessment of depression symptoms will be collected using the participant completed PHQ-9 surveys to assess pre-intervention data. I and a Psychiatric Mental Health Nurse Practitioner will be available to work in participant group sessions for 45-minute sessions twice weekly. These sessions, which focus on mindfulness principles and practices, will be conducted through in-person sessions at the clinic, but participants can also access the sessions through web conferencing via Zoom. Participants will be instructed on the daily 45-minute self-directed Mindfulness Based Stress Reduction activities and in logging their daily activities. During this intervention period for eight weeks, formative evaluations will take place. I will solicit and provide feedback through discussions with clinic leadership in meetings, biweekly huddles, and 1:1 weekly meetings with participants to discuss any challenges and experiences and get guidance. As the project manager, I will review the participant self-reported usage of the mindfulness activities and journal entries for week-to-week assessments. Besides the patients’ self-report, I will rely on in-person and Zoom meeting observations and participant attendance records for compliance assessments. Week 6: Participants will attend a virtual 8 hour mindfulness workshop conducted by a me and the Psychiatric Mental Health Nurse Practitioner. Topics will include yoga, mindful walking, and meditation to enhance their practice. Week 10: Conclusion. I will wrap up the project, administer post-intervention PHQ-9 screenings, and thank participants for being part of my DNP practice change project. I will conduct one-on-one discussions with participants to discuss post-intervention maintenance of mindfulness, and celebrate achievements. I plan to utilize this time to thank every participant for being part of the practice change project and for their support. Week 11: Analysis of data will begin. The aggregate project results will be disseminated.

Data collection plan- Pre and post-test depression assessments will be completed using Patient Health Questionnaire-9, a validated tool with high sensitivity, specificity, and reliability. Levis et al. (2019) found the tool has a sensitivity of 0.88 (95% CI 0.83-0.92) and a specificity of 0.85 (95% CI 0.82-0.88) in a meta-analysis of 29 studies with 6725 participants. I will collect the de-identified PHQ-9 scores, enter the scores into an Excel spreadsheet, and save to a password-protected computer.

Data Analysis- The outcome identified in the PICOT question is depression symptoms assessed through patient-reported signs and symptoms and scored using the PHQ-9. Descriptive statistics: median and range for baseline and post-test PHQ-9 scores will be calculated. Compliance with Mindfulness-Based Stress Reduction activities will be reported in the form of frequencies for the three levels. The chi-square test will be used for baseline and post-test comparisons.
Data collection process- Participant pre and post-implementation PHQ-9 scores obtained through completed survey

Data management
I will collect the de-identified PHQ-9 scores, enter the scores into an Excel spreadsheet, and save to a password-protected computer. All data will be in aggregate form to keep participant identity confidential. Use a coding system or unique identifiers will keep participants anonymous in the data sheet. Data will be stored in a secure and password-protected system and with limited access.
I will store project outcome data in a secure, password-protected computer and store backups in separate physical location in a secure, password-protected computer to mitigate the risk of data loss. I will save the project data for seven years and then delete the data.
I will disseminate the aggregate project results to participants by sharing key findings and aggregate project results in a simple audience language. I will communicate the aggregate project results with the practicum site in a detailed report and discuss any recommendations for improvement. I will disseminate the aggregate project results to Chamberlain College of Nursing faculty and peers through a poster presentation and manuscript. I am considering presenting the project at a conference either as a podium presentation or poster session to contribute to the professional community. I will communicate the importance of confidentiality and privacy during the presentation and maintain ethical standards. It is vital to maintain adherence to data protection measures especially when presenting findings in public. All results will be presented in aggregate format with no patient identifiers.