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Practicum Final DNP Manuscript: Schizophrenia

A Nurse-Led Intervention in Schizophrenia Patients to Improve Medication Adherence Compliance

Schizophrenia is a mental disorder that impairs thought processes and patterns, perceptions, emotional responses, and social interactions (NIMH, n.d.). Schizophrenia is persistent and can be severe and disabling when symptoms are not adequately managed (NIMH, n.d.). This DNP project pursues a nurse-led intervention to improve medication adherence and symptom management. Mucci et al. (2020) recommend a person-centered approach to healthcare that encompasses building therapeutic relationships between providers and patients and collaboration between providers when working with schizophrenia patients to achieve compliance. Specifically, the project aims to evaluate the impact of technology with motivational interviewing on medication adherence among inpatient schizophrenia patients. This DNP Project Manuscript provides the introduction and background, the problem, the project aim and supporting objectives, and the practice question, literature synthesis, and methodology. (Practicum Final DNP Manuscript: Schizophrenia)

Problem

Numerous studies have shown a varying prevalence of Schizophrenia globally and in the US. The global prevalence of Schizophrenia among non-institutionalized persons ranges between 0.33% and 0.75%, while in the United States, the prevalence of Schizophrenia is 0.25% to 0.64% (NIMH, n.d.). Nonadherence to medication among Schizophrenia patients is well documented in the United States (US) and globally. Desai and Nayak (2019) suggest most schizophrenia patients are non-compliant with medication, a national and global problem that affects 70% of patients.

Nonadherence increases the use of outpatient and hospital-related resources, while comorbidities and demographic factors exacerbate the problem. Additionally, it affects health outcomes among schizophrenia patients, increasing the risk of premature death compared to the general population, making it a significant health problem at the practicum site. The average life lost in the US due to Schizophrenia is about 28.5 years (NIMH, n.d.). Most comorbid conditions associated with Schizophrenia, including liver disease, heart disease, and diabetes, increase the risk of premature and go unrecognized. Significantly, over 50% of schizophrenia patients have additional behavioral and mental health problems. According to NIMH (n.d.), an estimated 4.9% of individuals diagnosed with Schizophrenia commit suicide, which is significantly higher than the general population, estimated at 14.2 per 100,000 people or 0.0142%.

The financial costs associated with the management of Schizophrenia increase exponentially with co-occurring mental, physical, and behavioral health conditions. The direct costs include those related to the hospital stay and medication due to worsening symptoms and general health conditions. In contrast, the indirect costs include costs due to social service needs, lost productivity, involvement of criminal justice, and issues beyond healthcare. The total cost of managing Schizophrenia and co-occurring health problems averages $2,004 to 94,229 per person per year (Kotzeva et al., 2022). Per Kotzeva et al. (2022), indirect costs make up 50-60% of the total cost, making it the primary cost driver, averaging $1,852 to $62,431 per person per year.

Nonadherence to medication among schizophrenia patients is a significant problem at the practicum site, associated with an increased risk of premature death compared to the general population, hospital stays, frequent readmissions, and increased healthcare burden for the family and the system. Currently, family and patient education help address nonadherence, but no evidence indicates desired success because it continues to be a problem among this patient population. In addition, there is no documentation of other interventions to address the nonadherence at the practicum site. This project is an opportunity to adopt motivational interviewing and technology, evidence-based interventions with indicated benefits, and high success rates in addressing nonadherence.

Project Aim and Supporting Objectives

The DNP project aims to determine the impact of motivational interviewing and technology on medication adherence among inpatient schizophrenia patients. The project objectives are as follows:

1. To evaluate the role of technology on medication adherence among inpatient schizophrenia patients.
2. To assess the impact of motivational interviews on medication adherence among inpatient schizophrenia patients.
3. To compare the impact of technology and motivational interviewing on medication adherence and the current interventions for enhancing medication adherence at the practicum site.

Practice Question

The following practice question will serve as the basis of the DNP project: For adults with a history of Schizophrenia (P) in the inpatient setting, does the implementation of technology with motivational interviewing (I), compared with current practice (C), impact medication nonadherence (O) in 8-10 weeks (T)?

 

Literature Synthesis and Evidence-Based Intervention

Part 2: Brief Description of Intervention and Endorsement

Evidence-Based Intervention

Motivational Interviewing (MI) is adopted as an evidence-based intervention to encourage behavioral change. MI is a collaborative, goal-oriented communication approach that focuses on the language of change to help people bolster personal or intrinsic motivation for and commitment to a particular objective by considering the individual’s need for change in an accepting and compassionate atmosphere. MI guides communication, balancing good listening and offering information and advice to empower individuals to change by eliciting their personal meaning, need and capacity for change. It is founded on a respectful and curious approach to interacting with people to promote a natural change process while honoring the patient’s autonomy. MI is primarily used for patients who are unwilling or ambivalent to change, combining different evidence-based interventions from cognitive and social psychology. It assumes that individuals with problematic attitudes and behaviors have varying readiness for change levels. Not recognizing the ambivalence would lead to patients rendering well-intentioned medical advice as threatening their autonomy and freedom of choice, increasing their will to exercise their freedom to make choices, which increases non-adherence. This paper adopts MI as an evidence-based intervention to increase personal motivation for and committed attitudes and behaviors to help schizophrenia patients find their own meaning and need for change in an accepting and empathetic atmosphere, aiming to improve medication adherence. The Motivation Interviewing Network of Trainers (MINT) endorses this intervention as an approach to encourage behavioral change. (Practicum Final DNP Manuscript: Schizophrenia)

Part 3: Process, Outcome, and Themes of Research Evidence

Evidence-Based Intervention

Ten articles fit the inclusion criteria, which required articles to be 5 years old or less, evidence-based, peer-reviewed, and demonstrate the efficacy of the chosen intervention, i.e., technology with motivational interviewing (MI) in improving medication adherence. Both qualitative and quantitative studies supporting the intervention were selected for this paper. The ten articles selected for review include Dobber et al. (2018), Dobber et al. (2020), Harmacnci and Budak (2022), Zomahoun et al. (2017), Pupus et al. (2022), Palacio et al. (2019), Hogan et al. (2020), Aubeeluck et al. (2021), Khadoura et al. (2021), and Abughosh et al. (2019).

Of the selected articles, six were level I, one was level II, and three were level III. The types of evidence included in level I evidence are clustered randomized controlled trials, experimental studies, and systematic reviews of RCT with or without meta-analysis. Types of evidence in level II evidence is a prospective study. In level III evidence, a qualitative multiple case study, mixed method study, and secondary analysis of data were included. All studies were high quality, with consistent, generalizable findings, a sufficient sample size for the respective designs and study purpose, adequate control, definitive conclusions, and pervasive recommendations based on the results. (Practicum Final DNP Manuscript: Schizophrenia)

Main Themes

Success Factors influencing MI Positive Effects

According to Dobber et al. (2018), trusting relationships between patients and therapists, the therapist’s ability to adopt or tailor MI strategy to a patient’s issues, and incorporating the patient’s values, needs, and perceptions of long-term medication adherence can increase MI-intervention success for medication adherence in schizophrenia patients. Dobber et al. (2020) established that a trusting relationship and empathy could help trigger mechanisms of change and enhance medication adherence. MI sessions were organized for 14 schizophrenia patients with a history of medication non-adherence. In the sessions, the patients demonstrated their medication cognitions, which were used to determine ambivalence patterns among the patient and identify success factors for MI’s positive effects. These studies established a trusting relationship between a client and the therapist, the therapist’s ability to adopt or tailor MI strategy to a patient’s issues, and incorporating the patient’s values, needs, perceptions to long-term medication adherence, and empathy as the success factors that influenced positive effects of MI.

Association between MI Techniques and Medication Adherence

Various MI techniques are identified across the studies, including telephonic MI, fidelity-based feedback, face-to-face MI, MI-consistent (MICO) method, and MI-techniques-based psychoeducation. Palacio et al. (2019) established that telephonic MI and fidelity-based feedback were significantly linked to medication adherence. According to Hogan et al. (2020), MI-consistent (MICO) method was positively associated with change and sustain talk. Abughosh et al. (2019) found that MI-based telephone intervention is promising in improving medication adherence. Patients who completed the initial call and at least 2 follow up calls were more likely to be adherent. Harmanci and Budak (2022) established that MI-techniques-based psychoeducation significantly enhanced medication adherence, hope and psychological well-being for patients in the experimental group.

MI Impact on Medication Adherence

Most studies explored MI in general and its effects on medication adherence without a focus on a specific MI technique or approach. According to Papus et al. (2022), MI improved medication adherence in 23 RCTs and risky behaviors and disease symptoms in 19 RCTs. Zomahoun (2018) established that MI interventions might be helpful in improving medication adherence for chronic conditions in adults. Per Aubeeluck et al. (2021), MI interventions significantly improved medication adherence in 5 RCTs and systolic blood pressure in 1 RCT. Khadoura et al. (2021) found that MI significantly improved medication adherence, self-efficacy, and intrinsic motivation for patients in the intervention group. (Practicum Final DNP Manuscript: Schizophrenia)

Contrasting Results or Themes in the Research

Palacio et al. (2019) established that telephonic MI was significantly linked to medication adherence. Abughosh et al. (2019) found that MI-based telephone intervention is promising in improving medication adherence. Both studies indicate telephonic MI is effective in enhancing medication adherence. However, Palacio et al. (2019) found varying effects across various categorical measures, implying that telephonic MI impacted different groups or measures differently. Abughosh et al. (2019) findings across all patient groups were consistent, indicating better results for those who received two or more calls. The studies also focus on varying themes. Dobber et al. (2018) and Dobber et al. (2020) address the success factors influencing MI’s positive effects. Palacio et al. (2019), Abughosh et al. (2019), Hogan et al. (2020), and Harmanci and Budak (2022) address specific MI techniques adopted to address medication adherence, including telephonic MI, fidelity-based feedback, face-to-face MI, MI-consistent (MICO) method, and MI-techniques-based psychoeducation. Papus et al. (2022), Zomahoun (2018), Aubeeluck et al. (2021), and Khadoura et al. (2021) address MI in general and its effectiveness in improving medication adherence. Other than the contrasting effects and themes of MI across the studies and for different disease conditions and patient populations, the studies’ results were consistent, indicating MI and MI techniques as effective in enhancing medication adherence.

Objective Overarching Synthesis of Research Statement Supporting the Evidence-Based Intervention

MI was selected because of its adaptability to many different settings (Pupus et al., 2022). Moreover, MI has significantly impacted medication adherence (Dobber et al., 2018; Dobber et al., 2020; Harmacnci and Budak, 2022; Zomahoun et al., 2017; Pupus et al., 2022; Palacio et al., 2019; Hogan et al., 2020; Aubeeluck et al., 2021; Khadoura et al., 2021; Abughosh et al., 2019). MI is also associated with various mental health outcomes that promote medication adherence, such as hope and mental well-being (Harmacnci & Budak, 2022). These aspects of MI suggest that the intervention is evidence-based and can help mitigate medication non-adherence among schizophrenia patients in an inpatient facility. (Practicum Final DNP Manuscript: Schizophrenia)

Part 4: Detailed Sequence of Intervention

Explanation of the Evidence-Based Intervention

Across the research studies, MI is adopted as an evidence-based, collaborative tool for improving medication adherence. The studies acknowledge MI focus on patient ambivalence and lack of the individual’s own motivation and commitment to change. MI across the studies address the common patient’s problem of ambivalence regarding medication adherence. Patients are aware of the positive effects of medication, such as preventing psychotic relapse and readmission but are burdened by the side effects and the need to take medication as prescribed. The therapist is at the center of implementing MI in healthcare organizations and is deliberately influencing patients’ motivation for change by adopting strategies such as change talk elicitation, sustain talk, developing trusting relationships with patients, adopting empathetic attitudes, communicating partnerships with patients and intervening through the four overlapping processes of MI, including engaging or relation building, focusing or identifying a patient’s change, evoking or eliciting change talk and client’s need for change, and planning or helping the patient create a comprehensive change plan. The therapists have also been integral across studies in implementing MI techniques such as telephonic MI, calling and communicating o the patients, fidelity-based feedback, face-to-face MI, MI-consistent (MICO) method, and MI-techniques-based psychoeducation. Generally, the studies consider the therapist as imperative in the process of implementing MI and the patient and patient perspectives as the drivers of MI.

Steps in the Intervention Implementation

Across the research studies, MI and MI techniques have been adopted using the four processes of MI: engaging, focusing, evoking, and planning. The first process, engaging, allows the therapist to develop a good trusting and working relationship with the client to understand the problem. This process requires reflective listening to understand the client and the ambivalent attitude. The second process is focusing, which involves identifying a clear objective and goal, including identifying target behavior, exploring ambivalence and barriers, and establishing discrepancy. For this paper, the target behavior is medication adherence. The evoking process requires a practitioner to focus on and help the client towards the target goal or behavior. The therapist tries to evoke the client’s own internal motivation and needs for change and reinforce the overall motivation for change. This process involves the change talk that involves evoking desire and motivation for change and mobilizing commitment to change. It also entails the sustain talk, which is about ensuring the target behavior is sustained over time. In the planning face, the therapist strives to establish a commitment to change and develop an action plan, including considering outside support, developing skills, and removing barriers.

Participant Engagement during Intervention Implementation

Motivational interviewing is more patient-centered, promoting the patient’s autonomy during the elicitation of motivation and need for change and commitment to change. The practitioner will engage patient perspectives through the implementation and the MI processes to ensure continuous patient engagement. Practitioners involved will continuously ask questions, reinforce responses using affirmations, and adopt a lot of reflective listening to ensure the patients feel heard and engaged, encouraging their involvement through the intervention implementation. A good and trusting relationship will precede every activity to establish good engagement before beginning the change conversation. The therapists will use the guiding style to engage participants, clarify strengths, motivation and need for change, and foster autonomy in decision-making to ensure full involvement throughout the implementation. (Practicum Final DNP Manuscript: Schizophrenia)

Methodology

This section describes organizational setting, project population, translation science model and project management, plans for sustainability, and anticipated outcomes.

Organizational Setting

The healthcare setting is a general mental health facility for treating various mental health disorders. The organization adopts mental health teams based in communities, especially for schizophrenia patients, that offer daily support and treatment while helping schizophrenia patients gain as much independence as possible. Mental health teams based in communities are more suitable for the patient population because most schizophrenia patients live with their families. The teams include nurses, therapists, psychiatrists, psychologists, and social workers. The healthcare organization is located in Los Angeles, California. The healthcare organization is located in Los Angeles, California.

The study focuses on schizophrenia patients with schizophrenia as the primary diagnosis. Schizophrenia is associated with significant thinking or cognitive, behavioral, and emotional problems. Individuals between the ages of 16 and 25 years are the most vulnerable, although new schizophrenia cases begin increasing in their teenage years. Most patients present with hallucinations, delusions, and confused or disturbed thoughts that impact behavior and social and occupational functioning. About 150-230 schizophrenia patients are seen each month either at the facility or in their respective homes by the mental health teams based in the communities. On average, a hospitalized schizophrenia patient can stay in the hospital for days, ranging between 11 days to 23 days, depending on the condition and symptoms severity. A full-team approach is adopted in addressing schizophrenia at the healthcare organization. A combination of psychopharmacologists, therapists, social workers, nurses, vocational counselors, and case managers contributes to patient health management and outcome. The psychiatrist experienced or specialized in treating schizophrenia guides disease treatment and management, supported by other members of the treatment team that help coordinate care.

Population

The project population typically includes schizophrenia patients experiencing thinking or cognitive, behavioral, and emotional problems. The patient population consists of both men and women reporting at the facility or requesting home visits from the mental health team based in the communities. The study will include 50 consecutive schizophrenia patients following up with treatment at the facility or home. The inclusion criteria required patients diagnosed with schizophrenia according to the International Statistical Classification of Diseases-10 criteria, patients aged between 18 and 65 years, patients receiving treatment for the last 6 months, follow-up patients, patients with multiple schizophrenia episodes, and patients with recent psychotic relapse after nonadherence to treatment. The exclusion criteria include acutely psychotic patients during the interview and patients with cognitive deficits impacting the interview or data collection. Existing users of health services at the facility will be requested to participate in the study. Informed consent will be required to collect data on the participants. Any follow-up schizophrenia patient attending psychiatric evaluation in the inpatient or outpatient departments will be recruited for the study after consent. The first 50 consecutive schizophrenia patients that fit the inclusion criteria will be involved in the study. Participation requests and details of the study will first be communicated via text messages, which are suitable even for older patients. (Practicum Final DNP Manuscript: Schizophrenia)

Translational Science Model and Project Management Plan

The Iowa model of evidence-based practice will help implement motivational interviewing to enhance medication adherence among schizophrenia patients. It supports evidence-based practice implementation, research utilization, and knowledge transformation processes (Duff et al., 2020). The Iowa model offers a systematic approach to synthesizing knowledge and research findings transformation to enhance patient outcomes and quality of care. The primary purpose of this model is to increase research findings’ meaningfulness and utility in clinical decision-making (Iowa Model Collaborative et al., 2017). The Iowa model is an application-oriented EBP process guide with the following primary steps:

1. Identifying either a knowledge-focused or problem-focused trigger that warrants EBP adoption.
2. Determining if the identifying problem is a priority for the institution, practice, department, or clinical setting (Cabarrus College of Health Sciences, 2023).
3. Establishing a team to develop, examine, and implement the required EBP change. This must be representative and interdisciplinary to evaluate and adopt the EBP change better.
4. Gathering and analyzing evidence related to the identified change, including developing the research question and performing a literature search using identified keywords.
5. Critiquing and synthesizing the collected research evidence to determine whether the EBP change is scientifically supported, sound, and clinically significant.
6. Assessing whether the evidence is sufficient to implement the EBP change.
7. Implementing the EBP change into a pilot program rather than a full practice change, for instance, implementing the change in a single nursing unit rather than the entire organization.
8. Evaluating outcomes or results to determine whether the change achieves its objectives, is feasible, and if it is appropriate to adopt it within the organization. Implementation results’ observation, evaluation, and analysis should continue even after full-practice implementation (Cabarrus College of Health Sciences, 2023).

Per the Iowa model, the DNP practice project development and implementation includes the following steps:

1. I identified medication non-adherence among schizophrenia patients as warranting EBP adoption.
2. Medication non-adherence is a priority for the organization as it is linked with increased treatment failure, hospitalization, readmission, and mortality rates. Addressing this problem would improve hospital and patient health outcomes.
3. I developed a team comprised of a combination of psychopharmacologists, therapists, social workers, nurses, vocational counselors, and case managers to develop, examine, and implement motivational interviewing to address medication non-adherence among schizophrenia patients.
4. I developed a practice question “For adults with a history of Schizophrenia (P) in the inpatient setting, does the implementation of technology with motivational interviewing (I), compared with current practice (C), impact medication nonadherence (O) in 8-10 weeks (T)?” to guide literature search and the DNP project. I searched for peer-reviewed articles from various databases, including PubMed, MEDLINE, and CINAHL, addressing the impact of motivational interviewing on medication adherence.
5. I reviewed the articles based on their abstract, research purpose, methodology, research findings, evidence level and quality and presented results of 10 articles on the evidence synthesis summary tool/table. Based on the evidence, motivational interviewing is scientifically supported, sound, and clinically significant.
6. Ten articles were identified as providing the best evidence to help answer the research question. Based on the assessment, the evidence is sufficient to guide and inform the implementation of motivational interviewing at the healthcare facility.
7. The project team and I will implement motivation interviewing into a pilot program that include follow-up schizophrenia patients only.
8. The team and I will evaluate the implementation results to determine the impact of motivational interviewing on medication adherence among schizophrenia patients. Clinically significant results will warrant the implementation of motivational interviewing organization-wide. (Practicum Final DNP Manuscript: Schizophrenia)

Project Management Plan

The DNP project implementation will take 12 weeks to complete. Week 1 will involve identifying participants and collecting pre-implementation data. In week 2, steps 1, 2, and 3 will be completed, which include problem identification, determination of priority, and team development. In week 3, steps 4, 5, and 5, involving evidence gathering and analysis, research articles critiquing and synthesis, and evidence assessment for adequacy will be completed. The implementation of motivational interviewing will begin in week 4 and through weeks 5, 6, 7, 8, 9, 10, and 11. In week 12, post-summative data after intervention implementation will be collected and outcomes evaluated, which is step 8 of the project implementation plan, to determine the effectiveness of motivational interviewing in addressing medication adherence among schizophrenia patients and whether it is suitable to implement in the rest of the organization and patient populations.

Table 1: Implementation Plan

Week	Activity
Week 1	Pre-implementation data collection.
Week 2	Step 1: Problem identification Step 2: Determining whether the problem is priority to the organization Step 3: Team development
Week 3	Step 3: Evidence gathering and analysis Step 4: Research articles critique and synthesis Step 5: Evidence assessment for adequacy
Week 4	Step 7: Intervention implementation
Week 5	Step 7: Intervention implementation
Week 6	Step 7: Intervention implementation
Week 7	Step 7: Intervention implementation
Week 8	Step 7: Intervention implementation
Week 9	Step 7: Intervention implementation
Week 10	Step 7: Intervention implementation
Week 11	Step 7: Intervention implementation
Week 12	Post-summative data collection Step 8: Outcome evaluation

Formative Evaluation Plan

The formative evaluation will include individual evaluation conducted before, during, and after intervention implementation aiming to improve project development and implementation design and performance and ensure activities are completed effectively and efficiently. This formative evaluation will help understand why and how the project works and other factors at work during project development and implementation. This evaluation plan will increase the likelihood of attaining successful results or outcomes through continuous improvements informed by evaluation results at different project implementation steps. (Practicum Final DNP Manuscript: Schizophrenia)

Table 2: Formative Evaluation Plan

Week	When	Why	How (Oversight)
Week 1	Pre-project implementation	·         Understand the need for the project	·         Leadership meetings
Week 2	Project development	·         Clarify the need for the project	·         Problem tree analysis ·         Priority Matrix ·         Stakeholder analysis
Week 3	Project development	·         Clarify the need for the problem ·         Identify problem impact ·         Clarify intervention selected	·         Literature review ·         Solution tree analysis
Week 4	Project implementation	·         Develop project design before roll-out	·         Focus group ·         Discussions
Week 5	Project implementation	·         Improve project design as it is rolled out	·         Semi-structured interview ·         ORID ·         Project diary
Week 6	Project implementation	·         Ensure project implementation activities are delivered efficiently and effectively.	·         Schedule tracking ·         Budget tracking ·         Observation ·         Dartboard ·         Questionnaire ·         Huddles
Week 7	Project implementation	·         Ensure project implementation activities are delivered efficiently and effectively.	·         Schedule tracking ·         Budget tracking ·         Observation ·         Dartboard ·         Questionnaire ·         Huddles
Week 8	Project implementation	·         Ensure project implementation activities are delivered efficiently and effectively.	·         Schedule tracking ·         Budget tracking ·         Observation ·         Dartboard ·         Questionnaire ·         Huddles
Week 9	Project implementation	·         Ensure project implementation activities are delivered efficiently and effectively.	·         Schedule tracking ·         Budget tracking ·         Observation ·         Dartboard ·         Questionnaire ·         Huddles
Week 10	Project implementation	·         Ensure project implementation activities are delivered efficiently and effectively.	·         Schedule tracking ·         Budget tracking ·         Observation ·         Dartboard ·         Questionnaire ·         Huddles and meetings
Week 11	Project implementation	·         Ensure project implementation activities are delivered efficiently and effectively.	·         Schedule tracking ·         Budget tracking ·         Observation ·         Dartboard ·         Questionnaire ·         Huddles and discussions
Week 12	Post-project implementation	·         Ensure project is completed successfully.	·         Leadership meetings ·         Project team discussions ·         Schedule tracking ·         Budget tracking ·         Observation ·         Dartboard ·         Questionnaire

 

Plans for Sustainability

The sustainability objective is to ensure motivational interviewing is adopted organization-wide and the organization continues to enjoy its benefits in improving medication adherence over time. The sustainability plan will ensure the sustainability objective is achieved. Continuous quality and performance improvement is a post-implementation objective to help ensure the project’s sustainability. First, critical success factors will be developed, including medication adherence measures that will help assess the continued effectiveness of the intervention. Critical success factors include a substantial decrease in treatment failure, hospitalization, readmission, and mortality rates among schizophrenia patients. Consistent improvement of medication adherence and persistent behavior, including patient motivation, self-efficacy, and change and sustain talk, are critical success factors that will also help determine sustainability.

Data collection, observation, and analysis will allow the organization to measure the continual effectiveness of the intervention. Patient records and the organization’s medical data will provide information regarding treatment failure, hospitalization, readmission, and mortality rates over time. Self-reported surveys and interviews will help gather qualitative data to determine changes in medication adherence behavior over time. Project auditing and feedback collection from various stakeholders will also offer insights into the performance of the intervention after implementation and over time. The team selected for patients’ health management and outcome, patients, leaders, and observers will offer feedback regarding the project to help with continuous improvement. Opinion leaders’ involvement and evaluation will help improve the intervention and ensure sustainability. Opinion leaders include external and internal experts, educators, and organizations that advocate for the project; their insights will be critical. The data from these data and insight sources will inform sustainability strategies for continuous quality improvement. Additionally, continuous quality and performance improvement and suitability over time will be achieved through continuous patient and provider education on motivational interviewing and medication management and summative evaluation of education outcomes. Ongoing provider and patient education will help ensure the sustainability of project benefits over time.  (Practicum Final DNP Manuscript: Schizophrenia)

Anticipated Outcomes

Relationship between Motivational Interviewing and Medication Adherence

The primary purpose of motivational interviewing is to enhance medication adherence among schizophrenia patients. Motivation interviewing and medication adherence have a direct relationship, which involves one value directly affecting another, such as variables increasing and decreasing together. In this case, motivational interviewing has no values that increase or decrease, and the presence or absence of it will be analyzed in this paper. Data will be collected for medication adherence measures, which include treatment failure rate, readmission rates, hospitalization rates, and mortality rates, before implementing motivational interviewing and after the implementation. The expectation is a direct causal relationship such that when motivational interviewing is implemented, medication adherence behavior, which will be measured using the indicated medication adherence measures. This direct causal relationship is described as “the implementation of motivational interviewing improved medication adherence” or “motivational interviewing was positively associated with medication adherence.”

Expected Change after Implementing Motivational Interviewing

Implementing motivational interviewing is expected to improve medication adherence behavior, which is indicated by measures including treatment failure rate, readmission rates, hospitalization rates, and mortality rates. The desired changes based on these measures include decreased treatment failure rate, reduced readmission rate, decreased hospitalization rates, and decreased mortality rate associated with schizophrenia. Per Aubeeluck et al. (2021), MI interventions significantly improved medication adherence in 5 RCTs and systolic blood pressure in 1 RCT. Khadoura et al. (2021) found that MI significantly improved medication adherence, self-efficacy, and intrinsic motivation for patients in the intervention group. According to Papus et al. (2022), MI improved medication adherence in 23 RCTs and risky behaviors and disease symptoms in 19 RCTs. Additionally, Zomahoun (2018) established that MI interventions might help improve medication adherence for chronic conditions in adults. The evidence indicates a positive relationship between motivational interviewing and medication adherence, although measures used vary for the different studies. (Practicum Final DNP Manuscript: Schizophrenia)

References

Abughosh, S., Wang, X., Serna, O., Esse, T., Mann, A., Masilamani, S., Holstad, M. M., Essien, E. J., & Fleming, M. (2019). A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence. Journal of managed care & specialty pharmacy, 23(5), 549–560. https://doi.org/10.18553/jmcp.2019.23.5.549

Aubeeluck, E., Al-Arkee, S., Finlay, K., & Jalal, Z. (2021). The impact of pharmacy care and motivational interviewing on improving medication adherence in patients with cardiovascular diseases: A systematic review of randomised controlled trials. International journal of clinical practice, 75(11), e14457. https://doi.org/10.1111/ijcp.14457

Cabarrus College of Health Sciences. (2023, February 3). Cabarrus College of Health Sciences Library: IOWA Model. https://cabarruscollege.libguides.com/c.php?g=465666&p=5283295

Desai, R., & Nayak, R. (2019). Effects of medication nonadherence and comorbidity on health resource utilization in Schizophrenia. Journal of Managed Care & Specialty Pharmacy, 25(1), 37-46. https://doi.org/10.18553/jmcp.2019.25.1.037

Dobber, J., Latour, C., de Haan, L., Scholte op Reimer, W., Peters, R., Barkhof, E., & van Meijel, B. (2018). Medication adherence in patients with schizophrenia: a qualitative study of the patient process in motivational interviewing. BMC Psychiatry, 18(1), 1-10. https://doi.org/10.1186/s12888-018-1724-9

Dobber, J., Latour, C., van Meijel, B., Ter Riet, G., Barkhof, E., Peters, R., … & de Haan, L. (2020). Active ingredients and mechanisms of change in motivational interviewing for medication adherence. A mixed methods study of patient-therapist interaction in patients with schizophrenia. Frontiers in psychiatry, 11, 78. https://doi.org/10.3389/fpsyt.2020.00078

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Harmanci, P., & Budak, F. K. (2022). The Effect of Psychoeducation Based on Motivational Interview Techniques on Medication Adherence, Hope, and Psychological Well-Being in Schizophrenia Patients. Clinical Nursing Research, 31(2), 202-216. https://doi.org/10.1177/10547738211046438

Hogan, A., Catley, D., Goggin, K., & Evangeli, M. (2020). Mechanisms of Motivational Interviewing for Antiretroviral Medication Adherence in People with HIV. AIDS and behavior, 24(10), 2956–2965. https://doi.org/10.1007/s10461-020-02846-w

Iowa Model Collaborative, Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B., Steelman, V., Tripp-Reimer, T., Tucker, S., & Authored on behalf of the Iowa Model Collaborative (2017). Iowa Model of Evidence-Based Practice: Revisions and Validation. Worldviews on evidence-based nursing, 14(3), 175–182. https://doi.org/10.1111/wvn.12223

Khadoura, K. J., Shakibazadeh, E., Mansournia, M. A., Aljeesh, Y., & Fotouhi, A. (2021). Effectiveness of motivational interviewing on medication adherence among Palestinian hypertensive patients: a clustered randomized controlled trial. European journal of cardiovascular nursing, 20(5), 411–420. https://doi.org/10.1093/eurjcn/zvaa015

Kotzeva, A., Mittal, D., Desai, S., Judge, D., & Samanta, K. (2022). Socioeconomic burden of Schizophrenia: A targeted literature review of types of costs and associated drivers across ten countries. Journal of medical economics, (just-accepted), 1-18.https://doi.org/10.1080/13696998.2022.2157596

Mucci, A., Kawohl, W., Maria, C., & Wooller, A. (2020). Treating Schizophrenia: Open Conversations and Stronger Relationships Through Psychoeducation and Shared Decision-Making. Frontiers in psychiatry, 11, 761. https://doi.org/10.3389/fpsyt.2020.00761

National Institute of Mental health. (No date). Schizophrenia. Available at: https://www.nimh.nih.gov/health/statistics/schizophrenia (Accessed January 14, 2023)

Palacio, A., Garay, D., Langer, B., Taylor, J., Wood, B. A., & Tamariz, L. (2019). Motivational Interviewing Improves Medication Adherence: a Systematic Review and Meta-analysis. Journal of general internal medicine, 31(8), 929–940. https://doi.org/10.1007/s11606-016-3685-3

Papus, M., Dima, A. L., Viprey, M., Schott, A. M., Schneider, M. P., & Novais, T. (2022). Motivational interviewing to support medication adherence in adults with chronic conditions: systematic review of randomized controlled trials. Patient Education and Counseling.

Zomahoun, H. T. V., Guénette, L., Grégoire, J. P., Lauzier, S., Lawani, A. M., Ferdynus, C., Huiart, L., & Moisan, J. (2018). Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: a systematic review and meta-analysis. International journal of epidemiology, 46(2), 589–602. https://doi.org/10.1093/ije/dyw273

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Appendix A

Part 1: Week 4 John Hopkins Individual Evidence Summary Tool

Article #	Author & Date	Evidence Type	Sample, Sample Size & Setting	Study findings that help answer the EBP question	Limitations	Evidence Level & Quality
1.	Dobber, J., Latour, C., de Haan, L., Scholte op Reimer, W., Peters, R., Barkhof, E., & van Meijel, B. (2018).	A qualitative multiple case study	14 cases of schizophrenia patients were used in the study	Trusting relationships between patients and therapists, the therapist’s ability to use MI-strategy in the patient process, and considering patient values in long-term medication adherence can increase MI-intervention success for medication adherence in schizophrenia patients.	Small sample size can limit generalizability	Level III/Quality A
2.	Palacio, A., Garay, D., Langer, B., Taylor, J., Wood, B. A., & Tamariz, L. (2019)	Systematic Review and Meta-analysis	17 RCTs were included in the review	Telephonic MI and fidelity-based feedback were significantly linked to medication adherence.	Included few studies focusing on non-minority populations. Most studies were on antiretroviral medications, limiting generalizability. The small sample size limited the power of analyses.	Level I/Quality A
3.	Dobber, J., Latour, C., van Meijel, B., Ter Riet, G., Barkhof, E., Peters, R., … & de Haan, L. (2020).	A Mixed Methods Study	14 cases of schizophrenia patients were included in the study.	A trusting relationship and empathy can help trigger mechanisms of change.	Small sample size limits generalizability. Limited visibility and measurability of most patient factors and change mechanisms.	Level III/Quality A
4.	Papus, M., Dima, A. L., Viprey, M., Schott, A. M., Schneider, M. P., & Novais, T. (2022).	Systematic review of randomized controlled trials	The study included 54 RCTs.	MI improved medication adherence in 23 RCTs and risky behaviors and disease symptoms in 19 RCTs.	The study focused on chronic conditions limiting generalizability for other disease conditions.	Level I/Quality A
5.	Zomahoun, H. T. V., Guénette, L., Grégoire, J. P., Lauzier, S., Lawani, A. M., Ferdynus, C., Huiart, L., & Moisan, J. (2018).	A systematic review and meta-analysis	The meta-analysis included 16 RCTs.	MI interventions might be helpful in improving medication adherence for chronic conditions in adults.	The sample size was small, limiting generalizability.	Level I/Quality A
6.	Hogan, A., Catley, D., Goggin, K., & Evangeli, M. (2020).	A secondary analysis of data	62 HIV adult patients were included in the study.	MI-consistent (MICO) method was positively associated with change and sustain talk.	The historic nature of the data and limited statistical control limits the study. One MI session was used and there was no variable manipulation, limiting establishment of causality.	Level III/Quality A
7.	Aubeeluck, E., Al-Arkee, S., Finlay, K., & Jalal, Z. (2021).	A systematic review of randomized controlled trials	8 RCTs were include in the study.	MI interventions significantly improved medication adherence in 5 RCTs and systolic blood pressure in 1 RCT.	Small sample size limited generalizability.	Level I/Quality A
8.	Khadoura, K. J., Shakibazadeh, E., Mansournia, M. A., Aljeesh, Y., & Fotouhi, A. (2021).	A clustered randomized controlled trial	355 hypertensive patients were included as participants.	MI significantly improved medication adherence, self-efficacy, and intrinsic motivation for patients in the intervention group.	The focus on one disease condition can limit generalizability.	Level I/Quality A
9.	Abughosh, S., Wang, X., Serna, O., Esse, T., Mann, A., Masilamani, S., Holstad, M. M., Essien, E. J., & Fleming, M. (2019)	A prospective study	11 students were included in implementing the intervention and 743 patients were the subjects.	MI-based telephone intervention is promising in improving medication adherence. Patients who completed the initial call and at least 2 fall up calls were more likely to be adherent.	The effects were for a short period of time and more research is required for longer time periods.	Level II/ Quality A
10.	Harmanci, P., & Budak, F. K. (2022)	A pretest-posttest control group design	150 schizophrenia patients participated in the study.	MI-techniques-based psychoeducation significantly enhanced medication adherence, hope and psychological well-being for patients in the experimental group.	The effects were for short period and clinicians should be careful when adopting the results.	Level I/Quality A

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