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Identifying Barriers to Nurse Compliance with

Depression Screening in Stroke Patients

Susan Alex

Texas Woman's University

Table of Contents

Introduction 2

Overview and Purpose 4

SWOT Analysis 5

Problem Statement 6

PICO Statement/Clinical Inquiry 6

Research Questions 7

Statement of Intervention 7

Evidence-Based Practice Model 7

Review of Literature 9

Literature Search Process 9

Background 10

Impact of Stroke and PSD 11

Barriers Preventing Nurses from Compliance 13

Analysis of the Literature 15

Instrumentation, Population, and Sample 15

Instrumentation 15

Population and Sample 16

Description of Intervention 16

Description of the Proposed Intervention 16

Implementation 17

Study Objectives 17

Timelines of Phases 17

Table of Contents Continued

Data Collection 18

Results and Findings 19

References 20

Appendices

A. Informed Consent and Survey Questions 25

B. Table 1: Critical Analysis of Quantitative Research Articles 29

Identifying Barriers to Nurse Compliance with Depression

Screening in Stroke Patients

Stroke is a major health problem in the United States. According to the American Heart Association (AHA) (2014), by the age of 20 years or more, approximately 6.8 million Americans have had a stroke. A higher prevalence of stroke occurs in older adults, Blacks, people with less education, and those living in the southeastern states (AHA. 2014). The Centers for Disease Control and Prevention (CDC (2014) found that three major risk factors for heart disease and stroke include (a) high blood pressure that is out of control, (b) high LDL cholesterol, and (c) smoking, and the CDC reported that 47% of Americans have at least one of these risk factors. Stroke is the third foremost cause of death in the United States and the major cause of debilitation among adults (Michael & Shaughnessy, 2006; CDC, 2011).

The American Stroke Association (ASA) (2013) noted that strokes can cause biochemical changes in the brain which lead to poststroke depression (PSD). Paolucci and Lucia (2008) found PSD as a common and serious complication after a stroke. Despite the fact that PSD can affect a patient’s functional recovery and quality of life after stroke, PSD is often ignored (Paolucci & Lucia). Paolucci and Lucia stated only a minority of patients is diagnosed, and even fewer are treated in clinical practice. Almost 33% of all stroke survivors experience depression in their lives (National Institute of Mental Health [NIMH], 2014). The National Institute of Neurological Disorders and Stroke (NINDS) (2012) predicted that by 2020, depression will be the second leading cause of disability in the world. Identification of PSD or effective intervention in the initial phase may prevent early deaths, promote effective rehabilitation, reduce costs, and improve one’s quality of life (NIMH, 2014).

Pfeil, Gray, and Lindsay (2009) reported nurses play a major role in caring for stroke patients and their families. A nurse’s care extends beyond the physical care of a stroke patient. Nurses initiate interventions that include early screening for PSD, providing treatment recommended by physicians, monitoring the effect of the treatment, and teaching families how to recognize PSD symptoms and care for their loved ones. Nurses play a key role in the stability of care between hospital and community.

Overview and Purpose

The NINDS (2012) described PSD as a feeling of hopelessness that hinders a person’s capacity to function and suppresses his quality of life. If not treated and managed properly, PSD can slow down recovery (NINDS, 2012). Hart and Morris (2007) stated depression screening is required if PSD is to be recognized and patients are to be provided with suitable treatment and emotional care. Depression can take root in weeks, months or even years after a stroke and can impede improvement of recovery and rehabilitation by impacting a stroke survivor’s quality of life (NINDS, 2012). PSD worsens neurological and psychological damage, adversely affecting activity performance and daily living (Jeong et al., 2014). Early recognition of PSD is essential in order to improve recovery, facilitate rehabilitation, and reduce mortality (Lokk & Delbari, 2010).

This designated hospital has implemented QIDS-SR (Rush et al., 2003) as a screening tool for all stroke patients. Per this facility’s implemented protocol, all stroke patients must be evaluated to identify cognitive decline, depression, and other social issues prior to discharge. Despite this facility’s implemented protocol for depression screening, lack of compliance is being observed from monthly audit. Hence, the purpose of this study is to review the current practice, identify barriers among nurses for depression screening, and to propose a plan to resolve the problem based on the results of the proposed survey at this designated hospital. The nurses will be asked to complete a survey based on three concepts: (a) knowledge/perception of depression screening in stroke patients among nurses, (b) possible barriers the nurses perceive in preventing implementation of depression screening, and (c) the value of completing the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) for patient well-being (Rush et al., 2003).

Strengths, Weaknesses, Opportunities, and Threats: Analysis

The strengths, weaknesses, opportunities, and threats (SWOT) analysis for this study consists of a description of the strengths, weaknesses, opportunities, and threats that are anticipated with the proposed intervention at the designated southern hospital specializing in neuroscience. There are mainly two strengths that support this study. One of these strengths is the availability of a neuroscience nursing research center which provides support for evidence-based research for the nurses who work there. A second strength for this 152-bed hospital is the availability of nurses who are highly skilled and well-trained.

One of the weaknesses may be a lack of proper performance auditing within this organization. Another weakness may be the lack of communication about the monthly scores of the depression screening between nurses and nurse managers. This lack of communication can and must be improved. The greatest weakness in this analysis is the noncompliance of depression screening among nurses for the stroke patients. The aim of this study is to explore the barriers that lead to noncompliance.

There are several opportunities available to staff and patients. The highly skilled nursing staff at the designated facility can offer input for improving the compliance for depression screening for stroke patients and can help family members through education in caring for these patients. Additionally, these skilled nurses will have opportunities to share their knowledge and abilities through training sessions, lectures, and writings.

One of the threats is the change that fatigue causes among nurses because nurses are often required to participate in various surveys and studies in addition to their patient care. These surveys and studies add to their nursing duties and are time-consuming. Another threat is the possibility that there may not be enough staff to participate in the proposed intervention.

Problem Statement

The problem statement for this study is the lack of nurse compliance with poststroke depression screening despite the implemented protocol.

PICO Statement/Clinical Inquiry

This study will focus on the barriers for nurses related to depression screening for acute care patients who have had a stroke. This PI will examine nurses’ perception of potential barriers in completing depression screening of stroke patients. The PICO question for this study has four components: population (P), intervention (I), comparison (C), and outcome (O). The population for this study consists of nurses who work in the ICU and Stroke Unit of the designated hospital for at least one year. The intervention for this study is an open-ended survey questionnaire used to determine (a) the nurses’ perception of depression screening in stroke patients, (b) possible barriers the nurses think are preventing proper implementation, and (c) how the nurses value completion of QIDS-SR for the patient’s well-being. This PI will conduct an analysis of the survey to determine the possible barriers and will propose a plan based on the findings to resolve the lack of compliance in screening.

A monthly score card for depression screening in stroke patients will be used to compare (C) patient scores before and after. The outcome (O) will be determined after implementing the proposal from the study. A higher compliance should be expected after implementing the proposal.

Research Questions

1. What is the current knowledge of nurses regarding depression screening in stroke patients?

2. What are the possible barriers the nurses think are preventing proper implementation of depressions screening?

3. How do nurses value the completion of QIDS-SR to the well-being of poststroke depression patients?

Statement of Intervention

This PI will send out a survey questionnaire and will conduct an analysis of the survey responses to determine the possible barriers among nurses for noncompliance of depression screening. Once the analysis is completed, this PI will propose a plan to resolve the lack of compliance with depression screening.

Evidence-Based Practice Model: Guiding Framework

The Iowa model of evidence-based practice to promote quality care is the theoretical framework used for this study. The Iowa model was developed by Titler et al. (2001). Since the Iowa model is copyrighted, a visual image of the Iowa model can be found at the following website ().

The Iowa model is a collaborative, organizational model that combines clinical inquiry and the use of research evidence along with a variety of types of evidence (Doody & Doody, 2011). Since it was created in 1994, the authors have received many requests to use the model in publications, presentations, graduate and undergraduate research courses, clinical research programs, and practice (Titler et al., 2001). The Iowa model was developed and originally implemented at the University of Iowa Hospitals and Clinics, and it serves as a guide to use research findings for improving patient care for nurses and other health care providers (Titler et al., 2001). Nurses from several community-based agencies and health care institutions provided feedback on the Iowa model. This feedback indicated that the process is easy to follow and provides three options to choose from if there is not enough research to guide practice (Titler et al., 2001). Based on the latest developments in the health care market and response from nurses, the model was revised to include new terminology and feedback loops, address changes in the health care market and to use additional sources of evidence such as theory, case reports, consensus of experts, and scientific principles to guide practice when research is unavailable or inconclusive (Titler et al., 2001). The decision was made to change the name of the model from “Research-Based Practice” to “Evidence-Based Practice” based on the experiences in (a) the use of the original model, (b) the current use of the term evidence-based practice in the nursing literature, and (c) the need to clarify the application of research findings in relation to the use of other evidence (Titler et al., 2001).

The main issues to consider when selecting a topic of evidence-based practice are how the topic fits into organizational goals, the magnitude of the problem, how many people are interested in the problem, support of nurse leaders and other interdisciplinary staff, costs, and potential barriers to change (Titler et al., 2001). The Iowa model approaches evidence-based practice from a system or organization perspective, rather than from the perspective of an individual provider. Depression screening in stroke patients is very important for their recovery and well-being.

The mission of this hospital is to improve health care in the community, the state, and the world through innovation and education, focusing on quality, safety, and service in patient care. When the Neurology Department and this PI determined that the issue of noncompliance existed, this PI introduced the idea of conducting a survey to find the barriers that were preventing compliance. Many people including the departmental head, physicians and the nurse managers showed interest and encouraged this PI to pursue this study. Thus, the support for this study is evident. Using this evidence-based practice model, this study may fill the gap to improve nurse compliance by reducing barriers among nurses for depression screening in stroke patients.

Review of Literature

Literature Search Process

The review of literature was performed through a comprehensive search of various electronic databases including CINAHL, Medline, and Medline Plus. The following key words or terms were used in the search: stroke, depression, screening, barriers, stroke screening and barriers, implementation of depressions screening in stroke patients. The goal was to identify barriers among nurses for noncompliance of depression screening in stroke patients and to improve compliance among nurses. Approximately 120 articles were retrieved that included nurses and other professionals’ intentions to use guidelines for compliance. Some authors discussed the reasons behind health care practitioners’ noncompliance to the use of guidelines. Other authors connected barriers to implementing stroke guidelines and recommendations. The literature review was based on 34 chosen articles that were congruent with the selected topic. Searches were limited to articles written in English that were dated between 2004 and 2014. However, because of their important information, three articles were included that were more than 10 years old.

Background

The background information in this section of the literature review deals with what is currently going on in practice that necessitates this intervention. Stroke is one of the most frequent causes of death and long-term disabilities in the Western World, regardless of the improved management of acute stroke (Sundseth, Thommessen, & Ronning, 2012). PSD is a common neuropsychiatric disorder that often occurs after a patient has experienced a stroke (Jiang, Lin, & Li, 2014). However, more than half of all PSD cases are neither diagnosed nor treated (Jiang et al., 2014). Hackett, Yapa, Parag, and Anderson (2005) reported some form of depression occurs in at least 25% of patients in the first year after stroke. Hackett et al. found the period of greatest risk was during the first few months after onset. According to Burton and Tyson (2014), timely diagnosis of PSD is very important in facilitating early access to treatment and improving prognosis.

National and international clinical guidelines recommend that stroke survivors be routinely screened for mood disorders using a validated tool (Burton & Tyson, 2014; Lees, Broomfield, & Quinn, 2014). In fact, the Joint Commission requires depression screening for all stroke patients (Joint Commission Resources, 2012). However, Morris, Jones, Wilcox, and Cole (2012) reported clinical experience for screening measures were normally executed only in cases where there was considerable suspicion of mood difficulties rather than being applied to all patients routinely. According to a study conducted by Hart & Morris (2007), 88% of the hospitals they surveyed had a local protocol for psychological assessment, but poor compliance resulted in an average screening rate of only 50%. Hart and Morris identified several individual and organizational factors relevant to screening: knowledge; perceived control; colleagues’ expectations; belief in effectiveness; having time for the screenings; having an awareness of guidelines; training to promote knowledge, skills, and evidence for effectiveness; provision of time and colleague support; and inclusion in routine assessment. According to Puffer and Rashidian (2004), practice nurses intend to use clinical guidelines, and their attitudes and behavior are important cognitive factors that influence their intentions to use clinical guidelines. Francke, Smit, Veer, and Mistiaen (2008) listed factors that influence the lack of implementation of guidelines: the guidelines are too complex, and there is a lack of involvement with a target group of nurses and physicians. Diffusion of innovation is communicated over time among the members of a social system. The process of adopting an innovation has four stages: (a) knowledge or awareness, (b) persuasion, (c) decision, and (d) implementation (Wahabi & Alziedan, 2012). Diffusion of innovation is influenced by factors related to (a) the attribute of the innovation, (b) the adopters’ characteristics, (c) the context or the environment where the innovation is implemented, and (d) the dissemination efforts (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004).

To summarize this section, this PI has discussed how stroke is often followed by PSD, patients need to be screened for PSD, and screening is required by the Joint Commission (Joint Commission Resources, 2012). Hospitals have protocols for depression screening. National and international clinical guidelines are available. Clinics offer screening measures for cases where depression is suspected. With these depression screening measures in place, barriers are hindering nurses’ compliance. In the next section, this PI will offer a brief description of stroke and depression and how depression impacts stroke patients.

The Impact of Stroke and PSD on Stroke Patients

Kouwenhoven, Kirkevold, Engedal, and Kim (2011) found 25% of stroke survivors develop PSD, and usually the outcome is very poor. Kouwenhoven et al. reported their patients often find themselves in unfamiliar and uncontrollable territory. They express feelings of being trapped inside their body in a state of isolation and boredom. These patients also feel like they have lost themselves and that their old self is no longer there. They convey thoughts of being miserable, sad, and in a state of despair (Kouwenhoven et al., 2011).

Kouwenhoven et al. (2011) stated that eventually some stroke survivors develop an optimistic attitude towards rehabilitation, with the hope that, if they work hard enough, they can gain back what they have lost. However, sometimes their expectations are unrealistic. Nurses can help their stroke patients to set realistic goals and help them to find ways of coping with their new situation (Kouwenhoven et al., 2011).

Jiang et al. listed risk factors that can cause acute stroke patients to develop PSD: those patients with a lower income, cognitive dysfunctions, life filled with uninteresting activities, a lack of social support, a history of hypertension, and having a previous stroke. Johnson, Bakas, and Williams (2011) linked some risk factors that pave the way for stroke survivors to have PSD. Situation variables are represented by stroke severity, history of depression, poststroke functional ability, and perceived social support. Personality disposition variables are represented by self-esteem and optimism (Johnson et al., 2011). Ried et al. (2010) determined patients with more severe strokes developed PSD. Paolucci et al. (2005) found Italian patients with a history of depression and a decrease in functional ability due to stroke were very likely to develop PSD. Williams, Ghose, and Swindle (2004) discovered a stroke patient’s mental state was tied to risk factors of death. Williams et al. determined stroke survivors with symptoms of depression had a greater risk of dying in the years following a stroke.

Stroke itself causes severe reduction in one’s quality of life. Pfeil et al. (2009) reported PSD leads to a considerable decline in quality of life and risk of suicide. About 50% of stroke patients have PSD. Depressed stroke patients are less active in their rehabilitation, and their daily activities are more impaired than patients who are not depressed but have the same severity of stroke (Pfeil et al., 2009). One out of every three patients with PSD experiences a negative impact on their quality of life, to the point where it affects their rehabilitation and their recovery (Jiang et al., 2014). Some of these affects include poststroke fatigue, feelings of apathy, and suicidal thoughts (Jiang et al., 2014).

PSD has a negative impact on family members and significant others (Franzen-Dahlin et al., 2006). Franzen-Dahlin and his associates found that the responsibilities of wives of male stroke patients had increased, which impacted the happiness in their lives. The researchers also found that younger caregivers experienced more burden than older caregivers, and this burden also affected the health of the caregiver. Emotional support from family members is very important in the recovery of stroke patients during their first 6 months of life (Franzen-Dahlin et al., 2006). Therefore, the identification and early treatment of PSD will prevent complications, will help early recovery of stroke patients, and will benefit the well-being of their care-givers.

Barriers Preventing Nurses from Complying with Depression Screening

Nursing documentation is significant as it describes the nature of nursing itself by documenting the outcome of patient care (Jefferies, Johnson, & Griffiths, 2010). Quality nursing documentation could improve patient outcomes through the recording of the patient’s condition and the patient’s responses to nursing interventions (Jefferies et al., 2010). According to Blair and Smith (2012), nurses face major barriers to documentation: time constraints, disparities between staffing resources and workload, lack of clear guidelines for completing documentation, uncertainty towards documentation, and organizational systems and institutional policies often associated with keeping accurate documentation. Duff, Walker, and Omari (2010) identified four barriers to venous thromboembolism prevention guidelines: a lack of motivation to change, a lack of systems support, knowledge or awareness deficit, and disputed evidence (Duff, Walker, & Omari, 2010).

Nutting, Rost, and Gallovic (2002) conducted a study using qualitative and quantitative methods to examine the reasons why doctors and nurses did not initiate PSD screening. The RCT consisted of 239 patients with 5 or more symptoms of depression. Sixty-six (27.6%) patients were identified as failing to meet criteria of guidelines for treatment. The research team interviewed 12 physicians and 6 nurse care managers to investigate the barriers that prevented these depressed patients from getting screened. The following barriers were listed: patient resistance (30.6%), patient noncompliance with visits (24.2%), physician judgment overruled the guideline (19.3%), patient psychosocial burden (12.9%), and health care system problems (12.9%). Nutting et al. came to three conclusions. First, they concluded that current interventions fail to address barriers to depressions screening. Next, they deduced that physicians feel barriers arise because of factors centered on the patients, their psychosocial circumstances, and their attitudes and beliefs about depression. Lastly, they determined that new interventions must be developed to address these barriers (Nutting et al., 2002).

McCluskey, Vratsistas-Curto, and Schurr (2013) conducted a qualitative study aimed at identifying barriers to depression screening at an Australian stroke unit. The sample consisted of 28 nurses and doctors who participated in interviews. Six barriers were identified: (1) beliefs about capabilities of individual professionals and their discipline, and about patient capabilities, (2) beliefs about the consequences, positive and negative, of implementing the recommendations, (3) memory of, and attention to, best practices, (4) knowledge and skills required to implement best practice, (5) intention and motivation to implement best practice, and (6) resources. The researchers concluded that depression screening was a major challenge. A common barrier was limited knowledge and skills. Intervention protocols and manuals could help clinicians to overcome their knowledge barrier (McCluskey et al., 2013).

Analysis of the Literature

All the articles used in this literature review are synthesized in a matrix table found in Appendix B. Articles in the literature review emphasize screening of PSD is necessary as early as possible following a stroke. Strokes and PDS have negative effects on patients. Depression screening is needed because the sooner patients are screened for depression, the sooner they will receive treatment. However, more than 50% of PSD cases are not screened or treated (Jiang et al., 2014). Hospital guidelines and hospital protocols are in place for screening, and the Joint Commission requires depression screening for all stroke patients (Joint Commission Resources, 2012). However, barriers such as limited knowledge and skills are preventing nurses from complying with this requirement (McCluskey et al., 2013). McCluskey, his cohorts, and other researchers agree that interventions are needed to help doctors and nurses overcome knowledge and skill barriers.

This PI has developed a tool in the form of an open-ended survey to be given to the registered nurses at the designated hospital. This survey may help identify the barriers that hinder compliance of nurses for depression screening in stroke patients. Based on the survey results, this PI will propose a plan for intervention.

Instrumentation, Population, and Sample

Instrumentation

The content validity of the questionnaire has been tested using a content validity test. A panel of four experts in the field of depression screening evaluated the survey for appropriateness of questions, and the survey was revised based on their comments. See Appendix A for the survey questionnaire based on the validity test.

Population and Sample

The population for this study will consist of a convenience sample of 62 registered nurses who work in the ICU and the stroke unit in a southern hospital in the United States (also known as the designated hospital). The inclusion criteria for this study are the registered nurses who work in the ICU and the stroke unit at the designated hospital as these two units are the primary units that take care of stroke patients. The nurse managers, float pool nurses, agency nurses, students nurses, and nurse coordinators will be excluded from this study as they are not always directly involved in stroke patient care.

Description of Intervention

Description of the Proposed Intervention

Data collection will begin following IRB approval using Psych Data. Psych Data is an online survey data collection service used to enable researchers to accomplish secure, precise, and dependable online research. With the aid of Psych Data, this PI will send a link for the survey questionnaire to the nurses of the ICU and the stroke unit. Nurses will be requested to complete the survey within 2 weeks.

← From the literature review, this PI found that a lack of knowledge and skills were common barriers for nurses to complete the screening for patients (McCluskey et al., 2013). In order to find the barriers among nurses in this hospital, this PI developed a survey of 22 questions based on three concepts: (a) knowledge/perception of depression screening in stroke patients among nurses, (b) possible barriers that are preventing implementation of screening among nurses, and (c) nurses’ value of completing QIDS-SR to patient well-being. The survey can be found in Appendix A. After analyzing the data from the survey, this PI will propose a plan to resolve the problem.

Implementation

Study Objectives

The aim of this study is to identify the barriers among nurses for depression screening in stroke patients. Based on the results of the survey, this PI will provide recommendations of this study to the hospital education department for further training of nurses.

Timelines of Phases

In order to establish a timeline for the various phases of the study, this PI has put together the follow dates and events:

September, 2014 Developed survey questionnaire

October, 2014 Established content validity

November, 2014 Completion of initial proposal

November 14, 2014 Defense of proposal

January, 2015 Revised paper according to the comments made by Chair and

committee members on the original proposal and submitted to IRB

February 10, 2015 Defense of revised proposal

April 17, 2015 Obtained TWU IRB approval

April 20, 2015 Distribution, data collection, analysis

May 1, 2015 Completion of study and Defense

Data Collection

← Data collection will begin after getting approval from UTSW. Using Psych Data, this PI will send a link for the survey questionnaire to the nurses of the ICU and the stroke unit. The survey is anonymous, and nurses are requested to participate voluntarily. Nurses will be asked to complete the survey within 2 weeks.

Results and Findings

The collected data will be analyzed using the Statistical Package for the Social Sciences (SPSS) program. Statistical analysis of the variables such as knowledge/perception of depression screening, possible barriers, and the value of QIDS-SR will be analyzed. This will be accomplished by examining the frequencies, mean, median, and standard deviation.

This PI hopes to find results of the survey will reveal the nurses expressing their need for more education and improvement of skills as these areas point to barriers for compliance from the literature review. It might be necessary to conduct an interactive teaching session with a PowerPoint presentation and hands-on training to improve the knowledge and skills of the nurses for better compliance of the PSD screening. After implementation of the proposed plan, the percentage of compliance will be compared using the monthly scorecard. If compliance has not improved, further research will need to be conducted based on the limitations of this particular study.

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Appendix A

Informed Consent and Survey Questions

(Participant Note: Your completion of this survey will be your consent showing voluntary participation in this study. This survey is anonymous, and hence, your signature is not required).

Title of Study: Identifying Barriers to Nurse Compliance with Depression Screening in Stroke Patients.

Investigator: Susan Alex, MS, APRN, ANP-BC

Contact Phone Number: 214-645-4740

Email: Susan.Alex@UTSouthwestern.edu

Purpose of the Study: You are invited to participate in a research study. The purpose of this study is to identify barriers to nurse compliance with depression screening in acute stroke patients. This study contains three elements: (1) to look at current practice, (2) to identify barriers among nurses for depression screening in stroke patients, and (3) to propose a plan to resolve the problem.

Participants

You are being asked to voluntarily participate in this study because your participation would help determine the barriers affecting nurse compliance in the completion of depression screening in acute stroke patients.

Targeted population is nurses who work in ICU and stroke unit.

Procedure

You will be asked to complete an open-ended questionnaire using a 5-point Likert scale. You are requested to voluntarily participate in the study. Volunteering to complete the online survey will be evidence of your consent. You are not required to sign a consent form. This survey is completely anonymous.

Benefits of Participation

There may not be direct benefits to the participants in this study. However, it is hoped that the study might increase the awareness and importance of completing depression screening in all stroke patients. In addition, it is hoped that, by identifying the barriers to completing depression screening, the barriers will be alleviated in the future.

Potential Risk

This study poses minimal risk to the participants as there is a potential risk of loss of confidentiality in all email, downloading and internet transactions. This risk will be minimized by providing a data collection site such as Psych Data website that has a reputation for being a secure website and no one will be able to identify who you are. The risk will also be minimized as the participation is purely voluntary and participation may be discontinued any time.

Confidentiality

Data collection will be done using Psych Data website that has a reputation for being a secure website and no one will be able to identify who you are.

Participant Consent

I have read the above information and agree to participate in this study. I am at least 18 years of age.

Open Ended Survey for Nurses Using Three Concepts:

A. Knowledge/perception of depression screening in stroke patients among nurses.

B. Possible barriers the nurses perceive in preventing implementation of depression screening.

C. Value of completing Quick Inventory of Depressive Symptomatology- Self Report (QIDS- SR) to patient well-being.

INSTRUCTIONS:

For each of the items below, on a scale of 1- 5, with 1 being the lowest score and 5 being the highest score, circle the number that best indicates your opinion to each of the statements according to the following choices:

5=Strongly Agree

4=Agree

3=Neutral/Unsure

2=Disagree

1=Strongly Disagree

A. Knowledge/perception of depression screening.

1. Depression is a common disorder following a stroke.

1 2 3 4 5

2. Being depressed affects functional ability.

1 2 3 4 5

3. Every stroke patient is screened for depression.

1 2 3 4 5

4. There is more than 80% compliance with depression screening.

1 2 3 4 5

5. Identification of post stroke depression in the early phase will improve quality of life.

1 2 3 4 5

6. There is an alternate version of QIDS-SR screening method for aphasic patients.

1 2 3 4 5

7. I have adequate skills to screen patients for depression after stroke.

1 2 3 4 5

8. I have adequate training to screen patients for depression after stroke.

1 2 3 4 5

B. Possible Barriers

1. There are potential barriers to completing the QIDS-SR.

1 2 3 4 5

2. Lack of education is a barrier to completing the QIDS-SR.

1 2 3 4 5

3. Work load is a barrier for completing QIDS-SR.

1 2 3 4 5

4. Lack of cooperation from co-workers is a barrier to completing QIDS-SR.

1 2 3 4 5

5. I feel like completing the QIDS-SR is an invasion of privacy.

1 2 3 4 5

6. I have no emotional discomfort when completing a QIDS-SR.

1 2 3 4 5

7. The method of reading sensitive items from the computer to the patient is awkward.

1 2 3 4 5

8. There is a lack of compliance from family members for completing the paper version for aphasic patients.

1 2 3 4 5

C. Value of QIDS-SR

1. Screening for depression after a stroke is useful.

1 2 3 4 5

2. Screening for depression following a stroke can reduce uncertainty about whether or not they have depression.

1 2 3 4 5

3. Screening for depression will help family members to support patient well-being.

1 2 3 4 5

4. Proper screening may reduce re-admission rates.

1 2 3 4 5

5. Screening provides early identification of depression in stroke patients.

1 2 3 4 5

6. The current QIDS-SR tool is easy to follow.

1 2 3 4 5

Please feel free to comment:

Appendix B

Table 1: Critical Analysis of Quantitative Research Articles

Table 1

Critical Analysis of Quantitative Research Articles

|Title |Patient Population |Intervention of Interest |Comparison of Interest |Outcome of Interest |Strengths |

|Principal Investigator or First Author |Sample Size |Design (Experimental, Observational, etc.) | |Results of Study |Limitations |

|Date | |Level of Evidence(I – VII) | |Conclusion | |

|Country | | | | | |

|1. Depression trumps recovery. | | | | | |

|2. American Stroke Association | | | | | |

|3. 2013 | | | | | |

|4. United States | | | | | |

|1. Nursing documentation: Frameworks and | | | | | |

|barriers. | | | | | |

|2. Blair | | | | | |

|3. 2012 | | | | | |

|4. United States | | | | | |

|1. Screening for mood disorders after |6. Thirty papers |7. Reviewed psychometric properties and | |12. Only the Stroke Aphasic |14 & 15. Valid and |

|stroke: A systematic review of |examining 27 screening |mood screening tools for stroke survivors. | |Depression Questionnaire |clinically feasible mood |

|psychometric properties and clinical |tools were identified |8. Systematic review with 10 verbal, 4 | |-Hospital version (SADQ-H) |screening tools for stroke |

|utility. |and 16 tools met |observational, and 2 visual prompt tools | |met all the psychometric and|were identified but |

|2. Burton |criteria. |9. Level II | |utility criteria. |methodological inconsistency|

|3. 2014 | | | | |prevented recommendations |

|4. United States | | | | |about the optimal cut-off |

| | | | | |scores. |

|1. A public health action to prevent | | | | | |

|heart disease and stroke. | | | | | |

|2. CDC | | | | | |

|3. 2011 | | | | | |

|4. United States | | | | | |

|1. Introducing evidence into nursing | | | | | |

|practice: Using the IOWA model. | | | | | |

|2. Doody, C. M. | | | | | |

|3. 2011 | | | | | |

|4. UK | | | | | |

|1. Translating venous thromboembolism |5. 250-bed acute care |7. A change plan was developed that | |12. The proportion of |15. A significant |

|(VTE) prevention evidence into practice: |private hospital in |attempted to match organizational barriers | |patients receiving |discrepancy appeared |

|A multidisciplinary evidence |Australia |to VTE guideline uptake with evidence-based| |appropriate VTE prophylaxis |between surgical and medical|

|implementation study | |implementation strategies using included | |increased by 19% from 49% to|patient prophylaxis rates |

|2. Duff, J. | |audit and feedback, documentation aids, | |68% (p= 0.02). Surgical |and will have to be |

|3. 2010 | |staff education initiatives, | |patient prophylaxis |resolved. |

|4. Australia | |collaboratively developed hospital VTE | |increased by 21% from 61% to| |

| | |prevention policy, alert stickers, and | |82% (p = 0.02) while medical| |

| | |other reminders. | |patient prophylaxis | |

| | |8. A practice improvement methodology was | |increased by 26% from 19% to| |

| | |employed to identify, diagnosis, and | |45% (p= 0.05). The | |

| | |overcome practice problems. Pre- and | |proportion of patients with | |

| | |post-intervention audits were used to | |a documented VTE risk | |

| | |evaluate performance measures. | |assessment increased from 0%| |

| | | | |to 35% (p < 0.001). | |

| | | | |13. The intervention | |

| | | | |resulted in a 19% overall | |

| | | | |improvement in prophylaxis | |

| | | | |rates, | |

| | | | | | |

|1. Factors influencing the implementation| |8. A search of five literature databases | |12. Twelve systematic |15. There was a lack of |

|of clinical guidelines for health care | |and one website was performed to find | |reviews met the inclusion |support from peers and |

|professionals: A systematic meta-review. | |relevant existing systematic reviews or | |criteria. |insufficient staff and time.|

|2. Francke, A. L. | |meta-reviews. | | | |

|3. 2008 | | | |13. Current reviews depict | |

|4. The Netherlands | | | |factors that control whether| |

| | | | |guidelines are actually | |

| | | | |used. However, the evidence | |

| | | | |is thin, and solid research | |

| | | | |is needed. | |

|1. Post-stroke depression: Effect on the |5 & 6. 71 couples (PSD | | |13. Patients with limited |15. The needs of significant|

|life situation of the significant other. |patients and their | | |functional deficits have |others must be identified in|

|2.Franzen-Dahlin, A. |significant others | | |more severe PSD. |order to support them in |

|3.2006 | | | | |their caregiving role. |

|4.Scandinavia | | | | | |

|1.Diffusion of innovations in service | | | | | |

|organizations: Systematic review and | | | | | |

|recommendations | | | | | |

|2. Greenhalgh, T. | | | | | |

|3. 2004 | | | | | |

|4. UK | | | | | |

|1. Frequency of depression after stroke: |5 and 6. Data were |8. A systematic review of all published | |13. PSD is common among |15. There is a need for more|

|A systematic review of observational |available from 51 |nonexperimental studies. | |stroke patients and can |research to improve clinical|

|studies. |studies (reported in 96| | |occur anytime during stages |practice |

|2. Hackett, M. L. |publications) conducted| | |of recovery. | |

|3. 2005 |between 1977 and 2002. | | | | |

|4. Australia | | | | | |

|1. Screening for depression after stroke:|5. & 6. 75 stroke HCPs |7. National guidelines recommend screening | |12. Response rates were low,| |

|An exploration of professionals’ |in 16 stroke units in |for poststroke depression, but staff | |but the 75 returns | |

|compliance with guidelines. |UK. |compliance is low. | |demonstrated poor compliance| |

|2. Hart, S. | |8. Study used a questionnaire based on a | |for screening, despite | |

|3. 2008 | |semi-structured interview. A postal | |positive attitudes towards | |

|4. U.K. | |questionnaire with 7-point rating scales | |screening. | |

| | |and open-ended questions was used. | |13. Compliance may be | |

| | | | |enhanced by increasing | |

| | | | |knowledge and skills, | |

| | | | |providing evidence of the | |

| | | | |utility, increasing | |

| | | | |awareness of guidelines, | |

| | | | |support from colleagues and | |

| | | | |integrating mood assessment | |

| | | | |into job roles and routine | |

| | | | |assessment. | |

|1. A meta-study of the essentials of | | | | | |

|quality nursing documentation | | | | | |

|2. Jefferies, D. | | | | | |

|3. 2010 | | | | | |

|4. United States | | | | | |

|1. The relationship between |5. & 6. Data were | | |13. PSD can be controlled by| |

|rehabilitation and changes in depression |collected for 120 | | |rehabilitation. | |

|in stroke patients |chronic stroke | | | | |

|2. Jeong, Y. |patients. | | | | |

|3. 2014 | | | | | |

|4. Korea | | | | | |

|1. Correlative study on risk factors of | | | |13. Risk factors for PSD | |

|depression among acute stroke patients | | | |were low income, poor daily | |

|2. Jiang, X. G. | | | |activities, poor social | |

|3. 2014 | | | |support, history of | |

|4. China | | | |hypertension, and previous | |

| | | | |stroke. | |

|1. Psychometric evaluation of the | | | | | |

|appraisal of health scale in stroke | | | | | |

|survivors | | | | | |

|2. Johnson, E. A. | | | | | |

|3. 2011 | | | | | |

|4. United States | | | | | |

|1. Disease-Specific Care Certification | | | | | |

|Manual | | | | | |

|2. Joint Commission Resources | | | | | |

|3. 2012 | | | | | |

|4. United States | | | | | |

|1. The acute phase after stroke. ‘Living | | | | | |

|a life in shades of grey: Experiencing | | | | | |

|depressive symptoms in the acute phase | | | | | |

|after stroke | | | | | |

|2. Kouwenhoven, S. E. | | | | | |

|3. 2011 | | | | | |

|4. United States | | | | | |

|1. Questionnaire assessment of usual | |8. Cognitive and mood assessment study | |12. 174 responses from | |

|practice in mood and cognitive assessment| |using questionnaire survey | |nurses, physiotherapists, | |

|in Scottish stroke units | | | |psychologists, occupational | |

|2. Lees, R. A. | | | |therapists and medical | |

|3. 2014 | | | |staff. Response rate was | |

|4. Scotland | | | |small. | |

|1. Management of depression in elderly |6. 28 nurses and |8. Qualitative methodology: interviews | |12. Six group and two | |

|stroke patients. |doctors. |focused on barriers and enablers to | |individual interviews were | |

|2. McCluskey, A. | |implementing PSD guidelines | |held. Six barriers were | |

|3. 2013 | | | |identified. | |

|4. Australia | | | |13. Depression screening is | |

| | | | |a major challenge. Common | |

| | | | |barriers were limited | |

| | | | |knowledge and skills. Online| |

| | | | |protocols and manuals might | |

| | | | |help knowledge deficit. | |

|1. Stroke prevention and management in | | | | | |

|older adults. | | | | | |

|2. Michael, K. M. | | | | | |

|3. 2006 | | | | | |

|4. United States | | | | | |

|1. The doctor of nursing practice | | | | | |

|scholarly study: A framework for success.| | | | | |

|2. Moran, K. | | | | | |

|3. 2014 | | | | | |

|4. United States | | | | | |

|1. Depression and anxiety screening after| |8. RCT of an educational and support |10. Compared 30 |12. The Lit Review confirmed| |

|stroke: Adherence to guidelines and | |package as an intervention to improve PSD |consecutive admissions |that PSD screening is not | |

|future directions. | |screening rates |before and after the |universally applied. | |

|2. Morris, R. | | |intervention. |13. Education and training | |

|3. 2012 | | | |about depression and anxiety| |

|4. UK | | | |screening and access to | |

| | | | |screening materials improved| |

| | | | |rates of screening slightly.| |

|1. Major depressive disorder among | | | | | |

|adults. | | | | | |

|2. National Institute of Mental Health | | | | | |

|3. 2014 | | | | | |

|4. United States | | | | | |

|1. Post stroke rehabilitation fact sheet:| | | | | |

|Emotional Disturbances. | | | | | |

|2. National Institute of Neurological | | | | | |

|Disorders and Stroke | | | | | |

|3. 2012 | | | | | |

|4. United States | | | | | |

|1. Barriers to initiating depression |5. 239 patients in RCT |8. Qualitative and quantitative RCT study | |13. The interviews of 12 | |

|treatment in primary care practice. |trial. |about why PSD patients were not being | |physicians and 6 nurses | |

|2. Nutting, P. A. | |screened. | |revealed the following | |

|3. 2002 | | | |barriers: patient resistance| |

|4. United States | | | |(30.6%), patient | |

| | | | |noncompliance with visits | |

| | | | |(24.2%), physician judgment | |

| | | | |overruled the guideline | |

| | | | |(19.3%), patient | |

| | | | |psychosocial burden (12.9%),| |

| | | | |and health care system | |

| | | | |problems (12.9%). | |

|1. Quantification of the risk of post |6. 1,064 stroke |8. Mood evaluation was performed using Beck| |12. 36% of stroke survivors | |

|stroke depression: The Italian |patients |Depression Inventory and Visual Analog Mood| |had PSD; 80.7% had | |

|multicenter observational study. | |Scale. | |dysthymia. | |

|2. Paolucci, S. | | | |13. It is possible to | |

|3. 2005 | | | |predict patients with PSD | |

|4. Italy | | | |upon admission to hospital. | |

|1. Depression and stroke: A common but | | | | | |

|often unrecognized combination. | | | | | |

|2. Pfeil, M. | | | | | |

|3. 2009 | | | | | |

|4. UK | | | | | |

|1. Practice nurses’ intentions to use |6. 48 practice nurses. |8. A cross-sectional survey using a postal | | | |

|clinical guidelines. | |52 question survey. | | | |

|2. Puffer, S. | | | | | |

|3. 2004 | | | | | |

|4. UK | | | | | |

|1. Does prestroke depression impact |6. 790 veterans. |8. Retrospective cohort design. | |12. A depression diagnosis | |

|poststroke depression and treatment? | | | |was noted for nearly 10% (N | |

|2. Ried, L. D. | | | |= 74) of veterans before | |

|3. 2010 | | | |their stroke and nearly 26% | |

|4. United States | | | |afterward (N = 205). | |

| | | | |13. Patients' depression | |

| | | | |status before the stroke is | |

| | | | |a significant predictor of | |

| | | | |PSD and providers' SSRI | |

| | | | |prescribing behavior but not| |

| | | | |age. Given the deleterious | |

| | | | |effects of PSD, physicians | |

| | | | |may be tending toward | |

| | | | |prophylaxis or early | |

| | | | |treatment even before the | |

| | | | |evidence to support such | |

| | | | |treatment leads to standard | |

| | | | |practice recommendations. | |

|1. The 16-item quick inventory of | | | | | |

|depressive symptomatology (QIDS) | | | | | |

|clinician rating (QIDS-C), and self | | | | | |

|report (QIDS-SR): A psychometric | | | | | |

|evaluation in patients with chronic major| | | | | |

|depression. | | | | | |

|2. Rush, A. J. | | | | | |

|3. 2003 | | | | | |

|4. United States | | | | | |

|1. Outcome after mobilization within 24 |6. Fifty-six patients |8. Prospective, randomized, controlled | |12. The control group had | |

|hours of acute stroke: A randomized |were included, 27 were |trial with blinded assessment at follow-up.| |milder strokes. | |

|control trial. |in the VEM group and 29| | |13. A trend developed of | |

|2. Sundseth, A. |were in the control | | |poor outcome, death rate, | |

|3. 2012 |group. | | |and dependency among | |

|4. Norway | | | |patients mobilized within 24| |

| | | | |hours after hospitalization,| |

| | | | |and an improvement in | |

| | | | |neurological functioning in | |

| | | | |favor of patients mobilized | |

| | | | |between 24 and 48 hours. | |

| | | | |Very early or delayed | |

| | | | |mobilization after acute | |

| | | | |stroke is still undergoing | |

| | | | |debate, and results from | |

| | | | |ongoing larger trials are | |

| | | | |required. | |

|1. The Iowa Model of evidence-based | | | | | |

|practice to promote quality care. | | | | | |

|2.Titler, M. G. | | | | | |

|3. 2001 | | | | | |

|4. United States | | | | | |

|1. Reasons behind non-adherence of | | | | | |

|healthcare practitioners to pediatric | | | | | |

|guidelines in an emergency department in | | | | | |

|Saudi Arabia | | | | | |

|2. Wahabi, H. A. | | | | | |

|3. 2012. | | | | | |

|4. Saudi Arabia | | | | | |

|1. Depression and other mental health | | | | | |

|diagnoses increase mortality risk after | | | | | |

|ischemic stroke. | | | | | |

|2. Williams, L. S. | | | | | |

|3. 2004. | | | | | |

|4. United States. | | | | | |

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