Running head: PEDIATRIC DEPRESSION SCREENING EFFECTIVE STAFF TRAINING IN ADMINISTERING PEDIATRIC DEPRESSION SCREENINGS Nakeshia Lynn Mouzon Capstone Paper submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice Chatham University 07 April 2019 Signature Faculty Reader Date Signature Program Director Date 1 2 PEDIATRIC DEPRESSION SCREENING Acknowledgments 3 PEDIATRIC DEPRESSION SCREENING Abstract Start typing here…. Key words: 4 PEDIATRIC DEPRESSION SCREENING Table of Contents Acknowledgments..................................................................................................................2 Dedication ..............................................................................................................................X Abstract .................................................................................................................................. 3 Chapter One: Overview of the Problem of Interest ..............................................................8 Background Information ............................................................................................9 Significance of the Problem .......................................................................................12 Question Guiding Inquiry (PICO) .............................................................................14 Variables of the PICO question .....................................................................15 Summary ....................................................................................................................16 Chapter Two: Review of the Literature/Evidence ................................................................18 Methodology ..............................................................................................................18 Sampling strategies ........................................................................................19 Inclusion/Exclusion criteria ...........................................................................19 Literature Review Findings........................................................................................20 Discussion ..................................................................................................................27 Limitation of literature review. ......................................................................28 Conclusions of findings .................................................................................28 Potential practice change ...............................................................................29 Summary ....................................................................................................................29 Chapter Three: Theory and Model for Evidence-based Practice ..........................................32 Theory ........................................................................................................................32 Application to practice change.......................................................................36 5 PEDIATRIC DEPRESSION SCREENING Model for Evidence-Based Practice ..........................................................................39 Application to practice change.......................................................................42 Summary ....................................................................................................................45 Chapter Four: Pre-implementation Plan ...............................................................................X Project Purpose ..........................................................................................................X Project Management ..................................................................................................X Organizational readiness for change ..............................................................X Inter-professional collaboration .....................................................................X Risk management assessment ........................................................................X Organizational approval process ....................................................................X Use of information technology ......................................................................X Materials Needed for Project .....................................................................................X Plans for Institutional Review Board Approval .........................................................X Plan for Project Evaluation ........................................................................................X Plan for demographic data collection ............................................................X Plan for outcome data collection and measurement ......................................X Plan for evaluation tool ........................................................................X Plan for data analysis ...........................................................................X Plan for data management ..............................................................................X Summary ....................................................................................................................X Chapter Five: Implementation Process .................................................................................X Setting ........................................................................................................................X Participants .................................................................................................................X 6 PEDIATRIC DEPRESSION SCREENING Recruitment ................................................................................................................X Implementation Process .............................................................................................X Plan Variation ............................................................................................................X Summary ....................................................................................................................X Chapter Six: Evaluation and Outcomes of the Practice Change ...........................................X Participant Demographics ..........................................................................................X Table or Figure X ...........................................................................................X Table or Figure X ...........................................................................................X Outcome Findings ......................................................................................................X Outcome One .................................................................................................X Table or Figure X ...........................................................................................X Table or Figure X ...........................................................................................X Summary ....................................................................................................................X Chapter Seven: Discussion ...................................................................................................X Recommendations for Site to Sustain Change .........................................................X Plans for Dissemination of Project ..........................................................................X Project Links to Health Promotion/Population Health ............................................X Role of DNP-Prepared Nurse Leader in EBP ..........................................................X Future Projects Related to Problem .........................................................................X Implications for Policy and Advocacy at All Levels ...............................................X Summary ..................................................................................................................X Chapter Eight: Final Conclusion ...........................................................................................X Clinical Problem ........................................................................................................X 7 PEDIATRIC DEPRESSION SCREENING Evidence Base ............................................................................................................X Theory and Model for Evidence-based Practice ........................................................X Project Management ..................................................................................................X Project Implementation ..............................................................................................X Outcome Findings ......................................................................................................X Discussion Summary .................................................................................................X Final Conclusions...................................................................................................................X References ..............................................................................................................................X Appendix A: XXXXXX .......................................................................................................X Appendix B: XXXXXX ........................................................................................................X Appendix C: XXXXXX........................................................................................................X Appendix D: XXXXXX .......................................................................................................X Appendix E: XXXXXX ........................................................................................................X Appendix F: XXXXXX ........................................................................................................X Appendix G: XXXXXX .......................................................................................................X Running head: PEDIATRIC DEPRESSION SCREENING 8 Chapter One: Overview of the Problem of Interest Depression in Children Depression has become an issue of concern due to its impact on the adult population. However, depression in children has been largely ignored, and it is only in the past few decades that it has been taken seriously. It is more challenging to diagnose depression in children as it is difficult to tell whether a child is undergoing a temporary phase, or if the symptoms indicate a larger problem. Depression is an issue of global concern, as it is the leading cause of disability for both males and females (Pennant et al., 2015). The purpose of the paper is to highlight the impact of depression in children, and how pediatric screening can improve detection. Background Depression is a mental disorder characterized by depressed moods, loss of interest in activities, lack of sleep and appetite, poor concentration, feelings of guilt, and decreased energy. Depression may also be simply defined as having an irritable mood for at least two weeks. There are different categories of depression involving mild, moderate, and severe. Depression may also be categorized into major depressive disorder, mood disorders such as bipolar disorder, and medical conditions involving hypothyroidism (Bitsko et al., 2018). Generally, depression is noticeable due to the individual’s withdrawal from social activities. Depression affects the individual’s ability to take care of everyday responsibilities. Depression is linked to suicide, as up to 3,000 people under the age of 18 are said to die by suicide each year (Bardach et al., 2014). The high suicide rates in the society are attributed to the prevalence of depression within the population. Suicide is the leading cause of death for young people between 10 and 24 years. Sheftall et al. (2016) estimates that for every person who 9 PEDIATRIC DEPRESSION SCREENING commits suicide, there are 20 people who may think about or attempt to commit suicide. Therefore, addressing depression may lower the prevailing suicide rates. In children, depression is common in every age, and it affects 16% of the children in the United States at some time in their lives. Depression is an imminent problem affecting young people, as up to 11% of the youth in the United States are diagnosed with depression by the age of 18 (Avenevoli et al., 2013). The high prevalence rate is an issue of concern as it demonstrates that depression is a major issue facing young people. Consequences of Depression in Children Depression has negative consequences on children’s health and wellbeing. The consequences of depression include poor performance in school due to truancy, dropping out of school, and lack of concentration (Wolk et al., 2016). If the depression is left unchecked, it compromises the child’s future due to poor academic performance. Children may also drop out of school due to lack of interest in their studies. Depression is linked to increased drug and alcohol abuse cases. When children are depressed their cognitive functioning is affected, which makes them prone to risky behaviors. Children may also engage in unsafe sexual practices as they may not care about their health and wellbeing. Depression results in strained relationships with peers and family due to the children’s anti-social tendencies. Depressed children may prefer spending time by themselves as opposed to socializing with other people. Last and most importantly, depression is linked to suicidal behavior (Patterson, DeBaryshe, & Ramsey, 2017). Depressed children are more likely to have suicidal thoughts Risk Factors of Depression in Children Depression in children is caused by psychological, biological, and environmental factors. Children may become depressed due to psychological factors such as feeling worthless and 10 PEDIATRIC DEPRESSION SCREENING inadequate. For instance, a child’s poor performance in school may result in depression if there are negative consequences associated with poor performance. If the child is pressurized to attain high grades by parents, sponsors, or the school, the child may become depressed over time due to the constant worrying over their grades. Depression may occur as a result of biological determinants involving neurotransmitters, neuroendocrine, and neurotropic factors. The biological factors make some individuals more prone to depression than others. Environmental factors affecting depression involve socioeconomic statuses, family setting, and race and ethnicity (Heslin et al., 2016). Studies indicate that children from low-income and minority communities have a higher likelihood of being depressed than their White counterparts from high-income earning families (Kids Data, 2018). Therefore, depression does not only involve the psychological factors, as it is also impacted by biological and environmental factors. Depression has been linked to race and ethnicity factors. A study conducted by Kids Data (2018) for years 2013 to 2015 indicated that children from different ethnicities have varying rates of depression. In Los Angeles, children from various ethnic and racial communities reported having depression-related feelings. Native Hawaiians had the highest prevalence rates at 32.5%, followed closely by Latinos, who had a prevalence rate of 32%. The data is worrying as it indicates that approximately 1 out of 3 children from Hispanic or Native Hawaiian ethnicities could be having depression. The ethnic community with the lowest depression prevalence rate is African Americans, and even so, 24.5%, or a quarter of children from the ethnic community report having depressive thoughts. The statistics are alarming as they indicate that depression among children is prevalent in the society across all races and ethnicities. This data from the research article are not all inclusive, as often many children suffering from depression are 11 PEDIATRIC DEPRESSION SCREENING unreported for fear or humility this may cause. This is also a cultural bias and many minority communities deny these emotions. The data is provided below. Table 1 Depression Prevalence among children for Different Ethnic Communities in Los Angeles County Barriers to Addressing Depression in Children Unfortunately, the majority of children undergoing depression do not receive treatment for the mental condition, and they end up having more serious mental health issues later in adulthood. Lack of treatment is likely due to misdiagnosis. Parents and caregivers may be unaware that their children are undergoing depression. Even when children are identified as having depression, their conditions are often not be taken with enough seriousness to warrant medical treatment. Diagnosing depression in children is difficult as there are no specific tests that can diagnose the condition. Mental health experts determine if a child has depression by 12 PEDIATRIC DEPRESSION SCREENING conducting interviews and screening tests with the child, peers, teachers, and family members. The data collected from the interviews is then evaluated for signs of depression. However, the unavailability of support systems makes the condition difficult to diagnose (Bitsko et al., 2018). For instance, if the child’s teachers and peers are unavailable to provide information, it would be challenging for mental health experts to diagnose the child with depression. Significance Depression among children needs to be addressed as it affects their mental development. Positive mental health is critical to a healthy development, as emotional health is integral to the overall health of a child. A study conducted by Bardach et al., (2017) indicate that up to 44% of all pediatric mental health conditions in 2015 can be traced back to depression. Therefore, depression is a significant mental health condition that influences the mental development of a child. Depression inhibits the physical development of a child as it causes changes in an individual’s self-perception and perception of others. Boyd, Bee, and Johnson (2015) indicate that mental health contributes to the physical development of an individual as it affects functioning in school, at home, and in other social settings. Depression affects children’s physical development. For young children who are depressed, they may avoid taking food or they could engage in overeating, which potentially compromises their physical development. Boyd, Bee, and Johnson (2015) indicate that children with existing medical conditions may find that their symptoms get worse after undergoing depression. Depression presents itself through physical signs involving headaches, diarrhea, constipation, insomnia, nausea, and inflammation. Children with depression also incur changes in appetite, which consequently cause unintended weight loss or gain. Health practitioners link 13 PEDIATRIC DEPRESSION SCREENING drastic change in weight to conditions such as diabetes and heart disease. Therefore, depression in children exposes them to increased risks of chronic illnesses that affect them for the rest of their lives. Depression has serious cost consequences for the individual, family, and the country. In terms of the individual, depression causes strains to parents, especially when it affects children from low and middle income earning families. The parents may incur increased health costs needed to cater for psychotherapy and counseling treatment. Due to the increased costs in managing depression, the household’s finances are strained, which may affect the parents’ abilities to provide food, educational materials, and other household needs. Depression is also an issue of great concern to the country. Mangione-Smith (2014) states that pediatric mental health costs in 2015 increase to over, $1.33 billion, an amount that consequently increased the overall costs of healthcare. Since more than 40% of all mental health cases are depression-related, the country spent up to $0.53 billion in the management of depression. Depression is related to one of the leading causes of death for children. Data provided by Kids Data (2018) indicates that the top five causes of death for children and the youth in Los Angeles County include suicide, cancer, homicide, heart disease, and congenital anomalies. The data is provided below. Table 2 Relationship between Depression and Mortality Rates in Children in Los Angeles County 14 PEDIATRIC DEPRESSION SCREENING Suicide is the top three cause of death among children in Los Angeles County. As displayed by the table, suicide is ranked third in the cause of death among children aged between 15 to 19 years, and it is ranked third in the cause of death of individuals aged between 20 to 24 years. Studies show a high correlation between depression and suicide (Sheftall et al., 2016). Assuming that all suicide cases are linked to depression, the mental health disorder is linked to the deaths of 104 people in Los Angeles County between 2013 and 2015. The high suicide rates in the county could be an indication of high depression prevalence in the area. Addressing the issue of depression may have positive impacts on the health outcomes of depression. Depression affects the psychological, physical and mental wellbeing of a child. Therefore, addressing depression improves the overall health of the child (Boyd, Bee, & Johnson, 2015). For instance, when children receive treatment for depression, they incur lower risks for getting diabetes and heart diseases later in life. As a result, the children do not only benefit from improved quality of life; but they also become healthier. When many children receive treatment for depression, households will be less strained financially, while the country 15 PEDIATRIC DEPRESSION SCREENING will incur reduced healthcare costs. As a result, addressing the issue of depression has positive implications on the wellbeing of the individual, family, and country. PICO Model The issue of depression can be addressed using the PICO model. PICO is an evidencebased model for framing a question, locating, evaluating, and repeating as needed. Elements of PICO involve Problem/Patient/Population, Intervention, comparison, an outcome. PICO is applied in evidence-based practice to frame a question, plan a search strategy, and filter evidence (Eriksen & Frandsen, 2018). The four elements of PICO are discussed in relation to depression in children below. Population The population element of PICO describes how the problem affects the patient population (Eriksen & Frandsen, 2018). The main problem at hand is depression while the patient population is children living in Los Angeles County. Depression is a major problem in Los Angele County based on the high number of children that have reported being depressed, as well as the high suicide rates in the population. Intervention The intervention element of PICO considers the prognostic factor or exposure under consideration (Eriksen & Frandsen, 2018). The intervention being considered is pediatric screening, where children are subjected to standardized tests that pinpoint to depression. Depression does not have a single test, but rather, it involves a number of tests on the individual’s conduct and behavior. Siu (2016) recommends undertaking pediatric screening for major depressive disorder in children and adolescents. Screening should be conducted to ensure 16 PEDIATRIC DEPRESSION SCREENING accurate diagnosis, effective treatment, and accurate follow-up. Screening and early detection of depression in children leads to improved health outcomes. Comparison Group The comparison element of PICO considers a control group that can be used to compare the outcome of administering the intervention versus not administering it (Eriksen & Frandsen, 2018). Comparison treatment for depression is no treatment at all. The proposed intervention for addressing depression is pediatric screening. The comparison group will provide a basis for determining the effectiveness of the intervention in early diagnosis and improving the child’s physical and emotional development. This way, the comparison group will highlight any differences between children that are administered pediatric testing for depression and children that are not administered pediatric depression screening PHQ-2. Outcome The outcome element of PICO considers the desired effect of the intervention. The side effect of the intervention is improved detection of depression in children (Eriksen & Frandsen, 2018). Administering pediatric depression screening should increase the number of children early diagnosed with depression. Consequently, increased detection of depression in children results in better physical and psychological health, for the long run. The PICO question is: Does pediatric depression screening PHQ-2, result in improved detection of depression among children? Summary Depression among children is an issue of concern due to its potential impact on their health and wellbeing. Children who are depressed report reduced functionality, reduced energy, lack of interest in social activities, and poor health and wellbeing. Depression strains the 17 PEDIATRIC DEPRESSION SCREENING relationships between children and their peers, friends, and parents. It leads to high costs in providing healthcare to the affected children. Therefore, it is important to address depression due to its implications on the child, child’s family, and country. The PICO model is effective in undertaking research on the problem, intervention, comparison, and outcome of pediatric screening of depression. 18 PEDIATRIC DEPRESSION SCREENING Chapter Two: Review of the Literature Introduction Depression among children has largely been unreported with the attention of the health sector being focused on depression among adults, which is more prominent. Depression among children has been linked to increased risks of suicidality affecting 2 to 3% of children aged six to twelve and 8% among teenagers (Bardach et al., 2014). Depression has been linked to the death of over 3000 children under the age of 18 years as noted by Bardach et al. (2014). The correlation between suicide and depression makes this disorder of particular importance in that suicide is the leading cause of premature death among persons between the ages of 10 and 24 years. Furthermore, depression affects about 11% of youths in the U.S (Bardach et al., 2014). The high prevalence rate therefore identifies the significant of depression as a national and global health issue. Depression affects the wellbeing and development of children in addition to affecting their ability to reach their potential. The paper below explores evidence from literature to support interventions aimed at improving the diagnosis of this disorder. The paper will provide extensive analysis of the credible literature in the field that informs the evidence based practice to be adopted within the pediatric setting. The purpose of this paper is to provide evidence to support the implementation of pediatric depression screening as a technique to improving the detection of depression among children. Methods The methods section explores the strategies adopted in the evidence research process. The section provides an in-depth insight into the sampling strategies used that entails the 19 PEDIATRIC DEPRESSION SCREENING databases, the types of studied focused on, the restriction used and the key terms used in the research. Additionally, the section explores the inclusion and the exclusion criteria. Sampling Strategies The database selected to aid in the research process is the EBSCOhost online research, Science Direct and Academic Search Complete. These databases provided an extensive list of studies on the topic of pediatric screening of depression within the pediatric setting. The databases had the most recent articles in addition to providing full access to the required materials. To ensure only recent articles were accessed the search parameters were changed to ensure that only articles published in the last seven years that is from 2012 were presented. Recent articles provide information that is applicable to the current healthcare practices and have more credibility. Additionally the research parameters were changed to ensure only peerreviewed articles was selected. Peer-reviewed articles tend to be reliable and valid, as professionals within the field have reviewed them. The quality and credibility of the articles selected was therefore prioritized through ensuring that all articles were peer-reviewed. Additionally empirical studies were another focus of the research process and this aimed at ensuring all articles selected had an introduction, methodology, results and discussions. Finding empirical studies was important as they included observed and measured phenomena as they derive knowledge and findings from actual experiences rather than from theories. The key terms used include “depression screening”, “pediatric depression screening” and “depression screening in pediatric care”. Criteria used An inclusion and exclusion criteria was used to guide the research process. The first inclusion criteria was on including all articles published between 2012 and 2019 with any 20 PEDIATRIC DEPRESSION SCREENING articles falling before this time period being disregarded. All articles had to be empirical studies and therefore had to have four main elements of an empirical research that is the introduction, methodology, results and the discussions. Additionally, the articles to be included had to be peerreviewed in nature. Furthermore, all articles had to deal with depression screening among children or adolescents. All articles whose study samples were adults were discarded. Additionally the articles to be included had to be from a reputable journal to enhance their credibility. Findings The section below explores the findings from the literature review. Two parts will be covered under the section that is the general findings and the chosen intervention. The general findings section explores all possible interventions evidenced in the literature that can address the issue of depression while the second section explores the chosen intervention and the findings. General findings The analysis of the literature highlighted various interventions that may be implemented within the pediatric setting to address the problem of depression among children. The concept of providing multi-disciplinary consultation is argued by Craighead (2013) as an effective approach towards promoting effective diagnosis and treatment of depression among children. Craighead (2013) argued that the multi-disciplinary perspective takes into considering all aspects of the life of the child thus helping to pinpoint the underlying causes of the symptoms observed. Craighead (2013) noted that the symptoms of depression are shared across other mental illnesses such as physical illnesses and sleep disorders further highlighting the need to take an in-depth assessment of all aspects of the child’s life. Thorough assessment of depression among children 21 PEDIATRIC DEPRESSION SCREENING takes into consideration of the behavior and the performance of the child at school and at home, social functioning, the child’s medical and social history as well as the individual or family psychiatric history. Consultation with other professionals is essential to gaining different perspectives of the child’s mental and psychological state thus informing a clear diagnosis. Multi-disciplinary consultation in the diagnosis process is therefore an effective approach towards gaining an objective diagnosis of depression in pediatric care (Craighead, 2013). Further analysis of literature identifies the value of cognitive behavioral therapy in addressing depression among children as stated by Michael, Huelsman and Crowley (2005). Michael et al. (2005) argued that the use of cognitive behavioral therapy can help children experiencing depression due to its ability to change the negative beliefs as well as thought patterns that are associated with depression. The intervention is effective in increasing the child’s awareness of the connections between thoughts, behaviors and feelings using fun games and reinforcement that are appropriate for the child’s age level. Furthermore, Michael et al. (2005) noted that that the application of cognitive behavioral therapy is effective in creating opportunities that that reinforce success as a measures of addressing the feelings of helplessness that are aligned with depression. The use of positive consequences and rewards can be used to shape behaviors and to reward efforts, success, and this is based on the operant conditioning theory (Craighead, 2013). The positive experiences that the child undergoes can be used to challenge the negative beliefs that are held by the depressed child. Craighead (2013) argued that techniques such as homework assignment and role-playing might be used successfully with children with the aim of achieving the goals of the cognitive behavioral therapeutic approach. This intervention is aimed at modifying cognitive distortions and this involves inviting the child to look at their thinking patterns helping to identify their 22 PEDIATRIC DEPRESSION SCREENING readiness for change in addition to identifying themes that link thoughts and thinking patterns together (Craighead, 2013). Under this intervention the role of the physician is to modify maladaptive behaviors into adaptive behaviors and this involves identifying satisfying as well as pleasurable activities to the child and making them party of their daily plan, Additionally teaching ways to cope with negative feelings and how to set goals that that improve happiness and wellbeing are important aspects of this interventions. Additionally, the setting of daily plans and actions that seek to regulate behaviors such as sleeping and eating are important in addressing depression among children. Another effective intervention to addressing child depression is the use of family therapy that is aimed at addressing familial support for the child with the aim of resolving the symptoms of depression. Mihalopoulos, Vos, Pirkis and Carter (2012) argued that the mental state of the child could not be understood without taking into consideration the family context as the family system affects how the child views and interacts with the world around them. According to Mihalopoulos et al. (2012), the different family interventions all seek to understand that the family members influence the family dynamics and therefore can affect the wellbeing of the children within those families. The interventions that may be applied include brief education interventions aimed at educating the family members on depression, its impact and the role of the family system in maintain the problem and resolving it. Another intervention that has been shared by Mihalopoulos et al. (2012) and Craighead (2013) is pharmacology. Although many physicians frown upon the act or prescribing antidepressant medications to children and adolescent, the use of medication is effective at addressing the symptoms of depression. The integration of pharmacology and family therapy is noted by Mihalopoulos et al. (2012) as an effective intervention to addressing depression 23 PEDIATRIC DEPRESSION SCREENING among children. Pharmacology is however noted to be used as a last resort when other interventions have failed or when a child is exhibiting severe symptoms of depression that could be alleviated through the use of antidepressant. According to Mihalopoulos et al. (2012) drug, therapy should only be used in situations in which the symptoms present an obstacle to other use of interventions and should be accompanied with close monitoring by a pediatrician. Other interventions evidenced from the literature including helping the child to cope with depression through various activities. Mihalopoulos et al. (2012) stated the importance of encouraging children with depression to list out as well as prioritize the things that are bothering them and work with the physician to problem solve how they can address these issues. Mihalopoulos et al. (2012) further noted about the value of trying to identify the stressors or situations that results in low mood in the life of the child and thus seek to avoid them or learn how to effectively respond to these situations in a different way that does not generate the negative feelings and perceptions. Mihalopoulos et al. (2012) further highlighted that recounting positive events that have occurred throughout the day is yet another activity that can help the child to cope with depression. Mihalopoulos et al. (2012) proposed other activities such as journaling that could help adolescents to write down their concerns in addition to highlighting the positive aspects of their life in addition to helping the child to identify supportive networks of friends and family who may offer comfort when the child is feeling low. Chosen intervention The intervention chosen and supported by evidence-based research is the use of pediatric screening to improve diagnosis of depression among children. The adoption of pediatric screening as a technique to improving diagnosis of depression among children is supported by the findings of the study by Allgaier et al. (2014). Screening tools are effective in aiding the 24 PEDIATRIC DEPRESSION SCREENING diagnostic process and the ability of the screening tools to identify the probability of depressive symptoms therefore informs the diagnosis of depression within the pediatric setting. The purpose of Allgaier’s et al. (2014) research was to improve the early detection of childhood depression with the Children’s Depression Screener (Child-S). The researcher sampled 79 children between the age of nine and twelve. With majority of the children (74.7%) were outpatients (Allgaier et al., 2014). Purposive sampling was used in the selection of the participants. Statistical analysis of the data was carried out. The findings validated the use of the depression-screening tool within pediatric care as it highlighted that 4.5% of the patients involved in the study suffered from depressive symptoms. The diagnostic accuracy of the ChilD-S tool was found to be high with an accuracy of 92% and therefore an effective tool to use in pediatric care (Allgaier et al., 2014). The results of this study indicate that screening tools such as the ChilD-S is accurate and effective at screening depression and thus informing the diagnosis of depression within the pediatric setting. The results may indicate the credibility of pediatric screening to diagnosing depression among children within the healthcare setting (Allgaier et al., 2014). The results indicate that the implementation of screening tools that have been tested shows reliability and validity of these tools and therefore lends its support to the adoption of screening tools to help the physicians in diagnosing the prevalence of depression within the pediatric setting. Pediatric screening as a technique to promote effective diagnosis of depression among children is further supported by research based evidence gathered by Bhatta, Champion, Young and Loika (2018). The purpose of the study by Bhatta et al. (2018) was to understand the benefit of routinely implementing the Patient Health Questionnaire (PHQ-9) screening tool among a group of 137 adolescents aged between 12 to 18 years of age to identify the level of risk of developing major depressive disorders (Bhatta et al., 2018). A quantitative research 25 PEDIATRIC DEPRESSION SCREENING methodology is evidenced in this study. The methodology adopted in this study was a retrospective chart review of 256 cases with data analysis including descriptive statistical methods (Bhatta et al., 2018). The results of the PHQ-9 depression screening tool identified that 56.3% of the participants were at risk of developing Major Depressive Disorder (Bhatta et al., 2018). The effectiveness of this tool within the school-based pediatric setting identified the value of adopting depression screening tools to aid in the diagnosis of depression among children. The findings from the screening tool facilitated referrals to mental health practitioners therefore improving morbidity and the mortality among the adolescent population. Pediatric screening is evidenced as an affective technique to promoting the diagnosis of depression among children based on the findings of this research study (Bhatta et al., 2018). With subtle symptoms of depression being evidenced among children the implementation of pediatric screening is vital to promoting the diagnosis of this disorder in addition to informing the necessary steps to be taken such as the referral of the pediatric patients to mental health services. The study by Esmaeeli et al. (2014) aimed at exploring the topic of depression in hospitalized pediatric patients. Esmaeeli et al. (2014) noted that hospitalized children tend to experience many mood changes and thus are at risk of developing depression. The researchers adopted a quantitative research methodology. The researchers sampled 90 children between the ages of 8 and 16 (Esmaeeli et al., 2014). The census sampling method was used while children who had a history of depressive mental disorders being excluded from the research. The results of the research showed that 63% of the participants had depression after being screened (Esmaeeli et al., 2014). A significant statistical relationship between the severity of depression and the duration of illness was evidenced with children who were hospitalized more than 3 times a year being experiencing higher levels of depression. The research therefore highlighted that 26 PEDIATRIC DEPRESSION SCREENING sufficient screening of depression be carried out among children hospitalized more than once as it informs accurate medical diagnosis of mood disorder and depression therefor promoting early treatment aimed at improving the quality of life as well as accelerating the treatment process of the medical conditions (Esmaeeli et al., 2014). The research further provided insights into the importance of screening as a tool for highlighting the mental state of the patient thus informing the need for referral to pediatric psychologists capable of helping the child. Esmaeeli et al. (2014) argued that screening of hospital pediatric patient helped in the identifying of depression thus directing for further assessment to informing accurate diagnosis. With 63% of the pediatric patients having some form of depression the study may highlight the critical nature of depression within the pediatric setting and therefore the importance of depression screening among children in this setting thus informing early diagnosis of the disorder. The study by Siu (2016) highlights the value of screening children and adolescents for Major Depressive Disorder. A systematic review of research articles on the topic was critical to understanding the benefits and the harms of screening in addition to the feasibility of screening tests. The participants involved in the studies were between the ages of 7 and 18 years. The evidence of the benefits of screening identified the need to recommend depression screening for adolescents aged 12 to 18 years of age. Screening as argued by Siu (2016) should be supported by adequate systems that ensure that accurate diagnosis and effective treatment is achieved. The researcher argued that screening tools would be effective in providing insights into the mental state of children and adolescents within the primary care setting. The findings identify that screening tools are effective in highlighting symptoms of depression among children as they provided opportunities for early detection, intervention and treatment (Siu, 2016). Therefore the benefits of screening as indicated by this research highlight the value of adopting specific 27 PEDIATRIC DEPRESSION SCREENING screening tools to support early diagnosis and intervention thus reducing the burden of depression experienced by the children and their families. The systematic review carried out by Thombs, Roseman and Kloda (2012) further supports the view that pediatric screening is effective at informing depression diagnosis within the pediatric setting. The researcher collected data from various articles from different bibliographic databases such as MEDline, EMBASE, PyscINFO, Cochrane Central and Lilacs. The studied analyzed involved children and adolescents between the ages of 6 to 18 years of age (Thombs et al., 2012). The purpose of the research was to validate the use of screening as possible solution to improving the diagnosis and the management of depression among children. The research questions aimed to answer the accuracy of the depression screening tools and the effectiveness of depression screening during childhood (Thombs et al., 2012). Additionally the research study aimed to explore the potential benefits and harms associated with depression screening. The results of the study points to the value of optimal depression management, which can only be, achieve through screening and subsequent diagnosis of this disorder. Screening in childhood is noted as an approach to help the health care providers in identifying patients and providing depression management services and programs (Thombs et al., 2012). The results of the article therefore indicate that screening would assist in highlighting symptoms of depression thus informing diagnosis and the implementation of treatment interventions. Discussion This section tackles three main points that is the limitations, the general conclusions and the potential project. The first section explores the limitations of the literature review process. The second section briefly highlights the chosen intervention, how robust the evidence was, and 28 PEDIATRIC DEPRESSION SCREENING why it was chosen. The potential practice changes that are informed by the literature will be explored. Limitations The literature was limited as few studies explored the outcomes of pediatric screening which would have enhanced the supportive evidence of the intervention selected. Although the literature explored the issue of depression screening among children, none was able to provide substantive evidence to show the impact that depression-screening tools have on the patient outcomes. Additionally most articles integrated into the literature review were quantitative in nature and none had adopted a qualitative research methodology to promote further understanding of the issue. Furthermore, generalizability of most articles include in the literature review process did not take into account the ethnic and cultural backgrounds of the participants and this creates the assumptions that depression screening does not differ regardless of differences in race, gender, culture and ethnicity. Furthermore, validity and reliability of the articles cannot be ascertained and this highlights a major limitation that affects then evidence provided. Most of the quality articles were outdated and were therefore excluded from the literature review, which handicaps the quality of the literature review. There is a need to expand research into other databases to collect more extensive evidence to support the claims made in this paper. General conclusions The chosen intervention was the use of pediatric screening in informing the diagnosis of depression among children. The evidence was robust in that it helped to provide empirical findings that were used to support the intervention. The evidence provided was robust as it was derived from recent, peer-reviewed articles. The scholarly nature of the articles and the limited 29 PEDIATRIC DEPRESSION SCREENING bias evidenced from these research articles further highlights the strength of the evidence used to support this intervention. Pediatric screening was chosen as a method to improve diagnosis of depression, which has become a major problem within the American society. The high prevalence rates of depression in the population especially among children and adolescents and the adverse effects of depression of growth and development identify the importance of screening and early detection and treatment of this disorder. Potential project The change of practice needed within the healthcare setting is the training of healthcare providers in the pediatric setting to implement screening tools to all children and especially, potential high-risk socio-economical risk factors of developing depression. The practice that would change is the adoption of regular screening of children who are at risk of depression, to screening all children as depression is masked differently by c various children relate dot their background, ethnicity, gender or cultural beliefs. The healthcare providers will learn and adopt various depression-screening tools such as the ChilD-S that helps in identifying symptoms of depression informing the diagnosis and the treatment of this disorder. Summary Depression as a mental disorder affects the growth and development of children and adolescents. The sampling strategies adopted such as setting year restrictions and seeking peer reviewed articles only were aimed at collecting quality and credible evidence to support the interventions. Inclusion criteria involved locating articles published after 2012 and empirical research articles as well. The general findings highlight various interventions to address depression and they are pharmacology and cognitive behavioral therapy. The chosen intervention that will change practice is the adoption of pediatric screening in the diagnosis of 30 PEDIATRIC DEPRESSION SCREENING depression among children. The limitations of the literature review process is that few quality articles were located, generalizability of the articles without consideration for ethnic and cultural differences and lack of any qualitative research articles. The evidence provided to support the intervention was strong as it was collected from peer-reviewed scholarly articles. The change of practice expected is the adoption of depression screening tools among healthcare providers when dealing with children who have a high risk of depression within the pediatric setting. 31 PEDIATRIC DEPRESSION SCREENING References Allgaier et al. (2014). Improving early detection of childhood depression in mental health care: The Children‫ ׳‬s Depression Screener (ChilD-S). Psychiatry research, 217(3), 248-252. Bardach et al. (2014). Common and costly hospitalizations for pediatric mental health disorders. Pediatrics, 133(4), 602-609. Bhatta, S., Champion, J. D., Young, C., & Loika, E. (2018). Outcomes of depression screening among adolescents accessing school-based pediatric primary care clinic services. Journal of pediatric nursing, 38, 8-14. Craighead, W. E. (2013). Interventions for childhood depression. Shanghai archives of psychiatry, 25(1), 50. Esmaeeli et al. (2014). Screening for Depression in Hospitalized Pediatric Patients. Iranian Journal of Child Neurology, 8(1), 47–51. Michael, K. D., Huelsman, T. J., & Crowley, S. L. (2005). Interventions for child and adolescent depression: Do professional therapists produce better results?. Journal of Child and Family Studies, 14(2), 223-236. Mihalopoulos, C., Vos, T., Pirkis, J., & Carter, R. (2012). The population costeffectiveness of interventions designed to prevent childhood depression. Pediatrics, 129(3), e723-e730. Siu, A. L. (2016). Screening for depression in children and adolescents: US Preventive Services Task Force recommendation statement. Annals of internal medicine, 164(5), 360-366. Thombs, B. D., Roseman, M., & Kloda, L. A. (2012). Depression screening and mental health outcomes in children and adolescents: a systematic review protocol. Systematic reviews, 1(1), 58. 32 PEDIATRIC DEPRESSION SCREENING Chapter Three: Theory and Model for Evidence-based Practice In healthcare, theoretical approaches are necessary to translate research into practice. They also provide a greater understanding into the factors that impact implementation outcomes. Therefore, evidence-based practices are useful in determining the efficacy of various initiatives and their impact on healthcare outcomes. The use of evidence-based practice is crucial as it ensures that nurses base healthcare practices on information grounded in research. Theories and models when implementing healthcare interventions influence nurses. While theories are analytical principles that structure observation, models are the guiding processes that translate research into practice (Nilsen, 2015). Jean Watson’s theory of caring and the Ace-Star Model will influence the implementation of the evidence-based practice. Theory Jean Watson’s theory of caring will guide the implementation of the evidence-based practice. The theory focuses on the provision of empathetic care, where the nurse is responsible for making a connection with patients to facilitate the healing process. Jean Watson developed the theory of caring, which is discussed in her book “Philosophy and Science of Caring”. Watson indicates that caring is crucial to nursing practice as it promotes healing. She indicates that medical cure alone cannot to bring about healing, but that a holistic approach to healthcare needs to facilitate improved health outcomes (Turkel, Watson, & Giovannoni, 2018). Watson believes that a proactive caring attitude in the nursing profession substantially improves healthcare outcomes. The theory of caring is based on ten carative factors. The carative factors are underlying principles of Jean Watson’s theory of caring. The first carative factor involves forming a humanistic system of values. Nurses are required to care for themselves and for others. Caring is 33 PEDIATRIC DEPRESSION SCREENING based on a philosophical, moral, and ethical foundation of love and values. The formation of humanistic values considers the nurse’s experiences and skills to be integral to the practice of nursing (Turkel, Watson, & Giovannoni, 2018). The experience that nurses have undergone in their personal and professional lives shapes their behavior towards others. Nurses are supposed to care for patients’ health and wellbeing. The figure below demonstrates Jean Watson’s ten carative factors. Figure 1: Jean Watson’s ten principles conceptualizing the theory of caring (Wills, 2011). The second carative factor involves providing faith and hope to patients. Nurses provide a sense of well-being for others. Patients battling illnesses may feel helpless and nurses are required to provide them with hope that their health situations will improve. Pointing out healthcare interventions that will improve the patients’ healthcare situation is one of the ways through which nurses can provide faith and hope to patients. Nurses should also incorporate the patients’ beliefs and values into the care plan to make them feel cared for (Watson & Brewer, 34 PEDIATRIC DEPRESSION SCREENING 2015). Nurses should also strive to create human connections by calling patients by viewing them as human beings and encouraging them to go on with life. This way, nurses will have supported the patients’ sense of self. The third curative factor entails being sensitive to oneself and to others. Nurses are required to empathize with the patients’ feelings. Nurses who empathize with others are more authentic. As a result, the nurse and patient achieve self-growth and self-actualization. Being sensitive to other people involves understanding their fears and concerns and responding in a way that will solve the patients’ problems (Watson & Brewer, 2015). Nurses should transform tasks into healing interventions. Rather than viewing their roles as providers of care, nurses should recognize that they play an integral role in promoting the patients’ healing. The form of interaction between nurses and patients largely contributes to healthcare outcomes. The fourth factor involves developing a helping-trust relationship between nurses and patients. The creation of trust between nurses and patients is crucial for positive health outcomes. Nurses have to create an environment of trust to facilitate meaningful interactions with patients. Without a trusting relationship, patients would be inclined to withhold information, which would negatively impact the extent to which the patients’ healthcare needs are addressed (Watson & Brewer, 2015). The helping-trust relationship is only possible when nurses seek to work from the patient’s subjective perspective. Nurses should be non-judgmental to facilitate the creation of a positive environment that leads patients to trust them. For nurses to provide care, they have to promote and accept the patients’ negative and positive feelings. Patients may demonstrate negative or positive feelings depending on what they could be going through. Nurses are required to acknowledge patients’ feelings to show that they understand the patients’ situations (Turkel, Watson, & Giovannoni, 2018). Nurses should be 35 PEDIATRIC DEPRESSION SCREENING aware that healing is an inner journey and that patients should be provided with the right to express themselves without judgment. Although patients may be pessimistic about their healthcare situations, nurses should assist them to see good aspects of their situation. Nurses are required to apply scientific methods of problem solving and decision making. Before nurses can implement any healthcare interventions, they need to be certain of the effectiveness in addressing various healthcare challenges. The demonstration of caring requires nurses to implement interventions that have undergone scientific reviews that have determined their effectiveness. Sinclair et al. (2016) indicate that applying healthcare interventions that are verifiable scientifically ensures that nurses practice the ethical principle of beneficence, where healthcare professionals are expected to provide healthcare interventions that promote the health and wellbeing of patients. The seventh carative factor entails promoting interpersonal teaching and learning. Nurses should always embark on expanding the skills and expertise in addressing healthcare challenges. Growth in skills and learning ensure that nurses implement healthcare interventions that promote healthcare outcomes. Also, nurses should strive to impart their knowledge on patients and other healthcare professionals to promote better techniques of providing care (Turkel, Watson, & Giovannoni, 2018). Learning should be continuous to equip nurses with improved skills in providing care. Nurses are required to display caring by providing a supportive environment for patients’ physical, spiritual, mental, and socio-cultural needs. While addressing physical health is important, addressing mental health is equally imperative as it affects an individual’s health and wellbeing. Nurses should to take a holistic approach when addressing the patient’s health condition. Other factors such as wholeness, comfort, and peace and dignity have are important 36 PEDIATRIC DEPRESSION SCREENING when providing care (Watson & Brewer, 2015). Nurses should create healing environments that anticipate and fulfill patients’ needs. The provision of care requires nurses to satisfy human needs based on Maslow’s hierarchy of needs. Each need is equally important in the promotion of the patient’s health. Nurses should understand that different people have unique needs requiring different approaches when delivering care. As a result, a patient’s unique needs such as their perceptions of the world, their expectations of privacy, and their needs for comfort a patient’s determines the best healthcare approach in addressing their needs (Watson & Brewer, 2015). Administering care requires the nurse to be cognizant of the fact that patients may need varied levels of care. The tenth carative factor involves the allowance of existential-phenomenological forces that assist nurses in viewing patients holistically while addressing their hierarchical ordering of needs. Nurses are required to consider the patients’ spiritual beliefs when providing care. They should also take into consideration the patient’s existential beliefs and acknowledge that their beliefs are important to them (Watson & Brewer, 2015). Thus, nurses should nurture and support patients’ beliefs in hope and miracles. They should also respect things that have meanings to others. Application to practice change. Jean Watson’s theory of care highlights the importance of supportive care for positive health outcomes. The carative principle of providing hope and faith to patients can be used to highlight the nurses’ role in facilitating the screening of pediatric patients. When patients screen positive for depression, nurses should provide them with hope that their mental health conditions can improve. The nurses’ referral of patients to mental health practitioners is one way through which they will be providing hope and care. 37 PEDIATRIC DEPRESSION SCREENING Jean Watson’s theory of care will have positive implications in the implementation of depression screening at the hospital. Nurses have to convince patients on the importance of carrying out depression screening. The results of the screening will rely on whether there is a helping-trust relationship between the nurse and patient. The presence of a trusting environment enables patients to be truthful when undergoing depression screening, as they will view the nurses as being empathetic to their situation. Nurses can create a trusting relationship though verbal and nonverbal communication (Brooks, Manias, & Bloomer, 2018). The use of verbal communication would involve using language that is clear and articulates the nurse’s intention to understand the patient. The use of nonverbal communication involves paying attention to patients and being responsive to them. The theory of care requires nurses to accept patients’ feelings, regardless of whether they are negative or positive. When administering depression screening, nurses should provide a safe place where patients can narrate their experiences. They should provide an environment for the patients’ stories to emerge, grow, and develop. The theory of care assists nurses to encourage patients to undergo reflections of their feelings and experiences (Watson & Brewer, 2015). Patients can only provide accurate answers on the screening tool after they have clearly evaluated their situations to determine the most appropriate response for each question. The carative factor of using scientific methods of problem solving is particularly important as it aligns with the depression screening initiative. The main aim of the intervention is to determine whether training nurses in the administration of depression screening will improve the health outcomes of pediatric patients with depression. The evidence-based activity aligns with Jean Watson’s emphasis on the need of using scientific methods when providing care. The evidence-based activity will provide information on whether training will promote the use of 38 PEDIATRIC DEPRESSION SCREENING depression screening. Increased depression screenings will potentially result in an increase in the number of pediatric patients that screen positive for depression (Forman-Hoffman et al, 2016). Therefore, nurses will support the screening of all pediatric patients, as the intervention would be effective. Jean Watson’s theory has identified interpersonal teaching and learning as an important principle when caring for patients. The evidence-based practice evaluates the importance of learning in the healthcare outcomes of pediatric patients with depression. The principle of learning will be applied through training nurses and equipping them with essential skills needed to undertake depression screening. On the other hand, the principle of teaching will be enforced through the interactions between nurses and patients, where nurses will impart information on the importance of undertaking screening in addressing mental health issues. Jean Watson’s caring theory can be applied holistically in the implementation of the evidence-based practice. Nurses are required to engage their emotions in developing a caring relationship with patients. The main aim of the evidence-based practice is addressing mental health challenges affecting pediatric patients. For nurses to provide care, they have to create an environment that facilitates trusting relationships with patients so that patients can divulge information that will be necessary in determining the result of depression screening (Brooks, Manias, & Bloomer, 2018). As a result, the theory of caring will facilitate the addressing of patients’ mental health challenges. Watson’s theory emphasizes the importance of creating a workplace environment that promotes caring. Lachman (2016) indicates that nurses often work in environments that breed frustrations, anger, and apathy. The negative feelings emanate from lack of environmental support, as the nurses are not well equipped to handle healthcare challenges that they face on a 39 PEDIATRIC DEPRESSION SCREENING day-to-day basis. Training nurses will equip them with the relevant skills needed to address patients’ mental health challenges. The nurses will undergo training that will create an environment for delivering effective nursing care. The application of Jean Watson’s theory of care in the implementation of the depression screening evidence-based practice will be useful as it will align research with practice. Evidence-Based Practice Change Model Nursing models are applied in determining how decisions are conceptualized to guide decision-making. Evidence-based practice emanates from the integration of available research to promote effective decision-making. The use of models in the implementation of evidence-based practices enhances the effectiveness and efficacy of healthcare interventions. For evidence-based practices to be successful and sustainable, a culture of readiness is facilitated through the adoption of an implementation framework (Rousseau & Gunia, 2016). As a result, evidence based practice models are useful in the translation of research into practice. Models play a significant role in identifying the clinical problem, appraising evidence, appraising the need for practice change, and evaluating outcomes. The Ace-star Model will be applied in providing a framework for organizing evidence based practice processes. The Ace-Star model was founded by faculty at the University of Texas Health Science Center at Saint Antonio. The model contains five points of sequential knowledge transformation. They comprise of discovery research, evidence summary, translation to guidelines, practice integration, and process outcome evaluation (White & Spruce, 2015). 40 PEDIATRIC DEPRESSION SCREENING The Ace-Star Model (White & Spruce, 2015). The first stage of the Ace-Star model is known as discovery research. It is also known as the knowledge-generating stage. The model involves the discovery of new knowledge through traditional research methodologies and scientific enquiry. During the discovery research stage, primary research activities may be carried out to gather information pertaining to the evidence based practice (White & Spruce, 2015). For an evidence based activity to be reliable, it has to produce similar results when replicated in another setting. As a result, the discovery research method has to consider the validity and reliability of the results, as well as the replicability of the activity. The second stage of the Ace-Star model, the evidence summary step, entails the process of synthesizing research knowledge into meaningful statements on the state of knowledge. 41 PEDIATRIC DEPRESSION SCREENING Evidence summary processes differ in credibility, which in turn affects the reproducibility of results. The evidence summary reduces large amounts of data into a manageable form. The process involves determining the consistency of the data collected and explaining the reason for data inconsistency. The evidence summary step also determines the cause and effect of a relationship. The process also reduces bias from random and systematic errors and improves the true reality of the situation. The evidence summary step takes into consideration the existing information on clinical care and compares it with the findings of the evidence based practice (Wilson et al., 2016). The results align with existing information to determine the importance of policy formation. The third stage of the Ace-Star model is the translation stage, and it entails transforming evidence summaries into practice recommendations that can integrate into practice. The process entails providing recommendations in form of care standards. The process involves establishing clinical practice guidelines that support clinical decisions. Based on the evidence summaries, healthcare organizations determine how they can implement various healthcare initiatives that will improve healthcare outcomes (Wilson et al., 2016). Policy guidelines are helpful as they establish standards of care followed by nurses when administering care. The translation stage requires management support for establishing the guidelines and integrating them into standards of care. The fourth stage of the Ace-star model is the integration process. The process entails making changes to the organization’s practices based on the new information. Healthcare organizations are required to undergo continuous learning to facilitate the implementation of new research into healthcare practices. Similarly, the information gained from the evidence-based activity should make changes that will improve the delivery of care. The organization has to 42 PEDIATRIC DEPRESSION SCREENING create a conducive environment to facilitate the integration of new information (Wilson et al., 2016). A positive environment of change facilitates the integration of the change into sustainable systems. The last stage of the Ace-Star model is identified as the evaluation stage. It is important to assess the effectiveness of a healthcare initiative by ensuring that it has a positive impact on health outcomes, efficiency, efficacy, cost, and health status. The evaluation sage involves assessing whether the evidence based practice is effective in addressing the challenges meant to be addressed. The evaluation stage is important as it critically examines the outcome of the intervention (Wilson et al., 2016). If the outcome is not aligned with the objectives, adjustments are made to ensure better outcomes. The process may be repeated with the new adjustments until a favorable outcome is attained. Application to practice change. The first stage of the Ace-Star model will be applied through engaging in knowledge gathering on the effectiveness of pediatric depression screening. Participants will be required to undergo pretest screening to determine their knowledge on carrying out depression screening. They will also be required to take a post-test to establish the number of screenings completed during the implementation phase of the project. The pretests and posttests will be compared to one month prior to determine any increase in the rate of screening, (b) age, gender and race of those screened, (c) number of positive screens, (d) what follow-up occurred. If positive screens are identified, a tally of the type of follow up will be kept. The first stage of the Ace-Star model is crucial to the evidence-based practice as it will identify the clinical problem, and facilitate knowledge gathering on the effectiveness of depression screening in resolving the problem of mental health challenges among pediatric patients. 43 PEDIATRIC DEPRESSION SCREENING The second stage of the Ace-Star model, the evidence summary stage, focuses on reviewing the results of the evidence based activity and summarizing them in a way that is manageable and easy to understand (Indra, 2018). The collected data will be synthesized in a manner that will allow for an understanding into the results of the study. Data will be transformed into information by determining the results, comparing the results against the existing body of knowledge, and highlighting any discrepancies in the data. The stage is crucial to the pediatric depression screening stage as it will synthesize all the data collected during the evidence-based project. The third stage of the Ace-Star model, the translation stage will guide the implementation of the recommendations identified by the evidence summary process. In the event that the evidence summary process establishes the effectiveness and efficiency of screening tools in addressing pediatric mental health, the healthcare organization will establish guidelines requiring all pediatric patients to undergo depression screening. The guidelines will also establish training protocols or nurses and other healthcare personnel in administering depression screening and referring patients who have tested positive to mental health practitioners. The fourth stage of the Ace-star model, the integration process, will be crucial to turning research into practice. The results of the evidence-based practice will provide insight into the changes needed to ensure that the healthcare organization provides effective and efficient healthcare services. The management should be provided with the results of the evidence based practice so that they can ascertain that providing training on depression screening tools translates to better health outcomes (Wilson et al., 2016). As a result, the management will be responsible for implementing actionable steps that will ensure that the changes are merge with organizational processes. For instance, the management can set up guidelines requiring all pediatric patients to 44 PEDIATRIC DEPRESSION SCREENING undergo depression screening. When the recommendation is set up as a guideline, it will be more effective as the healthcare staff will enforce it. While leadership will play an important role in the integration process, staff participation will also play a crucial role as healthcare providers will be required to facilitate the change process. At the conclusion of the project, an internal meeting will be held to discuss the impact of the program. All interested parties employed at the facility will be invited to attend. The meeting will discuss the impact of the program in facilitating best practices for assessment of screening for depression in pediatric patients. Discussions will involve sustainability measures for the new practice. It will be an interactive session where participants provide their views on the impact of the project on depression screening and treatment at the facility. The inclusion of the staff will enhance the rate of success in implementing the change initiative. Employees are more inclined to support a change initiative if they are involved in its implementation (Byron et al., 2015). Undoubtedly, requiring nurses to undergo training on the administration of depression screening tools will lead to major organizational changes due to adjustments in nurses’ duties and responsibilities. For the healthcare staff to support the new initiative, they have to have assurance that the new guidelines will not negatively affect their performance. The evaluation stage of the Ace-Star model is useful in ensuring that the intervention recommended by the evidence-based program has attained its intended objectives (Byron et al., 2015). The implementation of the depression screening evidence based program is intended to showcase that increased training results in an increase in the number of depression screenings that are conducted, which in turn improves the mental health statuses of pediatric patients diagnosed with depression. Although the evidence based practice may have determined 45 PEDIATRIC DEPRESSION SCREENING depression screening as having a positive impact in addressing the mental health challenges faced by pediatric patients, the claim needs validation in a real-life setting. Key performance indicators such as number of patients undergoing depression screening, number of positive screenings, the number of pediatric patients referred to mental health experts, and the overall impact in improving health outcomes. The healthcare facility has to examine the number of patients that have undergone depression screening after the implementation of the intervention. An increase in the number of patients undergoing screening is a demonstration that training has been effective in informing nurses on the importance of conducting depression screening among all pediatric patients. Evaluation will also entail assessing the number of screenings that have provided positive outcomes. An increase in positive results will demonstrate that the intervention has been effective in identifying pediatric patients who could be having depression. In addition, evaluations have to determine the impact of the intervention in improving healthcare outcomes. It may be challenging to determine the exact impact of the screening in determining healthcare outcomes, but one way implementing it is by assessing the number of individuals who underwent depression screening and given referrals to mental health experts. An increase in referrals to mental health experts is an indication that the patients’ mental health needs are ben addressed. When the patients successfully undergo treatment for depression, their overall health outcomes will improve. Therefore, the evaluation of the impact of the evidencebased practice in healthcare needs to examine the number of patients that have successfully undergone treatment for depression. Summary 46 PEDIATRIC DEPRESSION SCREENING The use of the theory and model in the implementation of the evidence-based practice will enhance the success of the project in addressing healthcare challenges. The theory of caring will influence the nurses’ perception of the evidence based practice (Turkel, Watson, & Giovannoni, 2018). Nurses will be required to change how they carry out their duties, and it is likely that they may fail to support the project if it significantly interferes with their duties. Nonetheless, the theory of caring will present the evidence based practice as an intervention with potentially positive results in addressing depression in pediatric patients. The Ace-Star model will determine how the organization can shift research into practice. Undertaking organizational change could be problematic without a framework for establish guidelines and influencing decision-making. The Ace-Star model contains five stages that are effective in ensuing that the organization successfully implements depression screening (Wills, 2011). The model addresses the responsibility of the nurses in undergoing training and ensuring the screening of all pediatric patients. The model is also effective in highlighting the management’s responsibility in change implementation. The management is responsible for setting rules and guidelines or the staff as well as evaluating the intervention to determine its effectiveness in improving health outcomes. The combination of the theory of caring and the Ace-Star model will enhance effectiveness in the implementation of the evidence-based practice. 47 PEDIATRIC DEPRESSION SCREENING Chapter Four: Pre-implementation Planning Start introduction here……….. Project Purpose Start typing here… Project Management Start typing here… Organizational readiness for change. Start typing here… Inter-professional collaboration. Start typing here… Risk management assessment. Start typing here… Organizational approval process. Start typing here… Use of information technology. Start typing here… Materials Needed for Project Start typing here… Plans for Institutional Review Board Approval Start typing here… Plan for Project Evaluation Start typing here…. Plan for demographic data collection. Start typing here… Plan for outcome data collection and measurement. Start typing here… Plan for evaluation tool. Start typing here… Plan for data analysis. Start typing here… Plan for data management. Start typing here… Summary 48 PEDIATRIC DEPRESSION SCREENING Chapter Five: Implementation Process Start introduction here……….. Setting Start typing here… Participants Start typing here… Recruitment Start typing here… Implementation Process Start typing here… Plan Variation (If Applicable) Start typing here… Summary Start typing here… 49 PEDIATRIC DEPRESSION SCREENING Chapter Six: Evaluation and Outcomes of the Practice Change Start introduction here……….. Participant Demographics Start typing here… Outcome Findings Start typing here… Outcome one. Start typing here… Outcome two. Start typing here… if there is more than one outcome Summary Start typing here… 50 PEDIATRIC DEPRESSION SCREENING Chapter Seven: Discussion Start introduction here……….. Recommendations for Site to Sustain Change Start typing here…. Plans for Dissemination of Project Start typing here… Project Links to Health Promotion/Population Health Start typing here…. Role of DNP-Prepared Nurse Leader in EBP Start typing here… Future Projects Related to Problem Start typing here…. Implications for Policy and Advocacy at All Levels Start typing here…. Summary Start typing here… 51 PEDIATRIC DEPRESSION SCREENING Chapter Eight: Final Conclusions Start introduction here……….. Clinical Problem Start typing here…. Evidence Base Start typing here…. Theory and Model for Evidence-Based Practice Start typing here…. Project Management Start typing here…. Project Implementation Start typing here…. Outcome Findings Start typing here…. Discussion Summary Start typing here…. 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Depression and Anxiety, 33(10), 978-986. 57 PEDIATRIC DEPRESSION SCREENING Appendix A Appendix Title Here 58 PEDIATRIC DEPRESSION SCREENING Appendix B Appendix title here 59 PEDIATRIC DEPRESSION SCREENING Appendix C Appendix title here Running head: PEDIATRIC DEPRESSION SCREENING Appendix D Appendix title here 60 61 PEDIATRIC DEPRESSION SCREENING Appendix E Appendix title here 62 PEDIATRIC DEPRESSION SCREENING Appendix F Appendix title here 63 PEDIATRIC DEPRESSION SCREENING Appendix G Appendix title here
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