Digital Repository Doctoral Projects Fall 2022 Quality Improvement of Mindfulness Program for Adolescent Anxiety Disorders in Residential Treatment Carly Reid Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Reid, C. (2022) Quality improvement of mindfulness program for adolescent anxiety disorders in residential treatment Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Quality Improvement of Mindfulness Program for Adolescent Anxiety Disorders in Residential Treatment by Carly Reid A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 _______________________________ _____December 16, 2022 Carly Reid DNP-FNP, RN Date December 16, 2022 DNP, MSN/Ed, RN, CNE, COI DNP Project Faculty (Electronic Signature) Date December 16, 2022 Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Kelley Trump Carly Reid Quality Improvement of Mindfulness Program 2 Quality Improvement of Mindfulness Program 1 Table of Contents Abstract ............................................................................................................................... 1 Background and Problem Statement .............................................................................................. 2 Diversity of Population and Project Site ......................................................................................... 3 Significance for Practice Reflective of Role-Specific Leadership ................................................. 3 Literature Review and Framework ........................................................................................ 4 Framework ........................................................................................................................................ 4 Search Methods ................................................................................................................................. 5 Synthesis of Literature ..................................................................................................................... 5 Adolescent Anxiety ........................................................................................................................ 7 Residential Treatment Centers ....................................................................................................... 8 Evidence-Based Practice Standards for Improving Mindfulness Program .................................... 9 Counter Research ......................................................................................................................... 10 Discussion ........................................................................................................................................ 10 Implications for Practice ................................................................................................................ 11 Project Plan ........................................................................................................................ 11 Project Design ................................................................................................................................. 11 Needs Assessment/Gap Analysis of Project Site and Population ................................................ 11 Cost Analysis and Sustainability of Project ................................................................................. 12 Project Outcomes ............................................................................................................................ 13 Consent Procedures and Ethical Considerations ......................................................................... 14 Instrument to Measure Interventions Effectiveness .................................................................... 14 Project Implementation ....................................................................................................... 14 Project Interventions ...................................................................................................................... 15 Difficulties with Execution ............................................................................................................. 15 Project Timeline .............................................................................................................................. 16 Project Evaluation .............................................................................................................. 17 Data Maintenance/Security ............................................................................................................ 17 Data Collection and Analysis ......................................................................................................... 18 Findings ........................................................................................................................................... 19 Strengths .......................................................................................................................................... 20 Weaknesses ...................................................................................................................................... 20 Discussion ........................................................................................................................... 20 Translation of Evidence into Practice ........................................................................................... 21 Implications for Practice and Future Scholarship ....................................................................... 21 Sustainability ................................................................................................................................ 22 Dissemination............................................................................................................................... 22 Conclusion ....................................................................................................................................... 22 Quality Improvement of Mindfulness Program 1 Abstract Purpose: A need for consistent, mindfulness-based interventions (MBIs) for adolescents experiencing anxiety disorders. The primary purpose of this project is to plan, implement, and evaluate evidence-based practice to improve a residential mindfulness program. As a result, this project decreased the amount of anxiety experienced and assisted adolescents in coping with the challenges of daily life. Methodology: Staff at Cascade Academy completed a pre-survey followed by a digital education module and post-education survey. Four interventions were implemented over four months, after which a post-survey was administered to measure the change in attitude and knowledge. These surveys contained both quantitative and qualitative data to measure improvement. Results: Overall, the data suggest an improvement in the knowledge and change of attitude of staff throughout the project, including an increase in perception of the importance of mindfulness. In addition, the interventions implemented by the DNP team created a higher percentage of Agree and Strongly Agree responses, indicating an increase in knowledge or a wanted change in attitude by staff. Implications for Practice: Outcomes show that knowledge and attitude changed when staff was educated on mindfulness's importance in treating anxiety disorders. Furthermore, the education module, and surveys, can be used in other residential treatment centers that seek to understand how to incorporate a quality mindfulness program into their treatment plan. Keywords: mindfulness, anxiety disorders, meditation for adolescent anxiety Quality Improvement of Mindfulness Program 2 Quality Improvement of Mindfulness Program for Adolescent Anxiety Disorders in Residential Treatment Anxiety is a growing problem among adolescents. In the United States, one in three adolescents (31.9%) develop an anxiety disorder by 18 years of age (Mcarthy, 2019). Half of lifetime mental illnesses in America are diagnosed by age 15, and almost three-quarters by age 18 (Radez et al., 2020). Adolescence provides a window of opportunity to strengthen mental health. Proper treatment can help young people thrive and not just survive (Galla, 2017). Although mindfulness originates from ancient eastern Buddhist philosophy, its introduction to the western world is still in its infancy. Mindfulness research shows positive results; however, utilizing translational science to implement quality mindfulness programs in residential treatment proves challenging. The primary purpose of this project is to plan, implement, and evaluate evidence-based practice to improve a residential mindfulness program, decreasing the amount of anxiety experienced and assisting adolescents in coping with the challenges of daily life. Background and Problem Statement Cascade Academy is a residential treatment facility for teenage girls with behavioral health problems related to anxiety disorders. High anxiety levels negatively impact behavioral and emotional well-being by leading to negative behaviors such as anger, blame, and denial (Monshat et al., 2012). Their philosophy embraces the balance of the body, mind, and soul. Currently, there are no guidelines for consistent mindfulness-based interventions (MBIs). MBIs reduce psychological distress and increase social connection, and the degree of a positive outcome depends on the duration and consistency of practice (Goldberg et al., 2020). Developing a policy for standardized MBIs at Cascade Academy can reduce the psychological distress and anxiety the girls experience and provide them with tools to manage symptoms after treatment. Quality Improvement of Mindfulness Program 3 Diversity of Population and Project Site Cascade Academy is a new residential treatment facility in Midway, UT, specializing in treating anxiety disorders in adolescent females aged 13-18. Girls come from all over the country with diverse backgrounds, and licensing for international students is currently in progress. Residents are primarily self-pay. The academy can house 26 girls and has a goal of three admissions per month. The current admissions rate is 1.2 clients per month. Criteria for admission include medical stability, an intelligence quotient (IQ) range of 90-120, and a clinical diagnosis of anxiety (Cascade Academy, 2021). Residents cannot have any current suicidal ideation or a history of suicide attempts in the last two months. Cascade Academy does not admit adolescents with existing eating disorders, oppositional defiance disorders, autism spectrum disorders (ASDs) greater than ASD I, and any criminal history or current substance abuse. Cascade Academy intentionally focuses on teenage girls with anxiety disorders to create an environment free from negative behavior and violence associated with other mental illnesses. This focus allows the program to address specific challenges adolescent girls face in their daily lives (Cascade Academy, 2021). This project site provides an environment to grow as a nurse leader and Doctor of Nursing Practice-Family Nurse Practitioner (DNP-FNP). Significance for Practice Reflective of Role-Specific Leadership Transformational leadership as a DNP-FNP is required to utilize translational science to improve the quality of patient care. This project will exercise DNP Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking (American Association of Colleges of Nursing [AACN], 2006). This essential includes both organizational and systematic leadership. Analyzing the impact of policies on the quality of patient care and patient safety is vital to the DNP-FNP role. This project will create and sustain new approaches to Quality Improvement of Mindfulness Program 4 improve practice while managing financial, ethical, and organizational culture. Advanced communication skills with stakeholders will be vital. It is necessary as a nurse leader to recognize and respond to this unique and vulnerable population (AACN, 2006). Adolescent mental illness is encountered more frequently than ever before in primary care. The skills obtained in this project assist in future DNP-FNP practice both clinically and as a nurse leader. Literature Review and Framework This literature review examines the evidence of stress and anxiety in adolescence and its relationship with mindfulness-based interventions (MBIs). In addition, this review will highlight evidence-based practice standards for developing and implementing a quality mindfulness program and address the research on residential treatment facilities for adolescent anxiety disorders. The framework used to guide this project is the Associates in Process Improvement (API) model for improvement (Associate for Process Improvement [API], 2021). Framework This quality improvement project utilizes the model for improvement to address the need for a higher-quality mindfulness program. The Institute for Healthcare Improvement and other healthcare organizations use this model to improve practice (Institute for Healthcare Improvement [IHI], 2021). The model for improvement involves three questions and a cycle. The first question is, what are you going to improve? This project will enhance the mindfulness program at Cascade Academy. The second question is, how will you know that a change is an improvement? Ideally, this answer would include assessing the anxiety level experienced directly. However, the staff evaluated outcomes through direct observation and post-training surveys to protect a vulnerable population. The third and last question is, what changes can you make that lead to improvement? The changes will include improving new staff’s education Quality Improvement of Mindfulness Program 5 during orientation to understand the vital role of mindfulness. Other changes include standardizing the current mindfulness program and enhancing communication between administration and frontline employees on the expectations for MBIs (API, 2021). The second part of the model for improvement is the plan, do, study, act cycle (PDSA). This cycle involves planning how you will test the change (plan), implementing the change (do), studying what you learn about the change (study), and making any modifications to the previous method (act) (IHI, 2021). This project will utilize the PDSA cycle by planning how to standardize the mindfulness program, implement the changes, study the consequences, and apply anything learned to the current program. Search Methods Search terms for this project include adolescent anxiety and mindfulness, adolescent anxiety disorders, mindfulness-based interventions, best practices for implementing mindfulness programs in residential treatment, adolescent residential treatment centers, mindfulness, meditation for adolescent anxiety, effects of stress and anxiety in adolescence, and adolescent suicide. The databases used were Weber State Stewart Library online search, Google Scholar, UpToDate, EBSCO, CINAHL, PubMed, and Medline. Database exclusion criteria included journal articles greater than ten years old and dissertations. In addition, the inclusion criteria contained the term adolescent. Synthesis of Literature Growing research supports MBIs to treat anxiety disorders. Meta-analyses comparing hundreds of randomized control trials find that meditation training decreases psychological distress such as depression, anxiety, and stress; and increases well-being properties such as Quality Improvement of Mindfulness Program 6 compassion, social connection, and meaning to life (Goldberg et al., 2020). In addition, Monshat et al. (2012) found in a qualitative study of 11 adolescents that mindfulness-trained participants appear to progress through 3 phases: distress and reactivity, gaining and stability, and insight and application. The study found that ongoing mindfulness improves emotional regulation and self-confidence (Monshat et al., 2012). In addition, other organizations involved in researching the efficacy of mindfulness include The National Institute of Health (NIH), which created The National Center for Complementary and Integrative Health (NCCIH). The purpose of the NCCIH is to scientifically research therapies that are not considered conventional (U.S. Department of Health and Human Services, National Institutes of Health, & National Center for Complementary and Integrative Health [NCCIH], 2017). The NCCIH states that meditation may be helpful for various conditions, including psychological disorders (NCCIH, 2016). In addition, the NCCIH quotes a 2017 report from the National Health Interview Survey that found the average use of meditation in the last 12 months tripled between 2012 and 2017, and the use of meditation in children increased from 0.6 % in 2012 to 5.4% in 2017. This data reflects the overall cultural acceptance of mindfulness practice in America (NCCIH, 2017). While clinical practice guidelines for adolescent anxiety disorders recommend cognitive behavioral therapy (CBT) and or selective serotonin reuptake inhibitors (SSRIs), the severe shortage of adolescent-trained behavioral health specialists suggests a need for a more convenient, efficient, and cost-effective treatment (Walter et al., 2020). In addition, research indicates that MBIs are a safe and effective treatment and could aid in the urgent demand for the treatment of adolescent anxiety disorders (Walter et al., 2020). Quality Improvement of Mindfulness Program 7 Adolescent Anxiety The World Health Organization (2021) defines adolescence as 10-19 (World Health Organization, 2021, p.1). Other organizations define it more generally as the period after the onset of puberty when a person develops into an adult (World Health Organization, 2021). Puberty appears to play a vital role in gender differences in anxiety. After puberty, female adolescents are twice as likely to develop an anxiety disorder as males (Paus, 2008). The plasticity of the brain in adolescence allows for skills and healthy behaviors to become more malleable, creating a healthy lifestyle for the rest of their life (National Academies of Science, 2019). The impact of untreated anxiety disorders in adolescents leads to social, occupational, mental, and physical impairments (Walter et al., 2020). Adolescence is a window of opportunity to strengthen mental health. Proper treatment can help young people thrive and not just survive (Galla, 2017). Only one-third of those diagnosed with adolescent anxiety will receive treatment (Anxiety & Depression Association of America, 2021). Barriers to treatment have been well researched, including high cost, negative stigma, and lack of resources. Radez et al., 2020 performed a systemic review of 53 studies in which young people reported the most significant barrier to treatment as negative societal views and attitudes toward mental health and help-seeking. Furthermore, research suggests suicidal ideation is highest among adolescents (Nepon et al., 2010). 70% of people who have a history of suicide attempts also have an anxiety disorder (Nepon et al., 2010). This relationship is especially true for panic disorder and post-traumatic stress disorder (PTSD). Unfortunately, resources to support children who experience mental health crises are limited in America. Expanding access to services to support adolescent mental Quality Improvement of Mindfulness Program 8 health is critical (Nepon et al., 2010, Walter et al., 2020). MBIs offer another treatment approach to help decrease anxiety and provide tools for adolescents with mental illness. Residential Treatment Centers Evidence supports residential treatment centers (RTCs) for treating severe anxiety in adolescents (Leonard et al., 2016; Schneider et al., 2017). Schneider et al. (2017) studied the efficacy of multimodal residential treatment with 70 adolescents who had been clinically diagnosed with one or more anxiety disorders. Authors found that residential treatment substantially decreased adolescent-reported anxiety, depression, and anxiety-related life interference (Schneider et al., 2017). Researchers also determined that comorbid mood disorders were not associated with treatment outcomes, and adolescents with higher pretreatment anxiety had the most significant reduction in symptoms. These results suggest that RTCs are suited for treating more severe anxiety disorders (Schneider et al., 2017). This success is related to the increased availability of resources and longer treatment interventions experienced in RTCs. It is important to note that those with more than one anxiety disorder were less likely to respond to treatment, similar to outpatient studies of anxiety (Schneider et al., 2017). While Obsessive-Compulsive Disorder (OCD) was removed as an anxiety disorder from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) in 2013, it is still closely associated with anxiety disorders due to similar treatment (Leonard et al., 2016). Leonard et al. (2016) studied 172 adolescents in RTCs with primary OCD and considerable anxiety comorbidity. They found that 80.8% revealed a change post-treatment, and 64% had a clinically significant change in OCD symptoms. This success was not due solely to medication treatment; most (90.7%) were already receiving psychotropic medication. Participants assessed 1.5 years later showed that the positive effects of the RTC remained. This study suggests that RTCs are Quality Improvement of Mindfulness Program 9 particularly effective for adolescents with complex OCD and significant comorbidity (Leonard et al., 2016). In addition, due to the availability of resources, longer treatment interventions, and increased access to healthcare professionals, RTCs are ideal for implementing quality mindfulness programs. Evidence-Based Practice Standards for Improving Mindfulness Program While evidence supports the use of MBIs, research for implementation is multidimensional and challenging for healthcare organizations to translate into practice. Jon Kabat‐Zinn and Herbert Benson have been leaders in implementing mindfulness programs in healthcare since the 1970s (Bohlmeijer et al., 2010). Levasseur et al. (2019) provide process and operational considerations while implementing a mindfulness program for staff and patients in hospitals and healthcare settings modeled after Kabat-Zinn’s mindfulness-based stress reduction (MBSR) program. The first consideration is assessing the needs in a particular context. This assessment includes identifying the current strengths, weaknesses, opportunities, and threats (SWOT) (Levasseur, 2019). Next, Levasseur et al. (2019) recommends modeling a new mindfulness program after a well-researched program and modifying it for particular needs. Well-known researched and validated programs include mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and mindfulness-based pain management (MBPM) (Breathworks, 2020; Kabat-Zinn, 2011; Williams et al., 2008). Other considerations include attending to logistical issues, ensuring collaboration between clinicians and educational teams, and continual assessment for improvement. Rac and Chakravarti (2020) researched how best to develop a sustainable mindfulness curriculum for medical students. They found the primary implementation obstacle was a lack of awareness regarding MBIs. Building mindfulness education into the curriculum is crucial to Quality Improvement of Mindfulness Program 10 gaining institutional support and student engagement. They also found that success increased if it was voluntary. Other suggestions include a facilitator with clinical and educational experience in mindfulness, consistency in time and day, providing a comfortable environment, and using evidence-based mindfulness programs. Counter Research Counter research suggests cultivating mindful traits or practice potentiates negative consequences after an optimal level. This correlation is known as a non-monotonic relationship (Britton, 2020). Evidence across disciplines suggests that even some positive characteristics, such as curiosity and optimism, appear to have a threshold of little return or even negative consequences after a prolonged time. More research is needed to measure the adverse effects of MBI and at what point positive effects are reduced (Britton, 2020). Some literature suggests that mindfulness practices create adverse effects in certain conditions. For example, higher self-focus, body awareness, and emotions may worsen anxiety in particular groups (Johnson et al., 2016). Critics of mindfulness also question the commercialization and over-marketing of potential benefits (Cassel, 2016). More randomized control trials with larger sample sizes in various settings are needed to reduce the positive bias associated with MBIs. Discussion The literature on the efficacy of MBIs most often focuses on the positive benefits of MBIs. However, multiple meta-analyses with greater than ten randomized control trials show that groups receiving MBIs do significantly better than the control group (Zhou et al., 2020; Goldberg et al., 2018, Strohmaier, 2020). As data collection continues to grow on the number of adolescent mental illnesses, well-designed meta-analyses are needed to address the limitations of Quality Improvement of Mindfulness Program 11 current studies, such as diversity, bias risks, placebo effect, longer follow-up, and best practices for implementation. Implications for Practice MBIs in RTCs can be safe and effective tools for adolescent anxiety disorders (Goldberg et al., 2018). Stress and anxiety play a critical role in adolescent development, with severe consequences if left untreated (Walter et al., 2020). MBIs decrease psychological distress and increase emotional well-being (Monshat et al., 2012). Considering the increase in teenage anxiety disorders globally and nationally, MBIs should be supported to treat adolescent anxiety. However, more research is needed to identify the threshold of mindfulness therapy and possible negative consequences for specific populations. Project Plan Project Design This quality improvement (QI) project aims to standardize and improve a mindfulness program. The QI design consists of ongoing improvement cycles without an endpoint. Four principles of success for this QI project include (1) establishing systems and processes, (2) patient-centered care, (3) team approach, and (4) collection of data for continuous improvement (Batalden & Davidoff, 2007). Needs Assessment/Gap Analysis of Project Site and Population This QI project impacts over 20 employees, including ten mentors, three clinical therapists, three educators, four administrators, and a yoga instructor. Key stakeholders include the director of clinical services and the program director, who assisted as project consultants. Indirectly this project impacts up to 26 students in residential treatment with three rotating admissions per month. Quality Improvement of Mindfulness Program 12 Social determinants of health (SDOH) that influence health disparity among female adolescents with anxiety disorders include family relations (especially parents), school environment, peer relationships, and neighborhood environment. Adolescent development includes socialization with proximal environments (Wang et al., 2021). Regarding mental health in adolescents, Aneshensel & Sucoff (1996) found that mental health disorders in adolescents are inversely related to social status and low socioeconomic status. For example, youth in low-income neighborhoods had a greater chance of experiencing negative behaviors such as crime, violence, drug use, and graffiti. In addition, the perception of living in a dangerous neighborhood increases adolescent anxiety (Aneshensel & Sucoff, 1996). While most residents at Cascade Academy are primarily self-pay, efforts made by the organization support those with SDOH. For example, the organization and its residents hold an annual bike ride, Pedalfest, to support the wellness initiative of the Forever Young Foundation. This initiative contributes financially to local youth with mental illness. Therefore, mindfulness concerning these social determinants of health was essential throughout this QI project. A needs gap analysis for this specific project identified a gap in the current mindfulness program concerning the knowledge and attitude of staff regarding mindfulness and the evidence-based practice for a quality mindfulness program. As a result, Cascade leadership confronted the problem of how to implement those interventions best to improve patient outcomes. Effective education of staff and implementation of evidence-based interventions can significantly close this gap to align Cascade better with its mission, vision, and values. Cost Analysis and Sustainability of Project Budgetary requirements of the project include paying staff to complete online learning during the initial orientation process. Initially, all employees completed this education during Quality Improvement of Mindfulness Program 13 monthly training or while working at the facility. The organization paid for this expense budgeted under its orientation program. Other costs include fees for books to assist mentors in mindfulness discussion and incorporate mindfulness into the academic curriculum. The chief expense was paying for a certified yoga instructor. However, the organization has already been implementing and paying for yoga, and this project did not increase the current budget for yoga. See Appendix A for a detailed account of costs. The sustainability of this project was achieved by appointing a mindfulness champion and adjusting the initial learning module to be utilized for future employees. In addition, the mindfulness champion was appointed a mindfulness leader within the administration to support and ensure continuous quality improvement. Other resources include access to the Qualtrics survey platform, where Cascade leadership can continue to survey staff. Project Outcomes The outcomes of this project included an increase in both the knowledge and attitude of the staff regarding mindfulness and the quality of the mindfulness program. In addition, measurable results include completing the education module, surveys, and the implementation of suggested interventions. Data was obtained through Qualtrics survey responses from staff. The sustained or long-term effects of the project include the impact on the mental health of each child who participates in the improved program. Other sustained results comprise the impact of the staff trained in mindfulness skills that they can now utilize in other occupations and in their own life. Also, any curriculum purchased for mindfulness practice in educating the residents is now available to future educators at the facility. Quality Improvement of Mindfulness Program 14 Consent Procedures and Ethical Considerations Institutional Review Board (IRB) approval was obtained for this project, and those involved maintained respect for persons, beneficence, and justice throughout the improvement process. All survey and observational data were anonymous, aggregated (except for disaggregated job title data to account for outliers), and password-protected. A plan for potential risk for harm was established to avoid adverse outcomes. Instrument to Measure Interventions Effectiveness Digital Qualtrics surveys (see Appendix B) were used to measure the effectiveness of interventions. These surveys are based on 5-point Likert scales to appropriately measure the change in the attitudes and knowledge of staff and staff perception of improvement (Likert, 1932). These surveys were executed before education, after, and post-implementation of new interventions. In addition, observational data was completed through in-person visits to the facility as needed. Project Implementation The five phases of project management were applied throughout the implementation period for this project. These phases include initiation, planning, execution, monitoring, controlling, and closing (Project Management Institute, 2015). In addition, essential leadership skills were incorporated, such as clear communication, independent action, group leadership, organizational awareness, and commitment to the organization (Carter et al., 2013). Finally, the administration received the initial buy-in, and interventions were presented to staff, including mentors, academics, therapists, recreational therapists, and the yoga instructor. Quality Improvement of Mindfulness Program 15 Project Interventions This project was implemented in January 2022 through five different interventions. These interventions included: • Staff education • Establishing consistent yoga/meditation times • Mentor-led mindfulness discussion • Utilizing a smartphone-based mediation app before technology time. • Incorporating mindfulness into the academic curriculum Deliverables included initial IRB approval by creating a project proposal PowerPoint (Appendix C). Once IRB approval was obtained, the pre-learning, post-learning, and post-implementation surveys were created utilizing the Qualtrics platform (Appendix B). The first two surveys were embedded through QR technology into the PowerPoint learning module initially presented to mentors (Appendix D). After the mentors were educated and leadership feedback was received, the educational learning module was exported to a pdf file and emailed to the rest of the staff at Cascade Academy. A clipboard was also generated for mentors to record topics of previous discussions so they could provide varied topics for students during mentor-led discussions (Appendix E). This clipboard also contained a list of researched apps for easy download to assist mentors in supporting the use of these apps before technology time (Appendix F). Difficulties with Execution Initial implementation included emailing the pre-survey to all staff. Unfortunately, only five staff members completed this baseline survey, so improvements were made to incorporate the pre-and post-learning surveys into the learning module through QR technology. While this Quality Improvement of Mindfulness Program 16 increased the response rate, a few staff members were unfamiliar with this technology, requiring a separate link to be emailed to those employees. Once it was realized that the organizational communication system was primarily in person, a date was created to present the learning module to staff on January 4, 2022. Unfortunately, an in-person presentation was impossible due to COVID-19 transmission, so the learning module was delivered via zoom. Only eight mentors attended the meeting, while the intended audience included therapists, academics, and mentors. Discussion with the project consultant resulted in emailing the learning module to the rest of the staff, resulting in another poor response rate. After meeting with team members, including the executive director of Cascade Academy, the learning module was converted to a more accessible pdf file and dispersed to employees via email from the executive director with a mandatory deadline. This intervention significantly increased the response rate from surveys. During observation, it was noted that the staff was not utilizing the clipboard to record mindfulness discussions. This error was remedied by further education and emailing this deliverable again to the program director. Communication with academic educators was initially challenging to establish but was overcome through in-person visits. Initial buy-in from educators proved challenging but in-person visits, flexibility, and becoming a respectful listener assisted in incorporating more mindfulness into the academic curriculum. Objectives were achieved through open communication with key stakeholders, thinking strategically, taking proactive action, and maintaining accountability with staff (Carter et al., 2013). Project Timeline The project timeline (Appendix G) covers the initial literature review until the evaluation of outcomes and dissemination of knowledge. Initial research included collecting evidence-based Quality Improvement of Mindfulness Program 17 research and case studies of quality improvement projects concerning the implementation of mindfulness in clinical practice. Evidence was then synthesized into making recommendations for improvement. Planning for implementation began with framing the project through project design and needs gap analysis, creating a cost analysis, and identifying effective measurement instruments. Implementation of planned interventions began on January 4, 2022, when the learning module was first presented to mentors. The learning module was dispersed to the rest of the staff on January 12, 2022. Observational data were collected on February 3 and 4th, 2022, through in-person visits to the facility. These visits included observing mentor-led discussions, meeting with team members, and participating in yoga and meditation. In addition, observational and resultant data from surveys were obtained to evaluate outcomes and disseminate knowledge. The timeline was used to achieve predefined goals and as a project management tool. Implementing the items listed on the timeline required DNP leadership skills to maintain organizational commitment and attain predefined objectives. Project Evaluation Data Maintenance/Security Data maintenance/security was achieved by utilizing the password-protected platform Qualtrics. Qualtrics allowed the data to remain accessible only to the DNP team and used for its intended purpose. The level of sensitivity for this data was minimal, considering that surveys were anonymous and job titles were the only demographic data obtained. The DNP student completed an inventory of data weekly throughout the project. This data was retained until after the dissemination of outcomes was achieved. Quality Improvement of Mindfulness Program 18 Data Collection and Analysis Ordinal data were obtained based on Likert scales from the three different surveys. Data with specific questions for each survey with sample size and answers are shown in appendix H. The responses to these surveys were summarized through Qualtrics, and graphic displays are shown chronologically in Appendix I. Finally, demographic data regarding job titles are shown in appendix J, which shows the responses were primarily from mentors. A higher percentage of Agree and Strongly Agree responses indicate an increased knowledge or the desired attitude change by staff. Overall, the data suggest an improvement in the knowledge and change of attitude of staff throughout the project. Initially, the pre-survey showed that 18% of respondents disagreed or remained neutral to questions asked about mindfulness. After the education on mindfulness was completed, that number dropped to 0%. In addition, Agree responses increased from 57% to 72%, and Strongly Agree responses increased from 25% to 28%. Four months after implementation, the final survey revealed the same trend, with 61% of staff responding with Strongly Agree and 33% Agree. The final survey also included an additional question: I feel like the mindfulness program at Cascade Academy has improved since implementing mindfulness education and training. 50% of staff responded with either Agree or Strongly Agree to this question which indicated the success of this project. The DNP team believes that these results allow for future growth and improvement of the mindfulness program at Cascade Academy. Qualitative data were obtained in the survey through two separate free-text questions. These questions asked, what is mindfulness? And what thoughts or ideas do you have to improve the mindfulness program at Cascade Academy? Commonly used words for each survey are presented in Table 1, and Appendix K presents a framework for qualitative data. The pre-survey Quality Improvement of Mindfulness Program 19 answers to What is Mindfulness? Overall themes included a connection of mind, body, and soul. In addition, respondents described an awareness of the present moment by focusing on the mind. The post-learning survey contained a more significant percentage, 72%, of the word present and incorporated judgment as a new descriptive word used in the education module. Table 1 Commonly Used Words for Qualitative Survey Responses Findings Overall, the post-education survey results reflected the words used in the digital learning module. When asked about ideas to improve the program, the themes included improving What is Mindfulness? Most Used Words What thoughts or ideas do you have to improve the mindfulness program at Cascade Academy? Most used words Pre-Survey Awareness 35% Present 65% Mind 19% Focus 19% Thoughts 12% N=26 Group 27% Communication 20% Schedule 40% Consistency 7% N=15 Post-Education Survey Present 72% Awareness 22% Mind 22% Judgment 22% Thoughts 6% N=18 N/A Post Implementation Survey N/A More Training 67% Better Communication 33% N=12 Quality Improvement of Mindfulness Program 20 employee training and communication on expectations and a desire for a more individualized approach towards mindfulness, depending on the needs of each student. The most used word in the pre-survey for improvement was Group used in 27% of responses. Phrases surrounding the word group included a desire to implement mindfulness in a smaller group setting and timing mindfulness groups to not occur before a scheduled activity. This timing makes it more challenging to stay in the present moment. Strengths The post-intervention ideas for improvement included a desire for more training, particularly for those who spend the most time with the students. Staff also requested reminders be placed on a whiteboard with ideas for application. Communication was used second most frequently regarding employees and students, as well as day and night shift mentors suggesting a need for better interpersonal collaboration between staff. In addition, staff expressed a desire to continue learning mindfulness and to appoint a group or person to continue with improvement efforts. Weaknesses Weaknesses of this data included a small sample size. Initially, the sample size for the presurvey was 28, which represented 70% of the staff. However, that dropped 50% of the staff for the post-education and post-implementation surveys. The decrease was due to a significant staff turnover over the 5-month implementation period causing a decline in staff survey responses. Future projects to improve mindfulness programs should include larger sample sizes in various settings to support evidence-based interventions. Discussion This quality improvement project incorporates key elements of the Standards for Quality Quality Improvement of Mindfulness Program 21 Improvement Reporting Excellence (SQUIRE) guidelines to provide a framework to report new knowledge and improve care (SQUIRE, 2020). These guidelines include a discussion of key findings, the relationship between interventions and outcomes, and the project's impact on people and systems. In addition, the translation of evidence into practice, implications for practice and future scholarship, sustainability, and dissemination are also discussed. Translation of Evidence into Practice Each intervention implemented in this project is evidence-based and translated into practice through involvement with key stakeholders and staff education. Overall, the data suggest an improvement in the knowledge and change of attitude of staff throughout the project. The results also indicate the staff would like continuous training in mindfulness and qualitative data suggests the staff would like to be involved as they shared new ideas for improvement. This knowledge can be utilized within Cascade as the administration begins to open other locations, such as their new obsessive-compulsive disorder center. In addition, other residential treatment centers can gain knowledge from this project on how to best implement or improve current mindfulness programs. Implications for Practice and Future Scholarship The findings from this project suggest that educating staff through a digital learning module is an effective way to improve the attitude and knowledge of the staff regarding mindfulness. Results also suggest more continuous training and staff involvement for future scholarship efforts within the academy. Suggestions for future practice would include a more significant sample size, implementing interventions in less than five months to avoid staff turnover, and implementing mindfulness in a setting that varies in the environment. Quality Improvement of Mindfulness Program 22 Sustainability The efforts to create a digital learning module will lay a foundation for future staff education on mindfulness-based interventions. This sustainability is accomplished by incorporating mindfulness education digitally into new staff orientation. In addition, this digital learning module and surveys can guide future mindfulness policies and programs at Cascade and other treatment centers. Furthermore, appointing a mindfulness champion is crucial to any program's sustainability of continuous improvement. Dissemination Dissemination of information first begins with sharing the key findings with the staff at Cascade. This dissemination can be accomplished by creating a summary of the outcomes and sharing it with the mindfulness champion to present to staff at a monthly training. Findings can also be disseminated to the professional community through stakeholders who can share positive outcomes with other residential treatment facilities. In addition, the DNP student will develop and present a digital poster for Weber State Faculty and students through a podium presentation. Finally, a permanent copy of this project paper will be available digitally through the university’s Doctoral Project Repository at the Stewart Library. Conclusion Much research has been aimed at the validity of MBIs on improved patient outcomes. However, utilizing translational science to implement quality mindfulness programs in residential treatment still proves challenging. As programs begin to implement and improve mindfulness programs, it is crucial to report how to best implement interventions and the difficulties of execution for future practice. Digital learning modules for staff appear to improve their knowledge and attitudes regarding mindfulness, and incorporating ideas from the frontline Quality Improvement of Mindfulness Program 23 staff is crucial for continuous improvement. While mindfulness is an ancient eastern Buddhist practice, its introduction to the western world is still in its infancy (Kabat-Zinn, 2011). Despite its recent introduction, mindfulness is a crucial tool in the fight against one of the highest rates of adolescent mental illness globally (United Nations Children’s Fund, 2019). 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Psychiatry Research, 289, 113002. https://doi.org/10.1016/j.psychres.2020.113002 Quality Improvement of Mindfulness Program 29 Appendix A Quality Improvement of Mindfulness Program 30 Appendix B Final Survey Links Pre-survey https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_agupGY0tTgLHG2q Post-Learning Survey https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_1YyqoTqMQTJmfeS Post Implementation Survey https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_5uKDhVe3X9Z07Fs Quality Improvement of Mindfulness Program 31 Appendix C PowerPoint for Oral Presentation Quality Improvement of Mindfulness Program 32 Quality Improvement of Mindfulness Program 33 Quality Improvement of Mindfulness Program 34 Appendix D Learning Module Quality Improvement of Mindfulness Program 35 Quality Improvement of Mindfulness Program 36 Quality Improvement of Mindfulness Program 37 Appendix E Clipboard Quality Improvement of Mindfulness Program 38 Appendix F List of Apps Quality Improvement of Mindfulness Program 39 Dissemination of Knowledge Completed Fall 2022 Evaluation of Outcomes Completed Fall 2022 Collection of Data Completed Spring 2022 Implement Interventions Completed Spring 2022 Submit Final Project Proposal, Complete oral presentation, and obtain IRB approval Completed Fall of 2021 Synthesize evidence into interventions Completed Fall of 2021 Complete critical appraisal of evidence and literature review Completed Summer of 2021 Appendix G Project Timeline Quality Improvement of Mindfulness Program 40 Appendix H Pre-Survey Post-Education Survey Quality Improvement of Mindfulness Program 41 Post- Implementation Survey Quality Improvement of Mindfulness Program 42 Appendix I Pre- Survey Post-Education Survey Post-Implementation Survey 6% Quality Improvement of Mindfulness Program 43 Appendix J Pre-Survey Demographics Post-Education Demographics Post-Implementation Demographics Quality Improvement of Mindfulness Program 44 Appendix K Organizational Framework for Quality Improvement of Mindfulness Program Quality Improvement of Mindfulness program • Awareness • Present • Mind • Focus • Thoughts • Improved training • Better timing/size of Group • Communication • More support Ideas and common themes Education/Interventions Reaction to new interventions Change in knowledge and attitudes Process New Strategies for Improvement • New hire training • More on the job training • Better organizational communication • Reminders • Appoint a person over mindfulness • Written schedule • Professionals give examples • Add to monthly training