nfralick
Tue, 05/30/2023 - 05:38
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Acknowledgments
I want to thank Dr. Jill Rodgers for her support and guidance throughout completing this DNP
research project. To my other committee members, Amanda Yost and Lisa Rovelli, your time
commitment, encouragement, and input into this project have been integral to its' conclusion.
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Development and Evaluation of a Web-Based Educational Toolkit on Knowledge,
Attitudes, and Practices of Psychiatric Prescribers
Lisa Lewis MSN, BSN, RN
Abstract
Long-acting injectable antipsychotics (LAIs) are underutilized pharmacological treatment
options for those with schizophrenia. Research examining psychiatric prescribers e a
with LAIs hypothesized that their knowledge deficits, uninformed attitudes, and poor prescribing
practices contribute to the underutilization of LAIs in clinical practice. There is a gap in the
literature regarding educational
e e
add e
c a c
e c be
edge
deficits, uninformed attitudes, and poor prescribing practices. The purpose of this Doctor of
Nursing Practice (DNP) research project, based on the Knowledge to Action Framework, was to
develop and evaluate the impact of a web-based educational toolkit on the knowledge, attitudes,
and practices of psychiatric prescribers. A seven-part web-based module that included a
presentation of the created educational toolkit regarding LAIs and a before and after knowledge,
attitudes, and practices questionnaire was hosted on an online-open source learning management
system and disseminated to psychiatric prescribers. Findings indicated that the web-based
educational toolkit slightly improved the knowledge, attitudes, and practices of psychiatric
prescribers regarding LAIs. It also revealed a relationship between a positive change in attitudes
and psychiatric prescribers practicing in a hospital setting. This DNP research project reflects the
essentials of the DNP degree. It contributes to the body of knowledge of psychiatric nursing,
created a lasting reference tool for prescribing LAIs, filled gaps in the literature regarding LAIs,
supports the use of continuing web-based education and toolkits, and serves as a catalyst for
other studies regarding LAIs.
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Keywords: Long-acting injectable antipsychotics, barriers to the use of LAIs, prescriber
knowledge, prescriber attitude, prescriber practices, web-based education, toolkit
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Table of Contents
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Appendix A: Knowledge, Attitudes, and Practices Questionnaire
Appendix B: Demographic Questions
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List of Appendices
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B: Demographic Questions
.......................................................................81
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List of Figures
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Chapter 1
Introduction
"Long-acting injectable antipsychotics (LAIs) are among the most effective treatments in
psychiatry, yet they remain underutilized in clinical practice" (Correll et al., 2016, p. 6). The
primary pharmacological treatment for schizophrenia is an oral antipsychotic. However, nonadherence to oral antipsychotic medication is a common problem associated with relapse,
rehospitalization, and worsening of the course of schizophrenia (Haddad et al., 2014; Patel &
David, 2005). LAIs have unique pharmacokinetics and offer advantages over oral antipsychotics.
They were designed to serve as a practical solution to oral antipsychotic non-adherence in those
with schizophrenia (Patel & David, 2005). LAIs are long-term pharmacological treatment
options that assure continuous compliance with antipsychotic medication. They are an essential
yet underutilized tool for both psychiatric prescribers and patients in the fight against
schizophrenia.
Clinical guidelines for schizophrenia recommend using LAIs when non-adherence is a
concern (Kaplan et al., 2013). Research and experts support the broadened use of LAIs to
minimize the neurodegeneration and disability associated with untreated schizophrenia
(Nasrallah, 2018). Despite their benefits, unique pharmacokinetics, advantages over oral
antipsychotics, and support of their use by clinical guidelines, research, and expert guidance,
LAIs continue to be underutilized in clinical practice.
The underutilization of LAIs in clinical practice is not completely understood due to
limited research investigating the problem. Research studies that examined the knowledge,
attitudes, and practices of psychiatric prescribers hypothesized that barriers to the underuse of
LAIs are the knowledge deficits, uninformed attitudes, and poor prescribing practices of
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psychiatric prescribers (Ciglar et al., 2016; Correll et al., 2016; Heres et al., 2006; Iyer et al.,
2013a; Iyer et al., 2013b; Llorca et al., 2013; Miles et al., 2011; Patel et al., 2003; Patel et al.,
2020; Sajatovic et al., 2018a; Sajatovic et al., 2018b; Samalin et al., 2013; Weiden et al., 2015).
Those barriers prevent translation of the evidence supporting the use of LAIs into the practice of
prescribing them. LAIs are effective pharmacological treatment options for those with
schizophrenia that have the potential to decrease personal suffering, family burden, and societal
costs associated with the illness (Kane et al., 1998). However, knowledge deficits, uninformed
attitudes, and poor prescribing practices among psychiatric prescribers remain barriers to the
utilization of LAIs in clinical practice.
There is a gap in the literature regarding evidence-based interventions that positively
affect psychiatric prescribers' knowledge, attitudes, and prescribing practices regarding LAIs.
Specific education needs to be developed for psychiatric prescribers targeting their knowledge
deficits, uninformed attitudes, and poor prescribing practices that are barriers to the utilization of
LAIs (Correll et al., 2016). If the barriers are not addressed, LAIs will continue to be
underutilized in clinical practice and deprive those with schizophrenia of pharmacological
treatment options that improve outcomes.
The clinical problem that serves as the basis for this Doctor of Nursing Practice (DNP)
research project was outlined. By establishing the background to the underutilization of LAIs due
c a c
e c be
edge def c ,
f
ed a
de , a d
ec b g
practices, it will prove the importance of this DNP research project. Review of the problem
statement, research question, hypothesis, definition of terms, need for the study, the significance
of the problem, assumptions, and limitations will serve to highlight the necessity for the
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development of a web-based educational toolkit aimed at improving the knowledge, attitudes,
and practices of psychiatric prescribers regarding LAIs.
Background of the Problem
Schizophrenia is a chronic, debilitating, severe mental illness that affects approximately
20 million individuals in the United States (NIMH, 2018). It is a leading cause of disability
(NIMH, 2018) and is estimated to cost the United States approximately 155 billion dollars
related to healthcare, lost productivity, and unemployment (Cloutier et al., 2013). In addition to
schizophrenia being a mental illness, it is also a medical illness with neurodevelopmental and
neurodegenerative mechanisms (Kaplan et al., 2013; Nasrallah, 2018). The symptoms of
schizophrenia are manifested as behavioral abnormalities that have significant psychosocial
consequences for those afflicted. The ripple effect of schizophrenia is far-reaching and
encompasses patients, families, communities, and the economy of health care.
The course of schizophrenia is marked by periods of remission and relapse. Relapse in
schizophrenia is associated with incarceration, homelessness, suicide, violence, mortality, and
morbidity (Hamer, 2006). The prevention of relapse in schizophrenia remains an enormous
public health challenge worldwide, and improvements in this area can have tremendous impact
on morbidity, mortality, and quality of life, as well as direct and indirect health ca e c
(Kane
et. al, 1998, p. 55).
Patients that are non-adherent to oral antipsychotic medication have five times the risk of
relapse (Caseiro et al., 2012 as cited in Morrissette & Stahl, 2012). Non-adherence to
antipsychotic medication occurs for various reasons, including side effects and continuing
psychotic cognitive processing" (Limandri, 2019, p. 7). Relapse into psychosis due to nonadherence to antipsychotic medication can result in "neurotoxicity and neurodegeneration with a
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progressive loss of gray matter and ventricular dilation with each psychotic episode" (Jeon et al.,
2005 as cited in Hamer, 2006, p. 2). If those with schizophrenia decrease or discontinue
prescribed antipsychotic medication, their relapses into psychosis become more frequent, more
severe (Hamer, 2006) and worsen the course of illness over time (Haddad et al., 2014).
Prevention of relapse and pursuit of meaningful recovery are treatment goals for those
with schizophrenia; both goals are contingent upon continued adherence with prescribed
antipsychotic medication. Relapse, rehospitalization, reduced quality of life, poor outcomes, high
economic costs, and worsening of the course of illness are all associated with non-adherence to
antipsychotic medications (Haddad et al., 2014). Non-adherence to antipsychotic medication is a
prevalent problem for those who have schizophrenia and a clinical challenge for psychiatric
prescribers (Desai & Nayak, 2019; Lasser et al., 2009).
Those with schizophrenia require uninterrupted, long-term pharmacological management
with antipsychotic medication to treat the illness, attain stability, prevent relapse, and promote
recovery. LAIs are evidence-based, long-term pharmacological treatment options that assure
continuous antipsychotic medication therapy and serve as a practical solution to non-adherence
in those with schizophrenia. The pharmacokinetics of LAIs offer advantages over oral
antipsychotics, including consistent bioavailability of the antipsychotic due to prolonged dosing
intervals and a reduction in peak and trough plasma levels (Brissos et al., 2014 as cited in
Samalin et al., 2016; Geerts & Schreiner, 2013).
Schizophrenia treatment guidelines from the American Psychiatric Association (APA),
Florida Best Practice Psychotherapeutic Medication Guidelines for Adults, National Institute for
Health and Clinical Excellence (NICE), Texas Medication Algorithm Project (TMAP), and
World Federation of Societies of Biological Psychiatry (WFSBP) advocate for the use of LAIs in
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patients with schizophrenia that are non-adherent to antipsychotic medication (APA, 2019;
Florida Medicaid Drug Therapy Management Program for Behavioral Health, 2018; Hasan et al.,
2013; NICE, 2013; TMAP, 2008) and experts in the pharmacological management of
schizophrenia advocate for the broader use of LAIs in the treatment of those with schizophrenia
(Nasrallah, 2018). Research reveals that LAIs are effective at decreasing psychotic symptom
severity, relapses, rehospitalizations, and ER visits while improving adherence in those with
schizophrenia (Buckley et al., 2014; Lafeulle et al., 2013; Lafeulle et al., 2016; Lin et al., 2019;
Poloni et al., 2019; Subotnik et al., 2015).
LAIs are underutilized treatment options for schizophrenia that are supported by experts,
clinical guidelines, and research. Underutilization of LAIs denies those with schizophrenia of a
pharmacological treatment option with many benefits. The reasons for the underutilization of
LAIs are not entirely understood. However, research that examined the views psychiatric
prescribers had of LAIs hypothesized that contributing factors to the problem were their
knowledge deficits, uninformed attitudes, and poor prescribing practices (Ciglar et al., 2016;
Correll et al., 2016; Heres et al., 2006, Iyer et al., 2013a; Iyer et al., 2013b; Llorca et al., 2013;
Miles et al., 2011; Patel et al., 2003; Patel et al., 2020; Sajatovic et al., 2018a; Sajatovic et al.,
2018b; Samalin et al., 2013; Weiden et al., 2015). Many psychiatric prescribers believe LAIs are
coercive and that patients will reject them as a treatment option (Iyer et al., 2013b). The attitudes
held by psychiatric prescribers about LAIs often prevent patients from learning about or being
offered a LAI as a treatment option (Correll et al., 2016). Psychiatric prescribers need education
about LAIs to correct their knowledge deficits, uninformed attitudes, and poor prescribing
practices that lead to the underutilization of LAIs in clinical practice. There is a gap in the
literature regarding effective educational interventions to target the knowledge deficits,
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uninformed attitudes, and poor prescribing practices of psychiatric prescribers that are barriers to
the use of LAIs.
The Knowledge to Action Framework assists in bringing evidence into clinical practice
(Graham et al., 2006), and toolkits are a tangible example of the framework in action. Toolkits
are effective educational methods for prescribers (Yamanda et al., 2015), and if within a webbased form, are easily accessible to many for use. Web-based education is convenient and has
become a preferred model of delivering continuing education. With the emergence of the global
pandemic, COVID-19, and the practice of social distancing, all forms of education are moving
toward distance learning through web-based platforms. A web-based educational toolkit is an
appropriate intervention to reach psychiatric prescribers to address their knowledge deficits,
uninformed attitudes, and poor prescribing practices that are barriers to the use of LAIs.
Statement of the Problem
Long-acting injectable antipsychotics are underutilized in clinical practice due to the
knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers.
Research Question
Does a web-based educational toolkit have an effect on the knowledge, attitudes, and
practices of psychiatric prescribers regarding long-acting injectable antipsychotics?
Hypothesis
A web-based educational toolkit will have a positive effect on the knowledge, attitudes,
and practices of psychiatric prescribers regarding long-acting injectable antipsychotics.
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Definition of Terms
For clarity, the definition of essential terms used in this Doctor of Nursing Practice
(DNP) research project will be defined. The definition of terms are as follows:
1.Attitudes- a mental position regarding a fact ("Attitude", 2020).
2.Educational Toolkit-a grouping of multiple knowledge translation tools that provide specific
knowledge to educate and change behaviors (Yamada et al., 2015).
3.Knowledge- information and skills acquired from education and experience ("Knowledge,"
2020).
4.Long-Acting Injectable Antipsychotics (LAIs)- antipsychotic medications that are formulated
to be injected and are absorbed slowly, allowing for dosing intervals of up to three months
depending on the formulation. Available formulations in the United States are Abilify Maintena,
Aristada, Haldol Decanoate, Invega Sustenna, Invega Trinza, Perseris, Prolixin Decanoate,
Risperdal Consta, and Zyprexa Relprevv.
5.Practice- application of attained knowledge and skills ("Practice," 2020).
6.Psychiatric Prescriber- a person who prescribes psychiatric medications, usually a physician,
advanced practice nurse, or physician assistant ("Prescriber," 2020).
7.Web-Based- using the world wide eb ( Web-ba ed, 2020).
Need for the Study
Psychiatric prescribers can offer and utilize LAIs as a treatment option for those with
schizophrenia. Based on the evidence regarding the benefits of LAIs in the management of
schizophrenia, especially in those with non-adherence to antipsychotic medications, psychiatric
prescribers should routinely be offering LAIs as a treatment option (Llorca, 2013). Nevertheless,
LAIs remain underutilized due to knowledge deficits, uninformed attitudes, and poor prescribing
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practices amongst psychiatric prescribers. A gap in the literature exists regarding interventions
that could address the knowledge deficits, uninformed attitudes, and poor prescribing practices of
psychiatric prescribers that contribute to the underutilization of LAIs in clinical practice.
The DNP research project's purpose was to develop and evaluate a web-based educational
toolkit that would add to the future of healthcare by serving as an educational reference tool to
improve the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. The
project addressed a gap in the literature regarding effective educational interventions to target the
knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers that are barriers to the use of LAIs. The overarching goal was to create an
intervention that could change healthcare through the education of psychiatric prescribers.
This DNP research project met several American Association of Colleges of Nursing
(AACN) DNP essentials. T e
ec
e a
c ea e a eb-based educational toolkit
about LAIs for psychiatric prescribers as an intervention to positively affect their knowledge,
attitudes, and practices regarding LAIs; this was determined by assessing the baseline and impact
through a before and after knowledge, attitudes, and practices (KAP) questionnaire. Analysis of
the knowledge, attitudes, and practices about LAIs was completed through a literature review.
Evidence-based information was obtained, and informatics was incorporated in the development
of the web-based module which included the educational toolkit about LAIs. Justification for and
development of this project was based upon evidence-based research. Dissemination of this
evidence-based research project to psychiatric prescribers was constructed to eliminate
knowledge deficits, uninformed attitudes, and poor prescribing practices regarding LAIs and
create a long-term resource tool.
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Significance of the Problem
The percentage of individuals that are non-adherent to oral antipsychotics is high and
varies between 40 % to 90 % (Agid et al., 2010 as cited in Taylor et al., 2018). Medication nonadherence is a barrier to achieving positive outcomes for those with schizophrenia (Emsley,
2013), and psychiatric prescribers frequently overestimate compliance with oral antipsychotics
(Taylor et al., 2018). LAIs serve as a practical solution to the common problem of antipsychotic
non-adherence in those with schizophrenia and eliminate the negative consequences related to
medication non-adherence. However, even with a high percentage of patients with schizophrenia
that are non-adherent to oral antipsychotic medication, psychiatric prescribers are reluctant to
utilize LAIs due to a lack of knowledge about their use (Correll et al., 2016). In many cases,
psychiatric prescribers' knowledge deficits and uninformed attitudes about LAIs prevent the
practice of offering a LAI as a treatment option (Correll et al., 2016). In the United States, only
15-18 % of eligible patients with schizophrenia have been prescribed a LAI (Sajatovic et al.,
2018a).
Assumptions
It is assumed that LAIs are effective treatment options for those with schizophrenia and
ensure continuous adherence to antipsychotic medication for prolonged intervals of up to three
months. It is also assumed that by addressing the knowledge deficits, uninformed attitudes, and
poor prescribing practices of psychiatric prescribers regarding LAIs that it may lead to increased
utilization of LAIs, resulting in improved outcomes for those with schizophrenia.
Limitations
The project design had several limitations. Limitations included participants being
required to complete multiple steps to take part in the DNP research project and complete the
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necessary data collection. The topic was specific and not interesting to all psychiatric prescribers.
Due to the time constraints, the impact of the web-based educational toolkit on the utilization of
LAIs in psychiatric prescribers over time was not possible. Lastly, participants' recruitment was
ed
a
g
a
e
fe
a
g
ga
a
e be forum and via
email to psychiatric prescribers found by word of mouth.
Summary of the Problem
LAIs are underutilized in clinical practice in part due to psychiatric prescribers'
knowledge deficits, uninformed attitudes, and poor prescribing practices (Ciglar et al., 2016;
Correll et al., 2016; Heres et al., 2006; Iyer et al., 2013a; Iyer et al., 2013b; Llorca et al., 2013;
Miles et al., 2011; Patel et al., 2003; Patel et al., 2020; Sajatovic et al., 2018a; Sajatovic et al.,
2018b; Samalin et al., 2013; Weiden et al., 2015). LAIs are evidence-based treatment options
that are a practical solution to the common problem of medication non-adherence in those with
schizophrenia and offer unique advantages over oral antipsychotics. They can prevent the
negative consequences of untreated schizophrenia (Patel & David, 2005). The underutilization of
LAIs deprives those with schizophrenia of a treatment that research, experts, and clinical
guidelines support. Although there is limited research about the reasons for the underutilization
of LAIs in clinical practice, research has hypothesized that it is in part due to psychiatric
prescribers' knowledge deficits, uninformed attitudes, and poor prescribing practices. There is a
gap in the literature regarding effective interventions to address the known barriers to the use of
LAIs perpetuated by psychiatric prescribers. Web-based education and toolkits are effective,
convenient methods of educating healthcare providers like psychiatric prescribers, and offer a
possible way to eliminate the knowledge deficits, uninformed attitudes, and poor prescribing
practices of psychiatric prescribers that are barriers to the use of LAIs in clinical practice.
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Finding interventions to eliminate the barriers to the use of LAIs in clinical practice could
improve their utilization and, in turn, improve outcomes for those with schizophrenia.
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Chapter 2
Review of the Literature
This chapter is a review of the literature that focuses on LAIs. The research articles
included in the review underpin themes and the theoretical framework that support this
interventional DNP research project aimed at improving the knowledge, attitudes, and practices
of psychiatric prescribers regarding LAIs through a web-based educational toolkit. The themes
emphasize the importance of this interventional DNP research project whose aim was to
overcome the knowledge deficits, uninformed attitudes, and poor prescribing practices of
psychiatric prescribers that are barriers to the use of LAIs in clinical practice.
Process
A literature search was conducted using the following databases: Academic Search
Ultimate, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete,
Health Source: Nursing/Academic Edition, and Medline Complete. The term "long-acting
injectable antipsychotics" was searched in the title along with the keywords "doctors or nurse
practitioners or prescribers or physicians or psychiatrists" and "attitudes or practices or
knowledge." The search yielded 30 articles. "Toolkit or education or web-based" was added to
the search, and the generated results decreased to 2 articles. An additional search using the same
databases was completed using the keyword search terms "long-acting injectable antipsychotics"
and "barriers" and "doctors or physicians or psychiatrists or nurse practitioners or prescribers,"
which yielded 3 articles that were contained in the previous original search. Following a review
of the 30 articles from the database searches, it was found that many were duplicates or not
applicable. Six articles were evaluated and included in the review of the literature. Since the
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number of articles yielded by the search of databases was limited, hand searching was done and
garnered 21 additional articles, and 16 were included in the review.
Benefits of Long-Acting Injectable Antipsychotics Compared to Oral Antipsychotics
Studies comparing oral antipsychotics to LAIs have produced varied results, most likely
due to each study's sample selection and design (Miyamato & Wolfgang-Fleischhacker, 2017).
Studies using a traditional randomized-control design and studies with a practical design show
differing results. A unique benefit of LAIs is that they assure continuous medication compliance
for intervals of up to three months and eliminate the common problem of oral antipsychotic nonadherence in those with schizophrenia. Medication compliance is guaranteed in the sample of a
randomized-control study and may not accurately reveal outcomes for those with schizophrenia
that struggle with adherence. Therefore, in studies comparing oral antipsychotics to LAIs, the
study's design and sample must be considered when determining the real-world translation of the
results.
Rehospitalization/ER visits
Lin et al.(2019) compared the length of time to and rate of rehospitalization over a year in
13,087 patients with schizophrenia or schizoaffective disorder discharged from a Taiwan
psychiatric hospital on either a LAI or an oral antipsychotic. This observational, cohort,
retrospective chart review study found that a year past discharge, 60% of the patients on a LAI
were re-hospitalized compared to 64.6% of patients on an oral antipsychotic; and time to
rehospitalization was greater in the LAI group (Lin et al., 2019). This study was unique and
showed the superiority of LAIs when compared to oral antipsychotics in a natural setting as
opposed to a controlled environment which could minimize the advantage of LAIs by assuring
oral antipsychotic compliance (Lin et al., 2019).
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Lafeulle et al. (2013) conducted a retrospective, matched cohort study of 3,828 patients
with schizophrenia and compared the rehospitalization rate and emergency room (ER) utilization
in those that switched to a second-generation LAI to those that stayed on an oral antipsychotic.
Rehospitalization and ER visits were significantly lower in patients on a second-generation LAI
(Lafeulle et al., 2013). This study suggested that patients with schizophrenia were less likely to
be hospitalized or visit the ER if they were switched to a second-generation LAI from an oral
antipsychotic (Lafeulle et al., 2013).
Poloni et al. (2019) conducted a unique mirror analysis study that examined the length
and number of hospitalizations and the number of ER visits one year before and one year
following initiation of a LAI in 153 patients in Italy with a schizophrenia spectrum disorder. The
study showed that in the same group of patients, there was a decrease in the number and length
of hospitalizations and the number of ER visits during the 12 months following the introduction
of a LAI (Poloni et al., 2019). The findings highlighted the benefit of a LAI over an oral
antipsychotic within the same patient in decreasing ER visits and the number and length of
hospitalizations.
Relapse/Psychotic Symptom Severity
The PROACTIVE (Preventing Relapse Oral Antipsychotic Compared to Injectable
Evaluating Efficacy) study by Buckley et al. (2015) was a randomized clinical trial that studied
276 patients with schizophrenia or schizoaffective disorder over 30 months at 8 academic centers
in the United States and compared the rates of relapse in those that were taking a secondgeneration oral antipsychotic to those taking the second-generation LAI, Risperdal Consta. The
primary outcome was time to relapse, and the secondary outcomes were psychiatric symptom
severity and level of functioning (Buckley et al., 2015). The study concluded no significant
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difference in relapse rates between the LAI and oral groups (Buckley et al., 2015). However, the
LAI group showed a greater reduction in psychotic symptom severity over time (Buckley et al.,
2015). This study did not find LAIs to be more advantageous than oral antipsychotics in
preventing relapse but did reveal their superiority in reducing the severity of psychotic symptoms
over time.
Subotnik et al. (2015) conducted a randomized clinical trial comparing the effectiveness
of LAI Risperidone with oral Risperidone over 12 months in 86 patients with recent-onset
schizophrenia. Effectiveness was measured by psychotic exacerbation or relapse, and secondary
outcomes measured were psychiatric hospitalization, psychotic symptom control, and drug
discontinuation (Subotnik et al., 2015). Psychotic exacerbation or relapse rates were 5% in those
on LAI Risperidone compare to 33% in those on oral Risperidone (Subotnik et al., 2015). LAI
Risperidone was also associated with greater medication adherence and psychotic symptom
control than oral Risperidone (Subotnik et al., 2015). This study supported a LAI's superiority in
adherence, control of psychotic symptoms, and prevention of relapse.
Adherence
Lafeuille et al. (2016) conducted a longitudinal, retrospective, cohort study of 12,990
patients with schizophrenia, identified by Medicaid claim data, and assessed the effect baseline
characteristics had on medication adherence. Adherence was defined as attainment of the
Healthcare Effectiveness Data and Information Set (HEDIS) measure, which was considered the
proportion of days covered (PDC) with antipsychotic medication as more than or equal to 80%
(Lafeuille et al., 2016). Approximately 49% of study participants achieved defined adherence
over a year (Lafeuille et al., 2016). The baseline characteristic of being prescribed the LAI
Invega Sustenna was associated with a 26% increase in medication adherence (Lafeuille et al.,
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2016). This study showed that many patients on oral antipsychotics are non-adherent, and LAIs
are superior in attaining medication adherence.
The various studies reviewed show that LAIs are as effective as oral antipsychotics and,
in many cases, are more effective at increasing adherence and decreasing relapse,
hospitalizations, ER visits, and psychotic symptoms. However, in clinical practice, oral
antipsychotics are used more frequently than LAIs. More naturalistic studies need to be
conducted to establish the real utility of LAIs compared to oral antipsychotics.
P chia ic P e c ibe
K
ledge, A i de , a d P ac ice Rega di g L
g-Acting
Injectable Antipsychotics
Underutilization of LAIs in clinical practice is believed to be due in part to psychiatric
prescribers' attitudes toward LAIs (Miles et al., 2011), which are based on their knowledge and
affect their prescribing practices. A limited number of studies have investigated the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs. Understanding the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs is instrumental in determining
their influence on the underutilization of LAIs.
Ciglar et al.(2016) noted the underutilization of LAIs in clinical practice despite their
advantages and theorized that psychiatrists' attitudes likely impacted their prescribing practices.
They investigated 48 psychiatrists' attitudes in Croatia regarding LAIs via a questionnaire (Ciglar
et al., 2016). General attitudes toward LAIs were positive; 81.25% reported a tendency to
prescribe LAIs, and 91.66% considered LAIs to significantly contribute to the treatment of
schizophrenia (Ciglar et al., 2016). However, only 37.5% said they preferred LAIs over oral
antipsychotics, and 66.67 % believed patients preferred oral antipsychotics over LAIs (Ciglar et
al., 2016). Researchers concluded that even though psychiatric prescribers had positive attitudes
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toward LAIs, they also had unsupported beliefs about LAIs and limited utilization (Ciglar et al.,
2016).
Heres et al. (2006) conducted a survey study on 246 psychiatrists that examined why
LAIs were not chosen as a treatment option for those with schizophrenia or schizoaffective
disorder. Reasons for not prescribing LAIs included concern for extrapyramidal symptoms,
patient refusal, and beliefs that patients were adherent to their oral antipsychotic medication
(Heres et al., 2006). The survey also revealed that 64.5% of the psychiatrists e g b e a e
had never been offered a LAI (Heres et al., 2006). Researchers concluded that the reported
reasons for not prescribing LAIs were unsupported by evidence-based knowledge (Heres et al.,
2006).
In the first part of a two-part qualitative study by Iyer et al. (2013b), the attitudes of 24
psychiatrists from Canada regarding LAIs were explored through a questionnaire and focus
group. Information gleaned from the questionnaires revealed that psychiatrists prescribed oral
antipsychotics more than LAIs, did not frequently offer LAIs as a treatment option, had limited
LAI prescribing experience, and would only prescribe a LAI if there were no other option (Iyer
et al., 2013b). Psychiatrists reported believing that patients would refuse LAIs, be unconvinced
about their benefits, fear pain, be aversive to needles, and interpret the suggestion of their use as
a lack of trust by the psychiatrist (Iyer et al., 2013b). Researchers hypothesized that psychiatric
prescribers' lack of knowledge and experience with LAIs, lack of offering of LAIs to patients,
and personal biases about LAIs might contribute to their underutilization of LAIs (Iyer et al.,
2013b).
In the second part of the two-part qualitative study by Iyer et al. (2013a), patients with
psychosis in Canada were examined to determine their perceptions about LAIs. Thirty-four
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KAP OF PSYCHIATRIC PRESCRIBERS
patients at multiple sites provided their views on LAIs through a questionnaire and focus group
(Iyer et al., 2013a). Patient perspective themes identified were unawareness and lack of
understanding of LAIs, negative perceptions of LAIs, cost and convenience issues, and coercion
involved with the presentation of LAI treatment (Iyer et al., 2013a). This study identified patient
barriers to the use of LAIs, which could be mitigated by educating psychiatric prescribers on the
improved prescribing practices of discussing and offering LAIs to patients through shared
decision-making.
Miles et al. (2011) conducted a two-phase, qualitative study that examined psychiatrists'
attitudes and knowledge from New Zealand regarding the LAI Risperdal Consta and the impact
of their attitudes upon their prescribing practices. Data in the first phase was gathered from 16
psychiatrists by utilizing a focus group, and in the second phase, data was collected from 35
psychiatrists through a focus group based on the results of the phase one data (Miles et al., 2011).
In both phases, a gap was identified between the psychiatrists' knowledge about best practices
regarding LAIs and their reported prescribing practices (Miles et al., 2011). There were
significant discrepancies in psychiatrists' initiation, dosing, titration, and monitoring strategies,
indicating that utilizing the LAI Risperdal Consta was needed (Miles et al., 2011). Many
psychiatrists reported negative perceptions of the LAI Risperdal Consta and described it as a last
resort option, harmful to the psychiatrist-patient relationship, and unpleasant due to needle
administration (Miles et al., 2011). This study revealed the varied and limited knowledge,
uninformed attitudes, and poor prescribing practices of psychiatric prescribers regarding the LAI
Risperdal Consta.
Patel et al. (2003) conducted a questionnaire study about the attitudes, beliefs, and
knowledge of 143 European psychiatrists regarding LAIs and how they impacted their utilization
26
KAP OF PSYCHIATRIC PRESCRIBERS
of LAIs. The study showed that 94% of psychiatrists surveyed knew LAIs prevented relapse,
91% knew they were as effective as oral antipsychotics, 81% knew they increased adherence,
69% believed they were not acceptable to patients, 48% thought they were stigmatizing, 40%
thought they were old fashioned, and 38% believed LAIs had more side effects than oral
antipsychotics (Patel et al., 2003). Researchers concluded that LAIs are underutilized in part due
to a dichotomy between psychiatric prescribers' knowledge and attitudes, which affects their
prescribing practices (Patel et al., 2003).
Patel et al. (2020) conducted a questionnaire study to investigate the beliefs and attitudes
of 136 European physicians regarding the acceptance and usage of LAIs for the treatment of
schizophrenia. Physicians reported an increase in their utilization of LAIs within the last five
years preceding the study but reported offering oral antipsychotic treatment more than LAIs
(Patel et al., 2020). The prescribing of LAIs was directly correlated to physician attitudes
regarding LAIs (Patel et al., 2020). The researchers concluded that psychiatric prescribers' poor
attitudes regarding LAIs influence patient acceptance of LAIs and, ultimately, psychiatric
prescriber usage (Patel et al., 2020).
Weiden et al. (2015) conducted an observational study that examined 33 psychiatristpatient conversations in which psychiatrists offered LAI therapy to determine if the conversation
impacted patient acceptance or refusal of a LAI. Analyses of the conversations revealed that 91%
focused on the actual injection or mode of delivery, and 9 % focused on the benefits of the LAI
(Weiden et al., 2015). Researchers also noted a tentative offer presented as an inconvenience and
not a beneficial treatment option (Weiden et al., 2015). Of the 33 offers to start a LAI, 67% of
the patients had a neutral or positive reaction; but only 50% of those with a positive or neutral
reaction agreed to start a LAI (Weiden et al., 2015). The study concluded that the low use of
27
KAP OF PSYCHIATRIC PRESCRIBERS
LAIs could be partially related to the ambivalence exhibited by psychiatric prescribers when
offering LAIs.
The research studies investigating the knowledge, attitudes, and practices of psychiatric
prescribers regarding LAIs revealed valuable information regarding the underutilization of LAIs
in clinical practice. Psychiatric prescribers have limited knowledge about and experience with
initiating, titrating, and managing LAIs. The attitudes held by psychiatric prescribers about LAIs
are often negative and associated with coercion, patient rejection, and harm to the prescriberpatient relationship. The prescribing practices of psychiatric prescribers are affected by their
attitudes and knowledge regarding LAIs. Oral antipsychotics are prescribed and offered more
than LAIs. Many psychiatric prescribers have never educated or offered those with schizophrenia
a LAI. If psychiatric prescribers offer LAIs, the benefits of the option are not highlighted.
Barriers to the use of LAIs are the knowledge deficits, uninformed attitudes, and poor
prescribing practices of psychiatric prescribers. Patients' choice of treatment and acceptance of
treatment is largely influenced by psychiatric prescribers' knowledge, attitudes, and practices.
Gap in the Literature Regarding Interventions to Improve the Knowledge, Attitudes, and
Practices of Psychiatric Prescribers Regarding LAIs
A gap in the literature exists between the knowledge deficits, uninformed attitudes, and
poor prescribing practices of psychiatric prescribers, which are barriers to the use of LAIs in
clinical practice, and interventions that could alleviate them. Psychiatric prescribers need
education about LAIs to correct their knowledge deficits, uninformed attitudes, and poor
prescribing practices that contribute to the underutilization of LAIs in clinical practice. The
management of LAIs can be complicated and requires specific knowledge about practical issues
such as dosing and switching to a LAI (Correll et al., 2016); there are insufficient data and
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KAP OF PSYCHIATRIC PRESCRIBERS
recommendations within the literature (Llorca et al., 2013). "Tailored education about LAIs
should be developed for different groups of professionals who interact with patients, including
physicians, nurse practitioners, nurses, physician assistants, pharmacists, social workers,
residents, peer counselors, and others" (Correll et al., 2016, p. 21). Psychiatric prescribers should
have easy access and evidence-based education about LAIs to offer and prescribe them as
treatment options for those with schizophrenia. Development of education to address psychiatric
prescribers' knowledge deficits, uninformed attitudes, and poor prescribing practices that prevent
LAIs from being utilized as a treatment option in those with schizophrenia is needed.
Development and Implementation of a Toolkit
Abdulrehman et al. (2019) addressed the problem of unrecognized and untreated iron
deficiency in pregnancy with the development and implementation of a toolkit for prescribers to
enhance iron deficiency identification and treatment in pregnancy (Abulrehman et al., 2019). The
toolkit's implementation resulted in improved study outcome measures (Abulrehman et al.,
2019). This study demonstrated the effectiveness of an educational toolkit for prescribers in
promoting positive practice changes.
Yamada et al. (2015) conducted a systematic review of the literature on toolkits to
evaluate their effectiveness as a knowledge translation strategy. The review included 39 research
studies, all of which used a toolkit as a knowledge translation strategy, but all had varying
methodologies and content (Yamada et al., 2015). Researchers concluded that a toolkit could be
an effective strategy to translate evidence into practice if the toolkit's content is based on
evidence, and the evaluation is thorough (Yamada et al., 2015).
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KAP OF PSYCHIATRIC PRESCRIBERS
Web-Based Education for Prescribers
Madsen et al. (2014) investigated the effects of a web-based educational module on
pediatric emergency medicine physicians' knowledge, attitudes, and behaviors regarding youth
violence. Researchers developed a short, web-based educational program about youth violence
(Madsen et al., 2014). The 18 participating pediatric emergency department physicians
completed a pre-module assessment, and one month later, a post booster module and postmodule assessment (Madsen et al., 2014). The pre and post-module assessments examined
knowledge and attitudes, and behavior changes were measured by a pre and post-module chart
review of youth violence patients for specific discharge instructions (Madsen et al., 2014).
Results indicated a significant increase in physician knowledge and attitudes regarding youth
violence (Madsen et al., 2014). Before the module, 1.6% of youths treated for violence-related
injuries were discharged with violence discharge instructions, and one month following the webbased module, 15.7% received youth violence discharge instructions (Madsen et al., 2014). This
study proved the utility of web-based education as a method that can positively affect physicians'
knowledge, attitudes, and behaviors.
Oliveira et al. (2017) conducted a study to evaluate the impact of an e-learning pediatric
cardiology course on the knowledge and user satisfaction of 62 doctors, nurses, and medical
students (Oliveira et al., 2017). The impact of the e-learning course using the learning platform,
Moodle®, was measured using a pretest and posttest; and user satisfaction was evaluated using a
questionnaire (Oliveira et al., 2017). The mean satisfaction rating of the e-learning course was
87% (Oliveira et al., 2017). In pretest scores, 67% passed, and in the posttest scores, 100%
passed (Oliveira et al., 2017). This study supported using an e-learning course on Moodle® as a
useful method to increase knowledge in health care providers.
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KAP OF PSYCHIATRIC PRESCRIBERS
Theoretical Framework: Knowledge to Action (KTA) Framework
The Knowledge to Action (KTA) Framework was the foundation of this DNP research
project. Graham et al. (2006) developed the KTA Framework as a guide to maximizing the
transfer of research findings into practice so patients receive the best evidence-based treatment.
Field et al. (2014) conducted a systematic review study about the KTA Framework. Ten studies
were identified and evaluated that utilized the framework to implemented health-focused
evidence-based treatment (Field et al., 2014). Researchers concluded that the KTA conceptual
framework could help facilitate bringing evidence into practice within the healthcare arena (Field
et al., 2014). The KTA process is flexible yet complex (Graham et al., 2006). It is composed of
two concepts, the knowledge creation and the action cycle (Graham et al., 2006). Illustration of
the framework shows the phases of the knowledge creation concept encircled by the action cycle
concept (Figure 1).
Knowledge Creation
This concept funnels through three phases. It begins with knowledge inquiry, moves to
knowledge synthesis, and ends with knowledge tools or products. The funneling reflects the
synthesis of knowledge to a useful product that meets identified needs (Graham et al., 2006).
Knowledge Inquiry. Knowledge inquiry represents "first-generation knowledge" or
primary studies on the problem being explored (Graham et al., 2006). Following an extensive
review of the literature obtained from the knowledge inquiry, it was found that the knowledge
deficits, uninformed attitudes, and poor prescribing practices of psychiatric prescribers contribute
to the underutilization of LAIs.
Knowledge Creation. Knowledge creation is considered "second generation knowledge"
and is a synthesis of all the information about the problem being explored in the knowledge
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KAP OF PSYCHIATRIC PRESCRIBERS
inquiry; it is typically composed of meta-analyses and systematic reviews (Graham et al., 2006).
The review of literature represents the knowledge creation phase.
Knowledge Tools or Products. Knowledge tools or products are considered "thirdgeneration knowledge" and are typically practice guidelines, protocols, and clinical pathways
(Graham et al., 2006). They are customized to meet the needs of those that will use the
knowledge tool (Graham et al., 2006). The web-based educational toolkit development regarding
LAIs was based upon information obtained from the knowledge inquiry and the knowledge
creation phases and served as a knowledge tool.
Action Cycle
This concept is a feedback loop that cycles through activities leading to implementing the
knowledge tool or product (Graham et al., 2006). The phases of the action cycle are the
identification of the problem; identification, review, and selection of knowledge, adapt
knowledge to the context, access barriers to use of the knowledge, monitor knowledge use,
evaluate outcomes, and sustain the knowledge use (Graham et al., 2006).
Identify Problem. Identification of the problem results from the knowledge inquiry and
determines if there is a gap in the literature that needs to be filled (Graham et al., 2006). For this
research project, the clinical problem identified was the underutilization of LAIs due to
knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers. A gap was identified in the literature regarding interventions to address the barriers
to the use of LAIs perpetuated by psychiatric prescribers, which led to this project's conception.
Adapt Knowledge to the Local Context. Adapting knowledge to a context involves
determining the importance of knowledge to a group and tailoring it to meet the group's needs
(Graham et al., 2006). Barriers to the use of LAIs perpetuated by psychiatric prescribers were
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KAP OF PSYCHIATRIC PRESCRIBERS
identified in the literature as knowledge deficits, uninformed attitudes, and poor prescribing
practices. Psychiatric prescribers have limited access to evidence-based education about the
complexities of prescribing LAIs, and the toolkit was developed by a psychiatric prescriber for
psychiatric prescribers.
Assess Barriers to Knowledge Use. Assessment of barriers to using the created
knowledge encourages targeting and overcoming barriers to disseminating the new knowledge
(Graham et al., 2006). Determining how to make psychiatric prescribers aware of the web-based
educational toolkit about LAIs was the primary barrier to dissemination. Using a network of
psychiatric prescribers through an online professional nursing organization member forum and
emails to known psychiatric prescribers found by word of mouth were chosen as means of
dissemination.
Select, Tailor, Implement Intervention. Selecting, tailoring, and implementing the
intervention based on the target group successfully implements and disseminates the new
knowledge based on the audience (Graham et al., 2006). The web-based educational toolkit was
tailored to target and overcome the knowledge deficits, uninformed attitudes, and poor
prescribing practices of psychiatric prescribers that contribute to the underutilization of LAIs.
Monitor Knowledge Use. Monitoring knowledge use is focused on determining if there
was a transfer of knowledge and is typically measured by a change in knowledge, attitudes, and
practices (Graham et al., 2006). This research project evaluated the toolkit's effectiveness by
measuring a change in knowledge, attitudes, and practices of psychiatric prescribers.
Evaluate Outcomes. Evaluating outcomes determines the impact of the new knowledge
on the problem identified (Graham et al., 2006). This project evaluated the impact of a webbased educational toolkit on psychiatric prescribers' knowledge, attitudes, and practices. Due to
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KAP OF PSYCHIATRIC PRESCRIBERS
the project's time constraints, the long-term outcome of a change in the utilization of LAIs in
clinical practice was not part of this project. However, changes to prescribing rates of LAIs by
psychiatric prescribers could be considered for investigation in the future.
Sustain Knowledge Use. Sustaining the use of the new knowledge created requires
evaluation of barriers to its use (Graham et al., 2006). Continued use of this web-based
educational toolkit would include incorporation into the curriculum of psychiatric prescriber
programs and endorsement by a professional practice organization. The toolkit would need to be
updated yearly to ensure that all the information is up to date, considering the rapid increase in
available LAIs over the last several years.
This review of literature detailed the KTA theoretical framework and themes of this
interventional DNP research project. Themes included benefits of LAIs over oral antipsychotics,
the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs, a gap in the
literature regarding interventions to eliminate barriers to the use of LAIs perpetuated by
psychiatric prescribers, web-based education, and toolkits. The themes and framework support
the importance of developing and evaluating a web-based educational toolkit aimed at improving
the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs.
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KAP OF PSYCHIATRIC PRESCRIBERS
Chapter 3
Methodology
The design and methods of this DNP research project, based on the KTA framework, will
be discussed. This DNP research project developed and evaluated the impact of a web-based
educational toolkit on psychiatric prescribers' knowledge, attitudes, and practices regarding
LAIs. The design and methods of this DNP research project assisted in answering the research
question, which asked if a web-based educational toolkit would have an effect on the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs. Participants took part in a webbased module composed of seven-parts. The setting, sample, ethical considerations,
instrumentation, data collection, and data analysis of this DNP research project will be detailed
in this chapter.
Research Design
This DNP research project had an interventional, one-group, before and after, quasiexperimental design. A web-based educational toolkit was developed to improve the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs. The intervention, a web-based
educational toolkit, was presented. A knowledge, attitudes, and practices (KAP) questionnaire
was conducted before and then after to determine the effect on participating psychiatric
prescribers' KAP questionnaire scores.
Setting
A seven-part web-based module, including the intervention and accompanying before
and after KAP questionnaire, was housed on the open-source learning management system,
Moodle®. The setting was any location where participants could access and complete the webbased module.
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KAP OF PSYCHIATRIC PRESCRIBERS
Sample
A convenience, purposive sample of psychiatric prescribers, recruited through an
invitation posted to an online professional nursing organization member forum and sent to the
email accounts of psychiatric prescribers found through word of mouth, was utilized. The only
criterion required to participate was a professional designation as a prescriber of psychiatric
medication. The only criterion that excluded an individual from participating was not being a
prescriber of psychiatric medication. A DNP research project recruitment announcement and
invitation were posted on an online professional nursing organization member forum and sent via
email to psychiatric prescribers located through word of mouth to recruit participants. The
invitation included the purpose of the DNP research project, a brief description of this DNP
research project, and a URL link to the open-source learning management system, Moodle®,
where the seven- part web-based module was housed.
Ethical Considerations
The Institutional Review Board of Edinboro University reviewed this DNP research
project before initiation and found it to be exempt. Permission was obtained from the
organization that governs the online professional nursing membership forum where the
recruitment announcement and invitation for participation in this DNP research project were
posted. All participants were voluntary, and online consent and verification as a prescriber of
psychiatric medication were obtained before the initiation of the web-based intervention.
Participants self-enrolled in the web-based module through Moodle®, which required the
provision of a personal email address, username, password, and acceptance of the Moodle® user
agreement. The demographic information collected was a range of years prescribing
medications, sex, age range, practice setting, and professional designation. Data retrieved from
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KAP OF PSYCHIATRIC PRESCRIBERS
participants was stored in the student researcher's password-protected Moodle® site, and a
personal email address identified the data. The data from Moodle® was de-identified from each
participant's email by assigning each email address a unique number from 1-100 before being
stored in an Excel and a Statistical Package for Social Science (SPSS) file on the student
researcher's password-protected computer. The Moodle® site and all data collected will be
retained for three years. No risks or discomfort were anticipated for participants except for the
time associated with completing the module, which was estimated to be approximately 30
minutes.
Instrumentation
To study the impact of the web-based educational toolkit on the knowledge, attitudes, and
practices of psychiatric prescribers regarding LAIs, the following tools were developed by the
student researcher:
(i). A web-based educational LAI toolkit and presentation were created using PowerPoint
and evidence-based information to enhance psychiatric prescribers' knowledge, attitudes, and
practices regarding LAIs. The toolkit was comprised of the following elements: an overview of
LAIs, review of evidence-based literature about LAIs, prescribing tables for each of the nine
LAIs available in the United States based on information from the manufacturers, websites
containing guidelines and an algorithm for the treatment of schizophrenia, manufacturer
websites, myths about LAIs, resources for psychiatric prescribers, advantages of LAIs,
disadvantages of LAIs, patient resources, and tips on how to engage patients in shared decisionmaking conversations about LAIs. The web-based educational toolkit and presentation were
housed on the open-source learning management system, Moodle®. Content validity of the webbased educational toolkit was established by submission to experts for evaluation and was based
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KAP OF PSYCHIATRIC PRESCRIBERS
on content, clarity, and organization. The consulted experts were a board-certified psychiatrist
and board-certified psychiatric mental health nurse practitioner. The toolkit was finalized
following suggested modifications from the consulted experts.
(ii). A 20-item KAP questionnaire was created using the content of the web-based
educational LAI toolkit (Appendix A). The KAP questionnaire was comprised of three subscales.
The first subscale included 11 knowledge questions. The second subscale included six attitude
questions. The third subscale included three practice questions. All questions were true or false.
The 20-item KAP questionnaire was based on a 56-item, pre-existing knowledge and attitudes
questionnaire regarding LAIs. Eleven of the 20-items in the KAP questionnaire were directly
used or modified from the pre-existing knowledge and attitudes questionnaire. The 56-item
questionnaire was based on and modified from a previous 44-item knowledge and attitudes
questionnaire, which had excellent reliability based on the test-retest method and moderate
internal reliability (Bawo, Omoaregba, Okonoda, Otefe, & Patel, 2012). Permission was obtained
from the author to utilize the knowledge and attitudes questionnaire. The content validity of the
newly created 20-item KAP questionnaire was established by submission to the previously
mentioned experts for suggestions and modifications. The questionnaire was tested for reliability
before its use by the test-retest method with a one-week interval and was found to have a good
intraclass correlation coefficient of .816.
(iii). A web-based module that consisted of seven-parts was created using the open-source
learning management system, Moodle®. Included in the web-based module was a brief
description of the research project and intervention, a question to verify each participant as a
prescriber of psychiatric medication with a yes or no option, a consent form with a yes or no
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KAP OF PSYCHIATRIC PRESCRIBERS
option, five multiple-choice demographic questions, the 20-item before KAP questionnaire, the
presentation of the web-based educational LAI toolkit, and the 20-item after KAP questionnaire.
Data Collection
Data was collected using the web-based, 20-item KAP questionnaire administered before
and after participants received access to the web-based educational toolkit presentation about
LAIs. In the KAP questionnaire, there were 20 questions, all true or false, correct answers got
one point, and incorrect answers got zero points. Knowledge questions were 1-11 (11 items),
attitudes questions were 12-17 (6 items), and practice questions were 18-20 (3 items). The range
for the total KAP score was 0-20, and the range for the three subscale scores were 0-11 for
knowledge KAP subscale score, 0-6 for attitudes KAP subscale score, and 0-3 for practices KAP
subscale score. Higher scores indicated better knowledge, more positive attitudes, and better
prescribing practices of the psychiatric prescribers regarding LAIs. Demographic data was
collected with five questions regarding age, sex, years prescribing medications, practice setting,
and professional designation (Appendix B). Verification that each participant consented to
participate and was a prescriber of psychiatric medication was completed by questions with a yes
or no response. All data was collected electronically by the web-based module created with and
housed on Moodle®.
The open announcement and invitation to participate in the DNP research project were
posted on the online professional nursing organization member forum and sent via email to
psychiatric prescribers found through word of mouth four times over three weeks. The
announcement and invitation provided a URL link to the web-based module on Moodle®, which
was available during the same three-week time frame. Before accessing the web-based module
on Moodle®, participants needed to become a registered user of Moodle® which required
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KAP OF PSYCHIATRIC PRESCRIBERS
consent to their user agreement, and creation of a username and password. The web-based
module included: a brief description of this DNP research project, question verifying the
participant as a prescriber of psychiatric medication with a yes or no option, consent form with a
yes or no option, demographic questions, before KAP questionnaire, presentation of the webbased educational LAI toolkit, and after KAP questionnaire.
Data collection was concluded after three weeks. Verification as prescriber of psychiatric
medication, consent, de
ga
c da a a d c e f
eac
a c a
KAP
e
a e
before and after they viewed the web-based educational toolkit presentation was collected by
Moodle® and stored in the Moodle® module. A personal email address identified each
participant's data. Email addresses were then de-identified by assigning each a unique numeric
code from 1 to 100 before transferring the data to an Excel file. After the data was de-identified,
it was also stored in both an Excel and a SPSS f e
e
de
e ea c e
c
e . All data
was password protected.
Data Analysis
The purpose of this data analysis was two-fold. The first was to determine if there were
differences in the knowledge, attitudes, and practices of psychiatric prescribers (measured using
the total and three subscales KAP scores) before and after the presentation of the web-based
educational toolkit about LAIs. The second was to determine if there were relationships between
changes of knowledge, attitudes, and practices (measured as the differences in the after and
before total and three subscales KAP scores) of psychiatric prescribers and any of their
demographic factors.
The data was imported into and analyzed using the Statistical Package for Social Science
(SPSS) version 23 for Windows (IBM Corp., Armonk, NY). Frequency tables were used to
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KAP OF PSYCHIATRIC PRESCRIBERS
summarize the KAP questionnaire responses and demographics of the participants. Descriptive
statistics, including mean, standard deviation, median, minimum, maximum, and range were
used to summarize the total and three subscales KAP scores before and after the presentation of
the web-based educational toolkit about LAIs.
Shapiro-Wilk tests were used to determine the normality of the data. As the data was not
normally distributed, non-parametric procedures, including Wilcoxon signed-rank tests, MannWhitney U tests, and Kruskal Wallis tests were applied (Field, 2013). Wilcoxon signed-rank
tests were performed to determine if there were differences in the knowledge, attitudes, and
practices (measured using the total and three subscales KAP scores) of psychiatric prescribers
before and then after the presentation of the web-based educational toolkit about LAIs. MannWhitney U tests (for categorical variables with two levels) and Kruskal Wallis tests (for
categorical variables with more than two levels) were used to determine if there were any
relationships between changes in knowledge, attitudes, and practices (measured as the
differences in the after intervention and the before intervention total and three subscales KAP
scores) of psychiatric prescribers and their demographic factors of age range, practice setting,
professional designation, range of years prescribing medications, and sex. For all the utilized
tests, a p-value of less than 0.05 indicated statistical significance. All p-values were two-sided.
Summary of Methodology
The design and methodology of this DNP research project, based on the KTA
Framework, were constructed to answer the research question that asked if the web-based
educational toolkit would have an effect on the knowledge, attitudes, and practices of psychiatric
prescribers regarding LAIs. The study was interventional with a quasi-experimental, one-group,
before and after design. Participants were a purposive, convenience sample of psychiatric
41
KAP OF PSYCHIATRIC PRESCRIBERS
prescribers recruited from an online professional nursing organization member forum and via
emails to psychiatric prescribers found through word of mouth. The module included a brief
description of the DNP research project, a question to verify each participant as a prescriber of
psychiatric medication, a consent form, demographic questions, before KAP questionnaire, a
presentation of the web-based educational LAI toolkit, and after KAP questionnaire. Data was
collected by the web-based module created with and housed on Moodle®. The data was analyzed
to determine if there were differences in the knowledge, attitudes, and practices of psychiatric
prescribers before and after the presentation of a web-based educational toolkit regarding LAIs
and to determine if there were relationships between changes in knowledge, attitudes, and
practices of the participants and their demographic factors.
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Chapter 4
Results and Discussion
In this chapter, this DNP research project's data analysis results will be presented and
discussed in detail. Justification of the sample size will be provided with the results of a priori
power analysis. The established research question will be answered based on the descriptive and
inferential statistical analysis of the obtained data. The results of the descriptive and inferential
statistical analysis will be displayed in tables. Discussion about the data and subsequent analysis
will include examining the findings in relation to the review of literature and the KTA
Framework of the study. The strengths and limitations of this DNP research project and its
implications for nursing practice will conclude this chapter.
Results
Power Analysis
A priori power analysis was conducted to determine the minimum number of participants
required for this DNP research project for a .80 power of finding statistically significant
differences in the knowledge, attitudes, and practices (measured using the total and three
subscales of KAP) of psychiatric prescribers before and after a presentation of the web-based
educational toolkit about LAIs, using the paired t-test family. The 0.80 for power analysis was
the desired power of the test, which means it was probable that the test would correctly reject the
null hypothesis when the null hypothesis was false (Cohen, 1988). The power analysis for the
paired t-test family was performed using G*power 3.1.9.4 (Faul et al., 2009) to determine the
minimum sample size that was needed for this DNP research project. For a large effect size of
0.8 (Cohen, 1988; Cohen, 1992) and an alpha level of 0.05, the minimum sample size needed to
achieve a 0.80 power was 15 participants. This DNP research project recruited 17 participants,
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KAP OF PSYCHIATRIC PRESCRIBERS
which was greater than the minimum sample size needed according to the power analysis to
detect the effects hypothesized in this DNP research project, and hence this DNP research project
had an adequate sample size.
Participant Demographics
A total of 25 participants registered for the study via Moodle®. Out of the 25 participants
that registered, eight were excluded from the data analysis. One participant completed data
collection but answered "no" to the question requesting consent to participate. Two participants
did not answer all the demographic questions. Lastly, five participants did not complete the after
KAP questionnaire. In the final data analysis, 17 participants were included after they consented
to participate, verified themselves as a prescriber of psychiatric medication, viewed the
intervention, and completed both the before and after KAP questionnaire.
Table 1 shows the demographics of the participants. Nearly 60% of the participants
(58.8%) were psychiatric nurse practitioners. Slightly over half of the participants (52.9%) were
51-65 years old. Most of the participants were female (76.5%) and practiced in outpatient
settings (88.2%). Over 40% of the participants (41.2%) had prescribed medications for 11-20
years.
Table 1
Demographics of the Participants
Variable
Professional designation
Age
N
%
Psychiatric nurse practitioner
10
58.8
Family nurse practitioner
6
35.3
Physician
1
5.9
20-35
2
11.8
44
KAP OF PSYCHIATRIC PRESCRIBERS
Sex
Years prescribing medications
Practice setting
36-50
4
23.5
51-65
9
52.9
66 and over
2
11.8
Female
13
76.5
Male
4
23.5
0-5
4
23.5
6-10
3
17.6
11-20
7
41.2
21 plus
3
17.6
Hospital
2
11.8
Outpatient
15
88.2
KAP Questionnaire Responses
Table 2 summarizes the percentage of participants with correct answers for each KAP
questionnaire item before and after the presentation of the web-based educational toolkit about
LAIs. For the knowledge KAP subscale (Q1-Q11), more participants had correctly answered six
questions (Q2, Q3, Q5, Q6, Q7, and Q11) after the intervention than before the intervention. Side
effects, initiation, plasma levels, duration of effect, pharmacokinetics, and advantages of LAIs
compared to oral antipsychotics were the content of the knowledge KAP subscale questions more
participants answered correctly after the intervention. One question, knowledge KAP subscale
(Q3), which asked about an opportune time to initiate a LAI, had the most remarkable
improvement in scores, with 35.3 % of participants answering the question correctly before the
intervention and 88.2% answering the question correctly after the intervention. Three questions
(Q1, Q9, Q10) had more participants answer incorrectly after the intervention than before the
45
KAP OF PSYCHIATRIC PRESCRIBERS
intervention. The questions pertained to patients that should be offered a LAI, expert
recommendations for the use of LAIs, and the steady state of a LAI.
For the attitudes KAP subscale (Q12-Q17), more participants had correctly answered 1
question (Q12) after the intervention than before the intervention. The content of the question
was regarding the patient preference of oral antipsychotics over LAIs. Before the intervention,
88.2% of participants correctly answered the question compared to 94.1% after the intervention.
For the practices KAP subscale (Q18-Q20), more participants had correctly answered two
questions (Q19 and Q20) after the intervention compared to before the intervention. Question 19
was related to the offering of LAIs to patients with a fear of needles. Before the presentation of
the web-based educational toolkit, 94.1% of participants answered the question correctly and
after 100% of participants answered correctly. Question 20 was regarding patients being offered
a LAI from the first episode of schizophrenia through recovery. Correct responses by
participants increased by 17.6 % after the presentation of the web-based educational toolkit
regarding LAIs.
Table 2
Percentage of Participants with Correct Answers for Each KAP Item
Item
Before the intervention
After the intervention
% change
Q1
17 (100)
16 (94.1)
-
Q2
16 (94.1)
17 (100)
+
Q3
6 (35.3)
15 (88.2)
+
Q4
17 (100)
17 (100)
Q5
15 (88.2)
16 (94.1)
+
Q6
16 (94.1)
17 (100)
+
46
KAP OF PSYCHIATRIC PRESCRIBERS
Q7
11 (64.7)
15 (88.2)
+
Q8
16 (94.1)
16 (94.1)
Q9
16 (94.1)
15 (88.2)
-
Q10
15 (88.2)
12 (70.6)
-
Q11
16 (94.1)
17 (100)
+
Q12
15 (88.2)
16 (94.1)
+
Q13
17 (100)
17 (100)
Q14
17 (100)
17 (100)
Q15
17 (100)
17 (100)
Q16
15 (88.2)
15 (88.2)
Q17
17 (100)
17 (100)
Q18
17 (100)
17 (100)
Q19
16 (94.1)
17 (100)
+
Q20
13 (76.5)
16 (94.1)
+
Note. Q1-Q11 are the knowledge KAP subscale questions, Q12-Q17 are the attitudes KAP
subscale questions, and Q18-Q20 are the practices KAP subscale questions. "% change"
quantifies the difference in the percentage of participants with correct answers before the
intervention and after the intervention, "-" indicating the percentage of participants with correct
answers before the intervention was greater than the percentage of participants with correct
answers after the intervention, "+" indicating the percentage of participants with correct answers
before the intervention was less than the percentage of participants with correct answers after the
e e
,ba
+
d ca
g e ce age f a c a
c
ec a
e bef e
e
47
KAP OF PSYCHIATRIC PRESCRIBERS
intervention was the same as the percentage of participants with correct answers after the
intervention.
Descriptive Statistics of KAP Questionnaire Data
Table 3 presents the descriptive statistics of the total and three KAP subscale scores
before and after the presentation of the web-based educational toolkit about LAIs. The results of
the Shapiro-Wilk tests indicated that except for the before total KAP scores (W = 0.919, p =
0.141), all the other data, including the before and the after knowledge KAP subscale scores, the
before and after attitudes KAP subscale scores, the before and after practices KAP subscale
scores, and the after total KAP scores, were not normally distributed (W ranged from 0.262 to
0.872, p < 0.05).
As not all data were normally distributed, median and range were used to summarize the
data. Median was used for the measure of central tendency, and range was used for the measure
of variation of the data. The median knowledge KAP subscale scores were 10 (range = 3) and 11
(range = 4) before and after the intervention, indicating participants had good knowledge
regarding LAIs before and after the intervention. The median attitudes KAP subscale scores were
6 (range = 2) and 6 (range = 2) before and after the intervention, indicating participants had
positive attitudes regarding LAIs before and after the intervention. The median practices KAP
subscale scores were 3 (range = 1) and 3 (range = 1) before and after the intervention, indicating
participants had good prescribing practices regarding LAIs before and after the intervention. The
median total KAP scores were 18 (range = 5) and 19 (range = 5) before and after the
intervention, indicating participants had good cumulative knowledge, attitudes, and practices
regarding LAIs before and after the intervention.
48
KAP OF PSYCHIATRIC PRESCRIBERS
Table 3
Descriptive Statistics of the Total KAP and Three KAP Subscales Scores
Shapiro-Wilk test
KAP scale
Knowledge
Attitudes
Practices
Total KAP
M
SD
Mdn
Range
Min
Max
W
df
P
Pre
9.59
0.80
10
3
8
11
0.872
17
0.024
Post
10.18
1.19
11
4
7
11
0.729
17
< 0.001
Pre
5.76
0.56
6
2
4
6
0.490
17
< 0.001
Post
5.82
0.53
6
2
4
6
0.391
17
< 0.001
Pre
2.71
0.47
3
1
2
3
0.579
17
< 0.001
Post
2.94
0.24
3
1
2
3
0.262
17
< 0.001
Pre
17.94
1.25
18
5
15
20
0.919
17
0.141
Post
18.94
1.43
19
5
15
20
0.758
17
0.001
Note. M=mean; SD=standard deviation; Mdn=median; Min=minimum Max=maximum; W=
Shapiro-Wilk test statistic ; df=degrees of freedom; P=p-value
Impact of the Web-Based Educational Toolkit on KAP Questionnaire Scores
Wilcoxon signed-rank tests were performed to determine if there were differences in the
knowledge, attitudes, and practices (measured using the total and three subscales scores of the
KAP questionnaire) of psychiatric prescribers before and after the presentation of the web-based
educational toolkit about LAIs. The results are presented in Table 4.
There was no statistically significant differences in the knowledge KAP subscale scores
(T = 81.50, Z = 1.904, p = 0.057, r = 0.461), attitudes KAP subscale scores (T = 1.00, Z = 1.000,
p = 0.317, r = 0.243), and practices KAP subscale scores (T = 1.00, Z = 1.000, p = 0.317, r =
0.243) before and after the presentation of the web-based educational toolkit about LAIs (Table
49
KAP OF PSYCHIATRIC PRESCRIBERS
4). However, there was a statistically significant difference in the total KAP scores before and
after the presentation of the web-based educational toolkit about LAIs (T = 110.00, Z = 2.933, p
= 0.003, r = 0.711; Table 4). In particular, participants had statistically significant higher total
KAP scores after the intervention (Mdn = 19, Range = 5) than before the intervention (Mdn = 18,
Range = 5) (Table 3).
Table 4
Results of Wilcoxon Signed-Rank Tests
KAP scale
N
T
Z
P
R
Knowledge
17
81.50
1.904
0.057
0.461
Attitudes
17
1.00
1.000
0.317
0.243
Practices
17
10.00
2.000
0.125
0.485
Total KAP
17
110.00
2.933
0.003
0.711
Note. N = sample size; T = Wilcoxon signed-rank test statistic; Z = standardized test statistic; p =
p-value. r = effect size, computed as |Z|/√𝑁, where Z is the standardized test statistic, and N is
the number of total observations (Tomczak & Tomczak, 2014).
Association Between Change in KAP and Participant Demographics
Mann-Whitney U tests (for categorical variables with two levels) and Kruskal Wallis
tests (for categorical variables with more than two levels) were used to determine if there were
relationships between the changes in knowledge, attitudes, and practices (measured as the
differences in the after and the before intervention total and three subscales KAP scores) of
psychiatric prescribers and their demographic factors, such as age range, professional
designation, range of years prescribing medications, practice setting, and sex. The results are
presented in Tables 5-9.
50
KAP OF PSYCHIATRIC PRESCRIBERS
Table 5 presents the results of Mann-Whitney U tests for determining if differences in the
total and three KAP subscales scores (After-Before) were associated with a professional
designation. The median differences for after the intervention and the before the intervention
knowledge KAP subscale scores were 1 (range = 3) and 1 (range = 4) for psychiatric nurse
practitioners and family nurse practitioners. There was no association between professional
designation and differences in the after and the before intervention knowledge KAP subscale
scores (U = 27.50, Z = -0.285, p = 0.776, r= 0.071).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0 (range = 1) and 0 (range = 0) for psychiatric nurse practitioners and family nurse
practitioners. There was no association between professional designation and differences in the
after and the before intervention attitudes KAP subscale scores (U = 27.00, Z = -0.775, p =
0.439, r = 0.194).
The median differences for the after and the before intervention practices KAP subscale
scores were 0 (range = 1) and 0 (range = 1) for psychiatric nurse practitioners and family nurse
practitioners. There was no association between professional designation and differences in the
after and the before practices KAP subscale scores (U = 37.00, Z = 1.121, p = 0.262, r = 0.280).
The median differences for the after and the before intervention total KAP scores were 1
(range = 3) and 1 (range = 3) for psychiatric nurse practitioners and family nurse practitioners.
There was no association between professional designation and differences in the after and the
before intervention total KAP scores (U = 26.50, Z = -0.403, p = 0.687, r = 0.101).
51
KAP OF PSYCHIATRIC PRESCRIBERS
Table 5
Results of Mann-Whitney U Tests for Determining if Differences in Total and Three
Subscales KAP Scores (After - Before) Were Associated with Professional Designation
Median (Range)
KAP scale
PMHNP
Mean rank
FNP
PMHNP
FNP
U
Knowledge 1 (3)
1 (4)
8.75
8.08
Attitudes
0 (1)
0 (0)
8.80
Practices
0 (1)
0 (1)
Total KAP
1 (3)
1 (3)
Z
P
R
27.50 -0.285
0.776
0.071
8.00
27.00 -0.775
0.439
0.194
9.67
7.80
37.00 1.121
0.262
0.280
8.85
7.92
26.50 -0.403
0.687
0.101
Note. PMHNP = Psychiatric NP, FNP = Family NP. n = 10 for PMHNP, n = 6 for FNP. U =
Mann-Whitney U test statistic; Z = standardized test statistic; p = p-value. r = effect size,
computed as |z|/√𝑁, where z is the standardized test statistic and N is the number of total
observations (Tomczak & Tomczak, 2014).
Table 6 presents the results of Kruskal-Wallis tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with age group. The median
differences for the after and the before knowledge KAP subscale scores were 1 (range = 2), 1
(range = 2), 1 (range = 3), and -0.5 (range = 3), for age group 20-35, 36-50, 51-65, and 66+.
There was no association between age group and differences in the after and the before
intervention knowledge KAP subscale scores (H(3) = 1.563, p = 0.668, ε2 = 0.098).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0 (range = 0), 0 (range = 0), 0 (range = 1), and 0 (range = 0), for age group 20-35,
36-50, 51-65, and 66+. There was no association between age group and differences in the after
and the before intervention attitudes KAP subscale scores (H(3) = 0.889, p = 0.828, ε2 = 0.056).
52
KAP OF PSYCHIATRIC PRESCRIBERS
The median differences for the after and the before intervention practices KAP subscale
scores were 0 (range = 0), 0 (range = 1), 0 (range = 1), and 0.5 (range = 1), for age group 20-35,
36-50, 51-65, and 66+. There was no association between age group and differences in the after
and the before intervention practices KAP subscale scores (H(3) = 1.325, p = 0.723, ε2 = 0.083).
The median differences for the after and the before intervention total KAP scores were 1
(range = 2), 1.5 (range = 2), 1 (range = 3), and 0 (range = 2), for age group 20-35, 36-50, 51-65,
and 66+. There was no association between age group and differences in the after and the before
intervention total KAP scores (H(3) = 1.902, p = 0.593, ε2 = 0.119).
Table 6
Results of Kruskal-Wallis Tests for Determining if Differences in Total and Three Subscales
KAP Scores (After - Before) Were Associated with Age Group
Median (Range)
KAP scale
20-35
ε2
36-50
51-65
66+
H
df
p
Knowledge 1 (2)
1 (2)
1 (3)
-0.5 (3)
1.563
3
0.668 0.098
Attitudes
0 (0)
0 (0)
0 (1)
0 (0)
0.889
3
0.828 0.056
Practices
0 (0)
0 (1)
0 (1)
0.5 (1)
1.325
3
0.723 0.083
Total KAP
1 (2)
1.5 (2)
1 (3)
0 (2)
1.902
3
0.593 0.119
Note. n = 2 for age group 20-35, n = 4 for age group 36-50, n = 9 for age group 51-65, and n = 2
for age group 66+. H = Kruskal Wallis test statistic; df = degrees of freedom; p = p-value. ε2 =
effect size, computed as H/((N2-1)/(N+1)), where H is the Kruskal Wallis test statistic and N is
the total number of observations (Tomczak & Tomczak, 2014).
Table 7 presents the results of Mann-Whitney U tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with sex. The median
53
KAP OF PSYCHIATRIC PRESCRIBERS
differences for the after and the before intervention KAP knowledge scores were 1 (range = 4)
and 0.5 (range = 3) for female and male. There was no association between sex and differences
in the after and the before intervention knowledge KAP subscale scores (U = 24.00, Z = -0.241, p
= 0.871, r = 0.014).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0 (range = 1) and 0 (range = 0) for female and male. There was no association
between sex and differences in the after and the before intervention attitudes KAP subscale
scores (U = 24.00, Z = -0.241, p = 0.871, r = 0.014).
The median differences for the after and the before intervention KAP practices scores
were 0 (range = 1) and 0 (range = 1) for female and male. There was no association between sex
and differences in the after and the before intervention practices KAP subscale scores (U =
26.50, Z = 0.077, p = 1.000, r = 0.005).
The median differences for the after and the before intervention total KAP scores were 1
(range = 3) and 1 (range = 3) for female and male. There was no association between sex and
differences in the after and the before intervention total KAP scores (U = 24.00, Z = -0.241, p =
0.871, r = 0.014).
Table 7
Results of Mann-Whitney U tests for Determining if Differences in Total and Three Subscales
KAP Scores (After-Before) Were Associated with Sex
Median (Range)
Mean rank
KAP scale
Female
Male
Female
Male
U
Z
P
R
Knowledge
1 (4)
0.5 (3)
9.15
8.50
24.00
-0.241
0.871
0.014
Attitudes
0 (1)
0 (0)
9.15
8.50
24.00
-0.241
0.871
0.014
54
KAP OF PSYCHIATRIC PRESCRIBERS
Practices
0 (1)
0 (1)
8.96
9.12
26.50
0.077
1.000
0.005
Total KAP
1 (3)
1 (3)
9.15
8.50
24.00
-0.241
0.871
0.014
Note. n = 13 for female, n = 4 for male. U = Mann-Whitney U test statistic; z = standardized test
statistic; p = p-value. r = effect size, computed as |z|/√𝑁, where z is the standardized test statistic,
and N is the number of total observations (Tomczak & Tomczak, 2014). * indicates significance
at the 0.05 level.
Table 8 presents the results of Kruskal-Wallis tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with years prescribing
medications. The median differences for the after and the before intervention knowledge KAP
subscale scores were 1 (range = 2), 1 (range = 1), 1 (range = 4), and 1 (range = 0), for years
prescribing medications 0-5, 6-10, 11-20, and 21+. There was no association between years of
prescribing medications and differences in the after and the before intervention knowledge KAP
subscale scores (H(3) = 3.379, p = 0.337, ε2 = 0.211).
The median differences for the after and the before intervention attitudes KAP scores
were 0 (range = 1), 0 (range = 0), 0 (range = 0), and 0 (range = 0), for years of prescribing
medications 0-5, 6-10, 11-20, and 21+. There was no association between years of prescribing
medications and differences in the after and the before intervention attitudes KAP subscale
scores (H(3) = 3.250, p = 0.355, ε2 = 0.203).
The median differences for the after and the before intervention practices KAP subscale
scores were 0 (range = 0), 0 (range = 1), 0 (range = 1), and 1 (range = 1), for years of practice 05, 6-10, 11-20, and 21+. There was no association between years of prescribing medications and
differences in the after and the before intervention practices KAP subscale scores (H(3) = 4.542,
p = 0.209, ε2 = 0.284).
55
KAP OF PSYCHIATRIC PRESCRIBERS
The median differences for the after and the before intervention total KAP scores were
1.5 (range = 2), 2 (range = 1), 1 (range = 3), and 1 (range = 1), for years of practice 0-5, 6-10,
11-20, and 21+. There was no association between years of prescribing medications and
differences in the after and the before intervention total KAP scores (H(3) = 3.929, p = 0.269, ε2
= 0.246).
Table 8
Results of Kruskal-Wallis Tests for Determining if Differences in Total and Three Subscales
KAP Scores (After - Before) Were Associated with Years of Prescribing medications
Median (Range)
KAP scale
0-5
6-10
11-20
21+
H
df
P
ε2
Knowledge
1 (2)
1 (1)
1 (4)
1 (0)
3.379
3
0.337
0.211
Attitudes
0 (1)
0 (0)
0 (0)
0 (0)
3.250
3
0.355
0.203
Practices
0 (0)
0 (1)
0 (1)
1 (1)
4.542
3
0.209
0.284
Total KAP
1.5 (2)
2 (1)
1 (3)
1 (1)
3.929
3
0.269
0.246
Note. n = 4 for years of practice 0-5, n = 3 for years of practice 6-10, n = 7 for years of practice
11-20, and n = 3 for years of practice 21+. H = Kruskal Wallis test statistic; df = degrees of
freedom; p = p-value. ε2 = effect size, computed as H/((N2-1)/(N+1)), where H is the Kruskal
Wallis test statistic, and N is the total number of observations (Tomczak & Tomczak, 2014).
Table 9 presents the results of Mann-Whitney U tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with practice setting. The
median differences for the after and the before intervention knowledge KAP subscale scores
were 1 (range = 0) and 1 (range = 4) for hospital and outpatient settings. There was no
56
KAP OF PSYCHIATRIC PRESCRIBERS
association between practice setting and differences in the after and the before intervention
knowledge KAP subscale scores (U = 12.00, Z = -0.475, p = 0.635, r = 0.115).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0.5 (range = 1) and 0 (range = 0) for hospital and outpatient settings. There was an
association between practice setting and differences in the after and the before intervention
attitudes KAP subscale scores (U = 7.50, Z = -2.739, p = 0.006, r = 0.664). Those participants
who practiced in a hospital setting had a statistically significant increase in attitudes KAP
subscale scores from before to after the web-based educational toolkit presentation compared to
the participants that practiced in outpatient settings.
The median differences for the after and the before intervention practices KAP subscale
scores were 0.5 (range = 1) and 0 (range = 1) for hospital and outpatient settings. There was no
association between practice setting and differences in the after and the before intervention
practices KAP subscale scores (U = 10.50, Z = -0.911, p = 0.362, r = 0.221).
The median differences for the after and the before intervention total KAP scores were 2
(range = 0) and 1 (range = 3) for hospital and outpatient settings. There was no association
between practice setting and differences in the after and the before intervention total KAP scores
(U = 4.00, Z = -1.742, p = 0.081, r = 0.422).
Table 9
Results of Mann-Whitney U Tests for Determining if Differences in Total and Three
Subscales KAP Scores (After-Before) Were Associated with Practice Setting
Median (Range)
KAP scale
Mean rank
Hospital Outpatient Hospital Outpatient U
Knowledge 1 (0)
1 (4)
10.50
8.80
12.00
Z
P
R
-0.475 0.635 0.115
57
KAP OF PSYCHIATRIC PRESCRIBERS
Attitudes
0.5 (1)
0 (0)
12.75
8.50
7.50
-2.739 0.006 0.664
Practices
0.5 (1)
0 (1)
11.25
8.70
10.50
-0.911 0.362 0.221
Total KAP
2 (0)
1 (3)
14.50
8.27
4.00
-1.742 0.081 0.422
Note. n = 2 for hospital, n = 15 for outpatient. U = Mann-Whitney U test statistic; z =
standardized test statistic; p = p-value. r = effect size, computed as |z|/√𝑁, where z is the
standardized test statistic, and N is the number of total observations (Tomczak & Tomczak,
2014). * indicates significance at the 0.05 level.
Discussion
The knowledge, attitudes, and practices of psychiatric prescribers play a vital role in
utilizing LAIs in clinical practice. Barriers to the use of LAIs in clinical practice are believed to
be the knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers (Ciglar et al., 2016; Correll et al., 2016; Heres et al., 2006, Iyer et al., 2013a; Iyer et
al., 2013b; Llorca et al., 2013; Miles et al., 2011; Patel et al., 2003; Patel et al., 2020; Sajatovic et
al., 2018a; Sajatovic et al., 2018b; Samalin et al., 2013; Weiden et al., 2015). There is a gap in
the literature regarding educational interventions to address the knowledge deficits, uninformed
attitudes, and poor prescribing practices of psychiatric prescribers. This DNP research project
was designed to develop and evaluate the impact of a web-based educational toolkit on
psychiatric prescribers' knowledge, attitudes, and practices regarding LAIs. The aim of this DNP
research project was to develop a web-based educational toolkit for psychiatric prescribers that
would improve their knowledge, attitudes, and practices regarding LAIs.
The research question of this DNP research project asked if the web-based educational
toolkit would have an effect on the knowledge, attitudes, and practices of psychiatric prescribers
regarding LAIs. The independent variable of this DNP research project was the presentation of
58
KAP OF PSYCHIATRIC PRESCRIBERS
the web-based educational toolkit regarding LAIs. The dependent variables were the knowledge,
attitudes, and practices of psychiatric prescribers. The outcome measures were the differences in
the median total and three KAP subscales scores of participants before and after the presentation
of the web-based educational toolkit regarding LAIs. It was hypothesized that the web-based
educational toolkit would have a positive effect on the knowledge, attitudes, and practices of
psychiatric prescribers regarding LAIs.
The data analysis of this DNP research project revealed that the web-based educational
toolkit regarding LAIs slightly improved the total and three subscales KAP scores of
participants. It also showed that the total and three subscales KAP scores were adequate before
and after the presentation of the web-based educational toolkit about LAIs (Table 3). The
improvement in the total KAP score was statistically significant, with a p-value of 0.003, but the
improvements in the three subscales KAP scores were not statistically significant (Table 4).
Changes in the total and three subscales KAP scores from before to after the web-based
educational toolkit presentation had no association with the participants' demographic factors
except for a relationship found between practice setting and changes in attitudes KAP subscale
scores of participants. Attitudes regarding LAIs had a statistically significant improvement
(p=0.006) for participants working in hospitals compared to participants practicing in an
outpatient setting following the presentation of the web-based educational toolkit about LAIs.
The findings of this DNP research project answered the research question and supported
the hypothesis. The web-based educational toolkit had a positive effect on the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs, as evidenced by the outcomes
of the improved total and three subscales KAP scores. However, improvements were slight and
only statistically significant when the totality of the improvements to knowledge, attitudes, and
59
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practices was combined as a total KAP score. Knowledge, attitudes, and practices are separate
concepts but culminate to have an overall impact on the utilization of LAIs by psychiatric
prescribers in clinical practice.
Even though baseline knowledge, attitudes, and practices of participants were adequate
before and after the intervention, the examination of the participants' KAP questionnaire
responses revealed specific areas of knowledge, attitudes, and practices regarding LAIs that were
impacted by the web-based educational toolkit. There was an improvement in knowledge KAP
subscale scores regarding side effects, plasma levels, duration of effect, pharmacokinetics, and
advantages of LAIs over oral antipsychotics. Several areas of knowledge deteriorated following
the presentation of the toolkit. Participants struggled with complex knowledge regarding expert
recommendations for the use of LAIs, steady states of LAIs, and appropriate patient candidates
for LAIs. If the toolkit were to be utilized in the future, changes would be made to focus on
knowledge areas that deteriorated since the content was complicated. The area of knowledge that
showed the greatest improvement by participants after the presentation of the web-based
educational toolkit was regarding initiation of a LAI before transitioning from a higher level of
care to a lower level of care. Only one area of improvement in attitudes was noted. Following the
web-based educational toolkit presentation, participants' attitudes improved concerning the belief
that patients only prefer oral antipsychotics. Prescribing practices improved related to the
practice of offering a LAI to a patient regardless of a fear of needles or their phase of illness.
In many ways, the results of this DNP research project supported aspects of the review of
literature, but in many ways, they contradicted the review of literature. The review of literature
revealed knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers regarding LAIs (Ciglar et al., 2016; Correll et al., 2016; Heres et al., 2006; Iyer et al.,
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2013a; Iyer et al., 2013b; Llorca et al., 2013; Miles et al., 2011; Patel et al., 2003; Patel et al.,
2020; Sajatovic et al., 2018a; Sajatovic et al., 2018b; Samalin et al., 2013; Weiden et al., 2015).
Contrary to the review of literature, the psychiatric prescribers of this DNP research project had
adequate knowledge, attitudes, and practices regarding LAIs, which may be related to the fact
that the sample of psychiatric prescribers within the review of literature were all psychiatrists and
in this DNP research project, most participants were primarily experienced nurse practitioners. It
raises questions about possible differences in education and training between psychiatrists and
nurse practitioners regarding LAIs. Other confounding factors that may have contributed to the
unexpected good baseline knowledge, attitudes, and practices of psychiatric prescribers
regarding LAIs in this DNP research study include the date of and the various countries' medical
culture in which the studies within the review of literature were conducted. This DNP research
project was based on a few studies from various countries conducted greater than five years ago.
The time-lapse may have led to improved knowledge, attitudes, and practice of psychiatric
prescribers. The difference in the medical culture in the United States compared to the medical
culture of other countries could result in differences in knowledge, attitudes, and practices
regarding LAIs amongst psychiatric prescribers.
The results indicated that web-based education and toolkits were effective methods to
transfer knowledge to psychiatric prescribers. It also demonstrated that the KTA Framework
assists in translating evidence into practice through the development of tailored educational
materials. The KAP questionnaire responses revealed specific deficits in knowledge, attitudes,
and practices of psychiatric prescribers that were supported by the review of literature.
Knowledge deficits identified by this DNP research project were related to side effects, plasma
levels, duration of effect, pharmacokinetics, advantages of LAIs over oral antipsychotics, and
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appropriate patient candidates for LAIs. Similar knowledge deficits regarding initiation, dosing,
titration, and monitoring of the LAI, Risperdal Consta, were identified in the study by Miles et
al. (2011). The only attitude that improved was the belief that patients always preferred oral
antipsychotics over LAIs. The belief that patients preferred oral antipsychotics was also found in
studies by Ciglar et al. (2016), Iyer et al. (2013b), and Patel et al. (2003). The prescribing
practice of psychiatric prescribers that was found to be poor based on the KAP questionnaire
responses was related to the practice of not offering LAIs due to fear of needles and the phase of
illness of the patient. This finding is similar to studies by Iyer et al. (2013b), Heres et al. (2006),
and Weiden et al. (2015) because they discovered that a lack of offering LAIs was a poor
prescribing practice of physicians that contributed to the underuse of LAIs in clinical practice.
Strengths and Limitations
The strength of this DNP research project is that if served to fill gaps in the literature
regarding LAIs. Few studies evaluated the knowledge, attitudes, and practice of psychiatric
prescribers regarding LAIs, and those that did only evaluated only psychiatrists and excluded all
other psychiatric prescribers. With the shortage of psychiatrists in the United States, many family
nurse practitioners, physician assistants, certified nurse specialists, and psychiatric nurse
practitioners prescribe psychiatric medications to treat those who have schizophrenia. To the
knowledge of this writer, this DNP research project serves as the first study to examine the
knowledge, attitudes, and practices of psychiatric prescribers other than psychiatrists. And there
has been no prior study that attempted to develop and evaluate an educational intervention to
address the gap in the literature regarding the knowledge deficits, uninformed attitudes, and poor
prescribing practices of psychiatric prescribers that are barriers to the utilization of LAIs in
clinical practice.
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Several limitations were associated with this DNP research project. The limitations were
related to the design, process, and recruitment strategy of the project. Any of the limitations may
have affected the results of the data analysis. Limitations within the project design included the
lack of a comparison group. The inclusion of a comparison group in the project's design would
have resulted in data that was representative of the intervention's effectiveness. Also, using one
group with one KAP questionnaire both before and after the intervention may have subjected
participants to sensitization and not revealed the true effect of the web-based educational toolkit
presentation about LAIs, but rather of the exposure to the KAP questionnaire.
The study's process was complex. Participants were required to have access to a
computer with internet capabilities and register as a Moodle® user. Independent completion of
multiple steps by the participants was necessary to finish the module and all data collection.
Many participants were excluded from data analysis due to missing portions of the required data
collection. This most likely occurred because participants were not automatically advanced but
rather had to advance to the next portion of data collection manually. Thus, making it easy to
skip portions of the data collection inadvertently. In addition, the process necessitated a
significant time commitment of at least 30 minutes.
Recruitment endeavors were unsuccessful and not representative of all psychiatric
prescribers. Efforts were made to maximize this DNP research project's visibility to potential
participants but were largely unsuccessful. Recruitment opportunities for psychiatric prescribers
other than nurse practitioners were limited and resulted in a sample that was not diverse. In
addition, the time frame and the specificity of the topic may have contributed to the lack of
participation and resultant small sample size. Those who participated in the DNP research project
were likely highly motivated, desirous of continuing education, and not fully representative of all
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psychiatric prescribers. Due to the limited number of participants and the sample not being
representative of all psychiatric prescribers, this DNP research project's generalizability is
limited.
Implications for Nursing Practice
This DNP research project contributes to the limited body of knowledge regarding LAIs
in many unique ways. It is significant to the profession of psychiatric nursing since it is the first
study that examined nurse practitioners' knowledge, attitudes, and practices regarding LAIs. It is
the only known study that developed a toolkit that targets the knowledge, attitudes, and practices
of psychiatric prescribers regarding LAIs. The developed web-based educational toolkit is
evidence-based and provides a useful resource for psychiatric prescribers regarding the
utilization of LAIs. It stands as a practical reference tool to guide psychiatric prescribers in the
process of prescribing a LAI. It supports web-based education and toolkits as effective
educational interventions to positively affect the knowledge, attitudes, and practices of
prescribers. Web-based education is a convenient, flexible, and effective form of education for
medical professionals. During the current COVID-19 pandemic, it has become necessary to
practice social distancing, making distance learning through web-based education essential.
Lastly, the completion of this DNP research project highlighted areas needing further
investigation regarding the underutilization of LAIs and acts as a catalyst for research regarding
LAIs.
This chapter reviewed the research question and answered it through the data analysis of
this DNP research project. This project aimed to develop and evaluate the impact of a web-based
educational toolkit on psychiatric prescribers' knowledge, attitudes, and practices regarding
LAIs. There were several limitations to this DNP research project, but the project's aim was
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obtained and resulted in several positive implications for psychiatric nursing. Several DNP
Essentials established by the American Association of Colleges of Nursing were utilized
throughout the planning, implementation, and analysis of this project.
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Chapter 5
Summary, Conclusions, and Recommendations
The DNP research project will be summarized in this chapter. Conclusions about this
project and the findings of the data analysis will be drawn. Dissemination strategies of the results
will be discussed. Recommendations for future research based on the findings of this DNP
research project will conclude this final chapter.
Summary of Findings
LAIs are useful pharmacologic tools in the fight against schizophrenia. Still, they are
underutilized in clinical practice due in part to the knowledge deficits, uninformed attitudes, and
poor prescribing practices of psychiatric prescribers (Ciglar et al., 2016; Correll et al., 2016;
Heres et al., 2006, Iyer et al., 2013a; Iyer et al., 2013b; Llorca et al., 2013; Miles et al., 2011;
Patel et al., 2003; Patel et al., 2020; Sajatovic et al., 2018a; Sajatovic et al., 2018b; Samalin et al.,
2013; Weiden et al., 2015). A review of the literature revealed few studies investigating the
issue. Studies that did examine the issue highlighted the specific unmet educational needs of
psychiatric prescribers regarding LAIs. There is a gap in the literature regarding effective
educational interventions to address the knowledge deficits, uninformed attitudes, and poor
prescribing practice of psychiatric prescribers that are barriers to the use of LAIs in clinical
practice. Toolkits and web-based education have shown promise in positively impacting
healthcare providers' knowledge, attitudes, and practices. Web-based education is convenient,
flexible, and necessary due to social distancing during the COVID-19 pandemic.
This DNP research project was based on the KTA Framework, which helped translate
evidence into practice through the knowledge creation and action cycle (Graham et al., 2006). It
was constructed to develop and evaluate the impact of a web-based educational toolkit on
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psychiatric prescribers' knowledge, attitudes, and practices regarding LAIs. The project aimed to
develop an effective educational intervention to eliminate barriers to the use of LAIs by
improving the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. It
was hypothesized that the web-based educational toolkit would have a positive effect on the
knowledge, attitudes, and practices of psychiatric prescribers. Findings of the data analysis of
this DNP research project indicated a slight improvement in knowledge, attitudes, and practices
of psychiatric prescribers following a presentation of the web-based educational toolkit regarding
LAIs, as evidenced by a difference in the before and the after total and three subscales KAP
scores. However, the only statistically significant difference was seen in the total KAP scores of
participants. There were not statistically significant differences in the before and the after three
subscales KAP scores. Changes in knowledge, attitudes, and practices of participants following
the presentation of the web-based educational toolkit had no association with participants'
demographic factors except for an associaition between improvement in attitudes amongst
participants practicing in a hospital compared to those practicing in an outpatient setting.
In assessing the baseline knowledge, attitudes, and practices of psychiatric prescribers
regarding LAIs, it revealed that contrary to the review of literature, psychiatric prescribers had
adequate baseline knowledge, attitudes, and practices regarding LAIs. However, the KAP
questionnaire examination indicated participants of this DNP research study had specific deficits
in their knowledge, attitudes, and practices regarding LAIs that were compatible with previous
studies. Due to the small sample that was not fully representative of all psychiatric prescribers
and its lack of a control group, this DNP research project's results have limited generalizability.
Despite this DNP research project's limitations, it was important to the body of knowledge
regarding LAIs. Although it wasn't the study's purpose, it stands as the only known study that has
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examined the knowledge, attitudes, and practices of psychiatric prescribers other than
psychiatrists. This DNP research project is also the first known study that attempted to create an
educational intervention aimed at improving the knowledge, attitudes, and practices of
psychiatric prescribers to eliminate barriers to the use of LAIs. The results of this DNP research
project indicated the effectiveness of the developed web-based educational toolkit at improving
the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. The web-based
educational toolkit regarding LAIs stands as an effective resource and support tool for
psychiatric prescribers.
Conclusions
In conclusion, this DNP research project answered the established research question.
Findings revealed that the developed and evaluated web-based educational toolkit could
eliminate barriers to the use of LAIs by providing a foundation for positive change to psychiatric
prescribers' knowledge, attitudes, and practices regarding LAIs. It contributed to the limited body
of knowledge regarding LAIs in unique ways by filling gaps in the literature. This DNP research
project is the first study that attempted to develop and evaluate an educational intervention
focused on eliminating the knowledge deficits, uninformed attitudes, and poor prescribing
practices of psychiatric prescribers that contribute to the underutilization of LAIs in clinical
practice. This DNP research project also stands as the only known study that investigated the
knowledge, attitudes, and practices of psychiatric prescribers other than psychiatrists and
revealed differences worthy of further investigation. Although the DNP research project
generated unique information with some significant findings, it is important to note that the
project had flaws that limit generalization. The study sample was small and not representative of
all psychiatric prescribers, and the design was not randomized. Still, this DNP research project
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serves as a platform for further investigation to guide research regarding knowledge, attitudes,
practices, web-based education, toolkits, and LAIs.
Recommendations for Further Research and Dissemination of Findings
This DNP research project indicated that the web-based educational toolkit slightly
improved the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. The
project can be considered feasible and should be implemented in a large randomized control trial
with a more diverse sample to validate the findings. A rigorous study with a control group would
more clearly demonstrate the independent effects of the web-based educational toolkit on the
knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs.
Based on this DNP research project's findings, additional gaps in the literature regarding
LAIs were identified and should be explored. This DNP research project was the first study that
examined the knowledge, attitudes, and practices of psychiatric prescribers other than
psychiatrists. The findings of this DNP research project did not agree with the review of
literature, which indicated that psychiatric prescribers had knowledge deficits, uninformed
attitudes, and poor prescribing practices regarding LAIs. Instead, the results of this DNP research
project showed that psychiatric prescribers had adequate baseline knowledge, attitudes, and
practices regarding LAIs. Since the psychiatric prescribers that comprised the participants of this
DNP research project were primarily nurse practitioners and not psychiatrists, it indicates a
possible difference in education and experience regarding LAIs amongst psychiatrists and nurse
practitioners. Further examination for differences in the knowledge, attitudes, and practices of
various psychiatric prescribers regarding LAIs should be pursued. Most importantly, research
exploring the low utilization rate of LAIs despite adequate knowledge, attitudes, and practices of
psychiatric prescribers could reveal valuable information in the pursuit of maximizing the use of
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LAIs in clinical practice. Lastly, a specific investigation into the practical application of the webbased educational toolkit should be conducted to determine if it influences psychiatric
prescribers' use of LAIs in clinical practice. The web-based educational toolkit could be used as
part of a protocol in a quality improvement project to maximize the use of LAIs in appropriate
patients.
This DNP research project supports web-based education and toolkits as methods to
increase the knowledge, attitudes, and practices of prescribers. Web-based education is valuable
for busy clinicians related to the convenience of asynchronous learning. Due to the COVID-19
pandemic, which necessitates social distancing, web-based education is a practical necessity.
Another advantage of web-based education in the form of a toolkit is that it can be widely and
rapidly disseminated through online resources and platforms. The web-based educational toolkit
about LAIs could easily be integrated into an existing curriculum for psychiatric prescribers.
This study serves as a model for future web-based medical education that supports evidencebased practice.
This DNP research study is a culmination of knowledge and experiences. It reflected the
AACN DNP essentials and was an attempt to improve healthcare indirectly through the
education of psychiatric prescribers. The intent was to positively impact the lives of those with
schizophrenia by educating the psychiatric prescribers that care for them.
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References
Abdulrehman, J., Lausman, A., Tang, G., Nisenbaum, R., Petrucci, J., Pavenski, K., Hicks, L., &
Sholzberg, M. (2019). Development and implementation of a quality improvement
toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A
before-and-after study. PLOS Medicine, 16(8), 1-12.
https://doi.org/10.1371/journal.pmed.1002867
American Psychiatric Association (APA). (2019). The American Psychiatric Association
practice guideline for the treatment of patients with schizophrenia.
https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guide
lines/schizophrenia.pdf
Attitude. (2020). In Merriam-Webser.com dictionary. https://www.merriamwebster.com/dictionary/attitude
Bawo, J., Omoaregba, J., Okonoda, K., Otefe, E., & Patel, M. (2012). The knowledge and
attitudes of psychiatrists towards antipsychotic long-acting injections in Nigeria.
Therapeutic Advances in Psychopharmacology, 2(5), 169-177.
Buckley, P., Schooler, N., Goff, D., Hsiao, J., Kopelowicz, A., Lauriello, J., Manschreck, T.,
Mendelowitz, A., Miller, D., Severe, J., Wilson, D., Ames, D., Bustillo, J., Mintz, J.,
&Kane, J. (2015). Comparison of SGA oral medications and long-acting injectable SGA:
The PROACTIVE study. Schizophrenia Bulletin, 41(2), 449-459.
Ciglar, M., Bjedov, S., & Malekovic, H. (2016). Attitudes of Croatian psychiatrists
towards long-acting injectable antipsychotics. Psychiatria Danubina, 28(3), 273-277.
71
KAP OF PSYCHIATRIC PRESCRIBERS
Cloutier, M., Aigbogun, M., Gueria, A., Nituleseu, R., Ramanakumar, A. Kanah, S., DeLuca,
M., Duffy, R., Legacy, S., Henderson, C., Francois, C., & Wu, E. (2013). The economic
burden of schizophrenia in the United States in 2013. The Journal of Clinical Psychiatry,
77(6), 764-771.
Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences. New York: Routledge.
Cohen, J. (1992). A power primer. Psychological bulletin, 112(1), 155-159.
Correll, C.U., Citrome, L., Haddad, P.M., Lauriello, J., Olfson, M., Calloway, S.M., & Kane,
J.M. (2016). The use of long-acting injectable antipsychotics in schizophrenia: evaluating
the evidence. Journal of Clinical Psychiatry, 77(supplement 3), 1-24.
Dx.doi.org/10.4088/JCP.15032su1
Desai, R., & Nayak, R. (2019). Effects of medication non-adherence and comorbidity on health
resource utilization in schizophrenia. Journal of Managed Care Spec Pharm, 25(1), 37-34.
Emsley, R., Chiliza, B., Asmal, L., & Harvey, B.H. (2013). The nature of relapse in
schizophrenia. BioMed Central Psychiatry, 13(50), 1- 8.
http://www.biomedcentral.com/1471-244x/13/50
Faul, F., Erdfelder, E., Buchner, A., & Lang, A.G. (2009). Statistical power analyses using
G*Power 3.1: Tests for correlation and regression analyses. Behavior Research
Methods, 41, 1149-1160.
Field, A. (2013). Discovering statistics using IBM SPSS statistics. Washington, DC: Sage.
Field, B., Booth, A., Llott, I., & Gerrish, K. (2014). Using the knowledge to action
framework in practice: a citation analysis and systematic review. BioMed Central, 9(172)
http://www.implementationsciende.com/content/9/1/172
72
KAP OF PSYCHIATRIC PRESCRIBERS
Florida Medication Drug Therapy Management Program for Behavioral Health. (2018). Florida
best practice psychotherapeutic medications: Guidelines for adults.
http://www.medicaidmentalhealth.org/_assets/file/Guidelines/2018Psychotherapeutic%20Medication%20Guidelines%20for%20Adults%20wit
h%20References.pdf
Graham, I.D., Logan, J., Harrison, M.B., Straus, S.E., Tetroe, J., Caswell, W., & Robinson, N.
(2006). Lost in knowledge translation: Time for a map? The Journal of Continuing
Education in the Health Professions, 26, 13-24.
Haddad, P., Brain, C., & Scott, J. (2014). Nonadherence with antipsychotic medication in
schizophrenia: challenges and management strategies. Patient-Related Outcome
Measures, 5, 43-62.
Hamer, A. (2006). Medication noncompliance and partial compliance: Identifying
contributing factors methods for improvement. Psychiatric Times, (April), 1-4.
Hasan, A., Falka, P., Wobrock, T., Liebernar, J., Glenthoj, B., Gattaz, W.F., Thibaut, F., &
Moller, H, J. (2013). World Federation of Societies of Biological Psychiatry (WFSBP)
guidelines for biological treatment of schizophrenia, part 2: Update 2012 on the longterm treatment of schizophrenia and management of antipsychotic-induced side-effects.
The World Journal of Biological Psychiatry, 14, 2-44.
Heres, S., Hamann, J., Kissling, W., & Leucht, S. (2006). Attitudes of psychiatrists toward
antipsychotic depot medication. Journal of Clinical Psychiatry,67(12), 1948-1953.
73
KAP OF PSYCHIATRIC PRESCRIBERS
Iyer, S., Banks, N., Roy, M., Tibbo, P., Williams, R., Manchanda, R., Chue, P., & Malla, A.
(2013a). A qualitative study of experiences with and perceptions regarding long-acting
injectable antipsychotics: Part -patient perspectives. Canadian Journal of Psychiatry,
58(5 supplement 1), 14S-22S.
Iyer, S., Banks, N., Roy, M., Tibbo, P., Williams, R., Manchanda, R., Chue, P., & Malla, A.
(2013b). A qualitative study of experiences with and perceptions regarding long-acting
injectable antipsychotics: Part 2-physician perspectives. Canadian Journal of Psychiatry,
58(5 supplement 1), 22S-29S
Kane, J. M., Aguglia, E., Altamura, A. C., Ayuso Gutierrez, J. L., Brunello, N., Fleischhacker,
W. W., Gaebel, W., Gerlach, J., Guelfi, J. D., Kissling, W., Lapierre, Y. D., Lindström,
E., Mendlewicz, J., Racagni, G., Carulla, L. S., & Schooler, N. R. (1998). Guidelines for
depot antipsychotic treatment in schizophrenia. European Neuropsychopharmacology
Consensus Conference in Siena, Italy. European Neuropsychopharmacology : the
Journal of the European College of Neuropsychopharmacology, 8(1), 55 66.
https://doi.org/10.1016/s0924-977x(97)00045-x
Kaplan, G., Casoy, J., & Zummo, J. (2013). Impact of long-acting injectable antipsychotics on
medication adherence and clinical, functional, and economic outcomes of schizophrenia.
Patient Preference and Adherence, 7, 1171-1180.
Knowledge. (2020). In Merriam-Webster.com dictionary. https://www.merriamwebster.com/dictionary/knowledge
74
KAP OF PSYCHIATRIC PRESCRIBERS
Lafeulle, M., Laliberte-Auger, F., Lefebvre, P., Frois, C., Fastenau, & Duh, M. (2013). Impact
of atypical long-acting injectable versus oral antipsychotics on rehospitalization rates and
emergency room visits among relapsed schizophrenia patients: a retrospective database
analysis. BioMed Central, 13(221), 1-11. http://www.biomedcentral.com/1471244x/13/221.
Lafeulle, M., Frois, C., Cloutier, M., Duh, M., Lefebrve, P., Pesa, J., Clancy, Z., Fastenau, J., &
Durkin, M. (2016). Factors associated with adherence to the HEDIS quality measure in
Medicaid patients with schizophrenia. American Health & Drug Benefits, 9(7), 399-409.
Lasser, R.A., Schooler, N.R., Kujawa, M., Jarboe, K., Docherty, J., & Weiden, P. (2009). A new
psychosocial tool for gaining patient understanding and acceptance of long-acting
injectable antipsychotic therapy. Psychiatry, 6(4), 22-27.
Limandri, B. (2019). Long-acting injectable antipsychotic medications: Why aren't they used as
often as oral formulations? Journal of Psychosocial Nursing, 57(3), 7-10.
Lin, C., Chen, F., Chan, H., & Hsu, C. (2019). Time to rehospitalization in patients with
schizophrenia receiving long-acting injectable antipsychotics. International Journal of
Neuropsychopharmacology, 22(9), 541-547.
Llorca, P.M., Abbar, M., Courtet, P., Guillaume, S., Lancrenon, S., & Samalin, L.(2013).
Guidelines for the use and management of long-acting injectable antipsychotics in serious
mental illness. BioMed Central, 13(340), 1-17.
Madsen, T.E., Riese, A., Choo, E.K., & Ranney, M.L. (2014). Effects of a web-based
educational module on pediatric emergency medicine physicians' knowledge, attitudes,
and behaviors regarding youth violence. Western Journal of Emergency Medicine, 15(5),
615-622.
75
KAP OF PSYCHIATRIC PRESCRIBERS
Miles, S.W., Wheeler, A., & Davies, K. (2011). Determining what practicing clinicians believe
about long-acting injectable antipsychotic medication. International Journal of
Psychiatry in Clinical Practice, 15, 135-144.
Miyamoto, S., & Wolfgang-Fleischhacker, W. (2017). The use of long-acting injectable
antipsychotics in schizophrenia. Current Treatment Options in Psychiatry, 4(2), 117-126.
Morrissette, D.A., & Stahl, S.M. (2012). Optimizing outcomes in schizophrenia: long-acting
depots and long-term treatment. CNS Spectrums, 17, 10-21.
doi:10.1017/S1092852912000739
Nasrallah, H.A. (2018). Triple advantages of injectable long-acting second-generation
antipsychotics: Relapse prevention, neuroprotection, and lower mortality. Schizophrenia
Research, 197, 69-70. doi:10.1016/j.schres.2018.02.004
National Institute for Mental Health (NIMH). (2018). Schizophrenia.
https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml#part_154881
National Institute for Health and Care Excellence (NICE). (2014). Psychosis and schizophrenia
in adults: Prevention and management clinical guidelines.
https://www.nice.org.uk/guidance/cg178
Oliveira, A.C., Mattos, S., Coimbra, M. (2017). Development and assessment of an e-learning
course on pediatric cardiology basics. JMIR Medical Education, 3(1):e10. doi:
10.2196/mededu.5434
Patel, M.X., Bent-Ennakhil, N., Sapin, C., Di Nicola, S., Loze, J.Y., Nylander, A.G., & Heres, S.
(2020). Attitudes of European physicians towards the use of long-acting injectable
antipsychotics. BMC Psychiatry, 20(123) 1-11. https://doi.org/10/.1186/s12888-02002530-2
76
KAP OF PSYCHIATRIC PRESCRIBERS
Patel, M., & David, A. (2005). Why aren't depot antipsychotics prescribed more often, and
what can be done about it? Advances in Psychiatric Treatment, 11, 203-211.
http://apt.rcpsych.org/
Patel, M.X., Nikolaou, V., & David, A.S. (2003). Psychiatrists' attitudes to maintenance
medication for patients with schizophrenia. Psychological Medicine, 33, 83-89.
Poloni, N., Ielmini, M., Caselli, I., Lucca, G., Gasparini, A., Lorenzoli, G., & Callegari, C.
(2019). Oral antipsychotic versus long-acting injections antipsychotic in schizophrenia
spectrum disorder: a mirror analysis in a real-world clinical setting. Psychopharmacology
Bulletin, 49(2), 17-27.
Potkin, S., Bera, R., Zybek, D., & Lau, G. (2013). Patient and prescriber perspectives on longacting injectable (LAI) antipsychotics and analysis of in-office discussion regarding LAI
treatment for schizophrenia. BioMed Central, 13(261), 1-11.
http://www.biomedcenteral.com/1471-244x/13/261
Practice. (2020). In Merriam-Webster.com dictionary. https://www.merriamwebster.com/dictionary/practice
Prescriber. (2020). In Merriam-Webster.com dictionary. https://www.merriamwebster.com/medical/prescriber
Psychiatric nurse practitioner. (2020). In Wikipedia.com.
https://en.wikipedia.org/wiki/Psychiatric-mental_health_nurse_practitioner
Sajatovic, M., Ross, R., Legacy, S., Byerly, M., Kane, J., DiBiasi, F., Fitzgerald, H., Correll, C.,
(2018a). Initiating/maintaining long-acting injectable antipsychotics in
schizophrenia/schizoaffective or bipolar disorder-expert consensus survey part 2.
Neuropsychiatric Disease and Treatment, 14, 1475-1492.
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Sajatovic, M., Ross, R., Legacy, S., Correll, C., Kane, J., DiBiasi, F., Fitzgerald, H., Byerly, M.
(2018b). Identifying patients and clinical scenarios for the use of long-acting injectable
antipsychotics-expert consensus survey part 1. Neuropsychiatric Disease and Treatment,
14, 1463-1474.
Samalin, L., Charpeaud, T., Blanc, O., Heres, S., & Llorca, P.M. (2013). Clinicians' attitudes
toward the use of long-acting injectable antipsychotics. The Journal of Nervous and
Mental Disease, 201(7),553-559.
Samalin, L., Garnier, M., Auclair, C., & Llorca, P. (2016). Clinical decision- making in the
treatment of schizophrenia: Focus on long-acting injectable antipsychotics. International
Journal of Molecular Sciences, 17(1935), 1-8. doi:10.3390/imjms17111935
Subotnik, K.L., Casaus, L.R., Ventura, J., Luo, J.S., Hellemann, G.S., Gretchen- Doorly, D.,
Marder, S., & Nuechterlein, K.H. (2015). Long-acting injectable Risperidone for relapse
prevention and control of breakthrough symptoms after a recent first episode of
schizophrenia: A randomized clinical trial. JAMA Psychiatry, 72(8), 822-829.
Taylor, D.M., Velaga, S., & Werneke, U. (2018). Reducing the stigma of long-acting injectable
antipsychotics-current concepts and future developments. Nordic Journal of Psychiatry,
72(51), 536-539.
Texas Medication Algorithm Project (TMAP). (2008). Schizophrenia algorithm procedural
manual. https://www.cdphp.com/-/media/files/providers/behavioral-health/hedis-toolkitand-bh-guidelines/tmap-schizophrenia.pdf?la=en
Web-based. (2020). In dictionary.com. https://www.dictionary.com/browse/web-based
Tomczak, M., & Tomczak, E. (2014). The need to report effect size estimates revisited. An
overview of some recommended measures of effect size. TSS, 21(1), 19-25.
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Weiden, P.J., Roma, R.S., Velligan, D.I., Alphs, L., DiChiara, M., & Davidson, B. (2015). The
challenge of offering long-acting injectable antipsychotic therapies: A preliminary
discourse analysis of psychiatrist recommendations for Injectable therapy to patients with
schizophrenia. Journal of Clinical Psychiatry,76(6), 684-690.
Yamada, J., Shorkey, A., Barwick, M., Widger, K., Stevens, B.J. (2015). The effectiveness of
toolkits as knowledge translation strategies for integrating evidence into clinical care: a
systematic review. BMJ Open, 5, 1- 10. doi:10.1136/bmjopen-2014-006808
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APPENDIX A
Knowledge
1. Long-acting injectable antipsychotics are only for patients that have a history of medication
non-adherence. T or F
2. A long-acting injectable version of an antipsychotic causes more side effects than its oral
equivalent. T or F
3. A preferred time to start a long-acting injectable antipsychotic is during a transition from a
higher level to a lower level of care. T or F
4. If long-term use of an antipsychotic is necessary, a long-acting injectable antipsychotic should
be considered. T or F
5. There is less individual variation in plasma levels with a long-acting injectable antipsychotic
than an oral antipsychotic. T or F
6. In an adverse event, the duration of a long-acting injectable antipsychotic is a disadvantage. T
or F
7. The pharmacokinetics of long-acting injectable antipsychotics are based on elimination
pharmacokinetics as opposed to absorption pharmacokinetics. T or F
8. Long-acting injectable antipsychotics offer a practical solution for the common problem of
medication non-adherence in those with schizophrenia. T or F
9. Experts recommend limited use of long-acting injectable antipsychotics. T or F
10. An advantage of long-acting injectable antipsychotics is that they typically take a longer time
to reach a steady-state. T or F
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11. Long-acting injectable antipsychotics are more effective than oral antipsychotics at
decreasing rehospitalization rates, relapse rates, psychotic symptom severity, and ER visits. T or
F
Attitudes
12. Patients always prefer an oral antipsychotic over a long-acting injectable antipsychotic. T or
F
13. The practice of prescribing a long-acting injectable antipsychotic is coercive. T or F
14. Prescribing a long-acting injectable antipsychotic is not part of patient-centered care or
shared decision-making. T or F
15. Discussing a long-acting injectable antipsychotic will harm the established relationship with
a patient. T or F
16. Patients prescribed a long-acting injectable antipsychotic usually have a history of
noncompliance and incarceration. T or F
17. A long-acting injectable antipsychotic is an outdated form of pharmacological treatment for
those with schizophrenia. T or F
Practices
18. When discussing a long-acting injectable antipsychotic, both the advantages and
disadvantages should be discussed with the patient. T or F
19. If a patient has a fear of needles, a long-acting injectable antipsychotic should not be offered
as a treatment option. T or F
20. A long-acting injectable antipsychotic should be offered as a treatment option for those with
schizophrenia from the first episode of schizophrenia to those in recovery. T or F
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APPENDIX B
1. What is your age?
a. 20-35
b. 36-50
c. 51-65
d. 66 and over
2. What is your sex?
a. Male
b. Female
3. What is the number of years you have been prescribing medications?
a. 0-5
b. 6-10
c. 10-20
d. 21 plus years
4. What is your professional designation?
a. Physician
b. Psychiatric Nurse Practitioner
c. Physician Assistant
d. Nurse Specialist
e. Family Nurse Practitioner
5. What is your place of practice?
a. Hospital
b. College/University
c. Outpatient practice
d. Long-term care
e. Home care
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Figure 1. The Knowledge to Action Framework. From Graham I, Logan J, Harrison M,
Strauss S, Tetroe J, Caswell W, Robinson N: Lost in knowledge translation: Time for a
map? The Journal of Continuing Education in the Health Professions 2006, 26, (1), p. 19.
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Acknowledgments
I want to thank Dr. Jill Rodgers for her support and guidance throughout completing this DNP
research project. To my other committee members, Amanda Yost and Lisa Rovelli, your time
commitment, encouragement, and input into this project have been integral to its' conclusion.
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Development and Evaluation of a Web-Based Educational Toolkit on Knowledge,
Attitudes, and Practices of Psychiatric Prescribers
Lisa Lewis MSN, BSN, RN
Abstract
Long-acting injectable antipsychotics (LAIs) are underutilized pharmacological treatment
options for those with schizophrenia. Research examining psychiatric prescribers e a
with LAIs hypothesized that their knowledge deficits, uninformed attitudes, and poor prescribing
practices contribute to the underutilization of LAIs in clinical practice. There is a gap in the
literature regarding educational
e e
add e
c a c
e c be
edge
deficits, uninformed attitudes, and poor prescribing practices. The purpose of this Doctor of
Nursing Practice (DNP) research project, based on the Knowledge to Action Framework, was to
develop and evaluate the impact of a web-based educational toolkit on the knowledge, attitudes,
and practices of psychiatric prescribers. A seven-part web-based module that included a
presentation of the created educational toolkit regarding LAIs and a before and after knowledge,
attitudes, and practices questionnaire was hosted on an online-open source learning management
system and disseminated to psychiatric prescribers. Findings indicated that the web-based
educational toolkit slightly improved the knowledge, attitudes, and practices of psychiatric
prescribers regarding LAIs. It also revealed a relationship between a positive change in attitudes
and psychiatric prescribers practicing in a hospital setting. This DNP research project reflects the
essentials of the DNP degree. It contributes to the body of knowledge of psychiatric nursing,
created a lasting reference tool for prescribing LAIs, filled gaps in the literature regarding LAIs,
supports the use of continuing web-based education and toolkits, and serves as a catalyst for
other studies regarding LAIs.
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Keywords: Long-acting injectable antipsychotics, barriers to the use of LAIs, prescriber
knowledge, prescriber attitude, prescriber practices, web-based education, toolkit
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Table of Contents
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Appendix A: Knowledge, Attitudes, and Practices Questionnaire
Appendix B: Demographic Questions
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List of Appendices
Appendix
Page
A: Knowledge, Attitudes, and Practices Q e
a e
.79
B: Demographic Questions
.......................................................................81
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List of Figures
Figures
1: K
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Chapter 1
Introduction
"Long-acting injectable antipsychotics (LAIs) are among the most effective treatments in
psychiatry, yet they remain underutilized in clinical practice" (Correll et al., 2016, p. 6). The
primary pharmacological treatment for schizophrenia is an oral antipsychotic. However, nonadherence to oral antipsychotic medication is a common problem associated with relapse,
rehospitalization, and worsening of the course of schizophrenia (Haddad et al., 2014; Patel &
David, 2005). LAIs have unique pharmacokinetics and offer advantages over oral antipsychotics.
They were designed to serve as a practical solution to oral antipsychotic non-adherence in those
with schizophrenia (Patel & David, 2005). LAIs are long-term pharmacological treatment
options that assure continuous compliance with antipsychotic medication. They are an essential
yet underutilized tool for both psychiatric prescribers and patients in the fight against
schizophrenia.
Clinical guidelines for schizophrenia recommend using LAIs when non-adherence is a
concern (Kaplan et al., 2013). Research and experts support the broadened use of LAIs to
minimize the neurodegeneration and disability associated with untreated schizophrenia
(Nasrallah, 2018). Despite their benefits, unique pharmacokinetics, advantages over oral
antipsychotics, and support of their use by clinical guidelines, research, and expert guidance,
LAIs continue to be underutilized in clinical practice.
The underutilization of LAIs in clinical practice is not completely understood due to
limited research investigating the problem. Research studies that examined the knowledge,
attitudes, and practices of psychiatric prescribers hypothesized that barriers to the underuse of
LAIs are the knowledge deficits, uninformed attitudes, and poor prescribing practices of
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psychiatric prescribers (Ciglar et al., 2016; Correll et al., 2016; Heres et al., 2006; Iyer et al.,
2013a; Iyer et al., 2013b; Llorca et al., 2013; Miles et al., 2011; Patel et al., 2003; Patel et al.,
2020; Sajatovic et al., 2018a; Sajatovic et al., 2018b; Samalin et al., 2013; Weiden et al., 2015).
Those barriers prevent translation of the evidence supporting the use of LAIs into the practice of
prescribing them. LAIs are effective pharmacological treatment options for those with
schizophrenia that have the potential to decrease personal suffering, family burden, and societal
costs associated with the illness (Kane et al., 1998). However, knowledge deficits, uninformed
attitudes, and poor prescribing practices among psychiatric prescribers remain barriers to the
utilization of LAIs in clinical practice.
There is a gap in the literature regarding evidence-based interventions that positively
affect psychiatric prescribers' knowledge, attitudes, and prescribing practices regarding LAIs.
Specific education needs to be developed for psychiatric prescribers targeting their knowledge
deficits, uninformed attitudes, and poor prescribing practices that are barriers to the utilization of
LAIs (Correll et al., 2016). If the barriers are not addressed, LAIs will continue to be
underutilized in clinical practice and deprive those with schizophrenia of pharmacological
treatment options that improve outcomes.
The clinical problem that serves as the basis for this Doctor of Nursing Practice (DNP)
research project was outlined. By establishing the background to the underutilization of LAIs due
c a c
e c be
edge def c ,
f
ed a
de , a d
ec b g
practices, it will prove the importance of this DNP research project. Review of the problem
statement, research question, hypothesis, definition of terms, need for the study, the significance
of the problem, assumptions, and limitations will serve to highlight the necessity for the
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development of a web-based educational toolkit aimed at improving the knowledge, attitudes,
and practices of psychiatric prescribers regarding LAIs.
Background of the Problem
Schizophrenia is a chronic, debilitating, severe mental illness that affects approximately
20 million individuals in the United States (NIMH, 2018). It is a leading cause of disability
(NIMH, 2018) and is estimated to cost the United States approximately 155 billion dollars
related to healthcare, lost productivity, and unemployment (Cloutier et al., 2013). In addition to
schizophrenia being a mental illness, it is also a medical illness with neurodevelopmental and
neurodegenerative mechanisms (Kaplan et al., 2013; Nasrallah, 2018). The symptoms of
schizophrenia are manifested as behavioral abnormalities that have significant psychosocial
consequences for those afflicted. The ripple effect of schizophrenia is far-reaching and
encompasses patients, families, communities, and the economy of health care.
The course of schizophrenia is marked by periods of remission and relapse. Relapse in
schizophrenia is associated with incarceration, homelessness, suicide, violence, mortality, and
morbidity (Hamer, 2006). The prevention of relapse in schizophrenia remains an enormous
public health challenge worldwide, and improvements in this area can have tremendous impact
on morbidity, mortality, and quality of life, as well as direct and indirect health ca e c
(Kane
et. al, 1998, p. 55).
Patients that are non-adherent to oral antipsychotic medication have five times the risk of
relapse (Caseiro et al., 2012 as cited in Morrissette & Stahl, 2012). Non-adherence to
antipsychotic medication occurs for various reasons, including side effects and continuing
psychotic cognitive processing" (Limandri, 2019, p. 7). Relapse into psychosis due to nonadherence to antipsychotic medication can result in "neurotoxicity and neurodegeneration with a
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progressive loss of gray matter and ventricular dilation with each psychotic episode" (Jeon et al.,
2005 as cited in Hamer, 2006, p. 2). If those with schizophrenia decrease or discontinue
prescribed antipsychotic medication, their relapses into psychosis become more frequent, more
severe (Hamer, 2006) and worsen the course of illness over time (Haddad et al., 2014).
Prevention of relapse and pursuit of meaningful recovery are treatment goals for those
with schizophrenia; both goals are contingent upon continued adherence with prescribed
antipsychotic medication. Relapse, rehospitalization, reduced quality of life, poor outcomes, high
economic costs, and worsening of the course of illness are all associated with non-adherence to
antipsychotic medications (Haddad et al., 2014). Non-adherence to antipsychotic medication is a
prevalent problem for those who have schizophrenia and a clinical challenge for psychiatric
prescribers (Desai & Nayak, 2019; Lasser et al., 2009).
Those with schizophrenia require uninterrupted, long-term pharmacological management
with antipsychotic medication to treat the illness, attain stability, prevent relapse, and promote
recovery. LAIs are evidence-based, long-term pharmacological treatment options that assure
continuous antipsychotic medication therapy and serve as a practical solution to non-adherence
in those with schizophrenia. The pharmacokinetics of LAIs offer advantages over oral
antipsychotics, including consistent bioavailability of the antipsychotic due to prolonged dosing
intervals and a reduction in peak and trough plasma levels (Brissos et al., 2014 as cited in
Samalin et al., 2016; Geerts & Schreiner, 2013).
Schizophrenia treatment guidelines from the American Psychiatric Association (APA),
Florida Best Practice Psychotherapeutic Medication Guidelines for Adults, National Institute for
Health and Clinical Excellence (NICE), Texas Medication Algorithm Project (TMAP), and
World Federation of Societies of Biological Psychiatry (WFSBP) advocate for the use of LAIs in
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patients with schizophrenia that are non-adherent to antipsychotic medication (APA, 2019;
Florida Medicaid Drug Therapy Management Program for Behavioral Health, 2018; Hasan et al.,
2013; NICE, 2013; TMAP, 2008) and experts in the pharmacological management of
schizophrenia advocate for the broader use of LAIs in the treatment of those with schizophrenia
(Nasrallah, 2018). Research reveals that LAIs are effective at decreasing psychotic symptom
severity, relapses, rehospitalizations, and ER visits while improving adherence in those with
schizophrenia (Buckley et al., 2014; Lafeulle et al., 2013; Lafeulle et al., 2016; Lin et al., 2019;
Poloni et al., 2019; Subotnik et al., 2015).
LAIs are underutilized treatment options for schizophrenia that are supported by experts,
clinical guidelines, and research. Underutilization of LAIs denies those with schizophrenia of a
pharmacological treatment option with many benefits. The reasons for the underutilization of
LAIs are not entirely understood. However, research that examined the views psychiatric
prescribers had of LAIs hypothesized that contributing factors to the problem were their
knowledge deficits, uninformed attitudes, and poor prescribing practices (Ciglar et al., 2016;
Correll et al., 2016; Heres et al., 2006, Iyer et al., 2013a; Iyer et al., 2013b; Llorca et al., 2013;
Miles et al., 2011; Patel et al., 2003; Patel et al., 2020; Sajatovic et al., 2018a; Sajatovic et al.,
2018b; Samalin et al., 2013; Weiden et al., 2015). Many psychiatric prescribers believe LAIs are
coercive and that patients will reject them as a treatment option (Iyer et al., 2013b). The attitudes
held by psychiatric prescribers about LAIs often prevent patients from learning about or being
offered a LAI as a treatment option (Correll et al., 2016). Psychiatric prescribers need education
about LAIs to correct their knowledge deficits, uninformed attitudes, and poor prescribing
practices that lead to the underutilization of LAIs in clinical practice. There is a gap in the
literature regarding effective educational interventions to target the knowledge deficits,
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uninformed attitudes, and poor prescribing practices of psychiatric prescribers that are barriers to
the use of LAIs.
The Knowledge to Action Framework assists in bringing evidence into clinical practice
(Graham et al., 2006), and toolkits are a tangible example of the framework in action. Toolkits
are effective educational methods for prescribers (Yamanda et al., 2015), and if within a webbased form, are easily accessible to many for use. Web-based education is convenient and has
become a preferred model of delivering continuing education. With the emergence of the global
pandemic, COVID-19, and the practice of social distancing, all forms of education are moving
toward distance learning through web-based platforms. A web-based educational toolkit is an
appropriate intervention to reach psychiatric prescribers to address their knowledge deficits,
uninformed attitudes, and poor prescribing practices that are barriers to the use of LAIs.
Statement of the Problem
Long-acting injectable antipsychotics are underutilized in clinical practice due to the
knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers.
Research Question
Does a web-based educational toolkit have an effect on the knowledge, attitudes, and
practices of psychiatric prescribers regarding long-acting injectable antipsychotics?
Hypothesis
A web-based educational toolkit will have a positive effect on the knowledge, attitudes,
and practices of psychiatric prescribers regarding long-acting injectable antipsychotics.
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Definition of Terms
For clarity, the definition of essential terms used in this Doctor of Nursing Practice
(DNP) research project will be defined. The definition of terms are as follows:
1.Attitudes- a mental position regarding a fact ("Attitude", 2020).
2.Educational Toolkit-a grouping of multiple knowledge translation tools that provide specific
knowledge to educate and change behaviors (Yamada et al., 2015).
3.Knowledge- information and skills acquired from education and experience ("Knowledge,"
2020).
4.Long-Acting Injectable Antipsychotics (LAIs)- antipsychotic medications that are formulated
to be injected and are absorbed slowly, allowing for dosing intervals of up to three months
depending on the formulation. Available formulations in the United States are Abilify Maintena,
Aristada, Haldol Decanoate, Invega Sustenna, Invega Trinza, Perseris, Prolixin Decanoate,
Risperdal Consta, and Zyprexa Relprevv.
5.Practice- application of attained knowledge and skills ("Practice," 2020).
6.Psychiatric Prescriber- a person who prescribes psychiatric medications, usually a physician,
advanced practice nurse, or physician assistant ("Prescriber," 2020).
7.Web-Based- using the world wide eb ( Web-ba ed, 2020).
Need for the Study
Psychiatric prescribers can offer and utilize LAIs as a treatment option for those with
schizophrenia. Based on the evidence regarding the benefits of LAIs in the management of
schizophrenia, especially in those with non-adherence to antipsychotic medications, psychiatric
prescribers should routinely be offering LAIs as a treatment option (Llorca, 2013). Nevertheless,
LAIs remain underutilized due to knowledge deficits, uninformed attitudes, and poor prescribing
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practices amongst psychiatric prescribers. A gap in the literature exists regarding interventions
that could address the knowledge deficits, uninformed attitudes, and poor prescribing practices of
psychiatric prescribers that contribute to the underutilization of LAIs in clinical practice.
The DNP research project's purpose was to develop and evaluate a web-based educational
toolkit that would add to the future of healthcare by serving as an educational reference tool to
improve the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. The
project addressed a gap in the literature regarding effective educational interventions to target the
knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers that are barriers to the use of LAIs. The overarching goal was to create an
intervention that could change healthcare through the education of psychiatric prescribers.
This DNP research project met several American Association of Colleges of Nursing
(AACN) DNP essentials. T e
ec
e a
c ea e a eb-based educational toolkit
about LAIs for psychiatric prescribers as an intervention to positively affect their knowledge,
attitudes, and practices regarding LAIs; this was determined by assessing the baseline and impact
through a before and after knowledge, attitudes, and practices (KAP) questionnaire. Analysis of
the knowledge, attitudes, and practices about LAIs was completed through a literature review.
Evidence-based information was obtained, and informatics was incorporated in the development
of the web-based module which included the educational toolkit about LAIs. Justification for and
development of this project was based upon evidence-based research. Dissemination of this
evidence-based research project to psychiatric prescribers was constructed to eliminate
knowledge deficits, uninformed attitudes, and poor prescribing practices regarding LAIs and
create a long-term resource tool.
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Significance of the Problem
The percentage of individuals that are non-adherent to oral antipsychotics is high and
varies between 40 % to 90 % (Agid et al., 2010 as cited in Taylor et al., 2018). Medication nonadherence is a barrier to achieving positive outcomes for those with schizophrenia (Emsley,
2013), and psychiatric prescribers frequently overestimate compliance with oral antipsychotics
(Taylor et al., 2018). LAIs serve as a practical solution to the common problem of antipsychotic
non-adherence in those with schizophrenia and eliminate the negative consequences related to
medication non-adherence. However, even with a high percentage of patients with schizophrenia
that are non-adherent to oral antipsychotic medication, psychiatric prescribers are reluctant to
utilize LAIs due to a lack of knowledge about their use (Correll et al., 2016). In many cases,
psychiatric prescribers' knowledge deficits and uninformed attitudes about LAIs prevent the
practice of offering a LAI as a treatment option (Correll et al., 2016). In the United States, only
15-18 % of eligible patients with schizophrenia have been prescribed a LAI (Sajatovic et al.,
2018a).
Assumptions
It is assumed that LAIs are effective treatment options for those with schizophrenia and
ensure continuous adherence to antipsychotic medication for prolonged intervals of up to three
months. It is also assumed that by addressing the knowledge deficits, uninformed attitudes, and
poor prescribing practices of psychiatric prescribers regarding LAIs that it may lead to increased
utilization of LAIs, resulting in improved outcomes for those with schizophrenia.
Limitations
The project design had several limitations. Limitations included participants being
required to complete multiple steps to take part in the DNP research project and complete the
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KAP OF PSYCHIATRIC PRESCRIBERS
necessary data collection. The topic was specific and not interesting to all psychiatric prescribers.
Due to the time constraints, the impact of the web-based educational toolkit on the utilization of
LAIs in psychiatric prescribers over time was not possible. Lastly, participants' recruitment was
ed
a
g
a
e
fe
a
g
ga
a
e be forum and via
email to psychiatric prescribers found by word of mouth.
Summary of the Problem
LAIs are underutilized in clinical practice in part due to psychiatric prescribers'
knowledge deficits, uninformed attitudes, and poor prescribing practices (Ciglar et al., 2016;
Correll et al., 2016; Heres et al., 2006; Iyer et al., 2013a; Iyer et al., 2013b; Llorca et al., 2013;
Miles et al., 2011; Patel et al., 2003; Patel et al., 2020; Sajatovic et al., 2018a; Sajatovic et al.,
2018b; Samalin et al., 2013; Weiden et al., 2015). LAIs are evidence-based treatment options
that are a practical solution to the common problem of medication non-adherence in those with
schizophrenia and offer unique advantages over oral antipsychotics. They can prevent the
negative consequences of untreated schizophrenia (Patel & David, 2005). The underutilization of
LAIs deprives those with schizophrenia of a treatment that research, experts, and clinical
guidelines support. Although there is limited research about the reasons for the underutilization
of LAIs in clinical practice, research has hypothesized that it is in part due to psychiatric
prescribers' knowledge deficits, uninformed attitudes, and poor prescribing practices. There is a
gap in the literature regarding effective interventions to address the known barriers to the use of
LAIs perpetuated by psychiatric prescribers. Web-based education and toolkits are effective,
convenient methods of educating healthcare providers like psychiatric prescribers, and offer a
possible way to eliminate the knowledge deficits, uninformed attitudes, and poor prescribing
practices of psychiatric prescribers that are barriers to the use of LAIs in clinical practice.
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Finding interventions to eliminate the barriers to the use of LAIs in clinical practice could
improve their utilization and, in turn, improve outcomes for those with schizophrenia.
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Chapter 2
Review of the Literature
This chapter is a review of the literature that focuses on LAIs. The research articles
included in the review underpin themes and the theoretical framework that support this
interventional DNP research project aimed at improving the knowledge, attitudes, and practices
of psychiatric prescribers regarding LAIs through a web-based educational toolkit. The themes
emphasize the importance of this interventional DNP research project whose aim was to
overcome the knowledge deficits, uninformed attitudes, and poor prescribing practices of
psychiatric prescribers that are barriers to the use of LAIs in clinical practice.
Process
A literature search was conducted using the following databases: Academic Search
Ultimate, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete,
Health Source: Nursing/Academic Edition, and Medline Complete. The term "long-acting
injectable antipsychotics" was searched in the title along with the keywords "doctors or nurse
practitioners or prescribers or physicians or psychiatrists" and "attitudes or practices or
knowledge." The search yielded 30 articles. "Toolkit or education or web-based" was added to
the search, and the generated results decreased to 2 articles. An additional search using the same
databases was completed using the keyword search terms "long-acting injectable antipsychotics"
and "barriers" and "doctors or physicians or psychiatrists or nurse practitioners or prescribers,"
which yielded 3 articles that were contained in the previous original search. Following a review
of the 30 articles from the database searches, it was found that many were duplicates or not
applicable. Six articles were evaluated and included in the review of the literature. Since the
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number of articles yielded by the search of databases was limited, hand searching was done and
garnered 21 additional articles, and 16 were included in the review.
Benefits of Long-Acting Injectable Antipsychotics Compared to Oral Antipsychotics
Studies comparing oral antipsychotics to LAIs have produced varied results, most likely
due to each study's sample selection and design (Miyamato & Wolfgang-Fleischhacker, 2017).
Studies using a traditional randomized-control design and studies with a practical design show
differing results. A unique benefit of LAIs is that they assure continuous medication compliance
for intervals of up to three months and eliminate the common problem of oral antipsychotic nonadherence in those with schizophrenia. Medication compliance is guaranteed in the sample of a
randomized-control study and may not accurately reveal outcomes for those with schizophrenia
that struggle with adherence. Therefore, in studies comparing oral antipsychotics to LAIs, the
study's design and sample must be considered when determining the real-world translation of the
results.
Rehospitalization/ER visits
Lin et al.(2019) compared the length of time to and rate of rehospitalization over a year in
13,087 patients with schizophrenia or schizoaffective disorder discharged from a Taiwan
psychiatric hospital on either a LAI or an oral antipsychotic. This observational, cohort,
retrospective chart review study found that a year past discharge, 60% of the patients on a LAI
were re-hospitalized compared to 64.6% of patients on an oral antipsychotic; and time to
rehospitalization was greater in the LAI group (Lin et al., 2019). This study was unique and
showed the superiority of LAIs when compared to oral antipsychotics in a natural setting as
opposed to a controlled environment which could minimize the advantage of LAIs by assuring
oral antipsychotic compliance (Lin et al., 2019).
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Lafeulle et al. (2013) conducted a retrospective, matched cohort study of 3,828 patients
with schizophrenia and compared the rehospitalization rate and emergency room (ER) utilization
in those that switched to a second-generation LAI to those that stayed on an oral antipsychotic.
Rehospitalization and ER visits were significantly lower in patients on a second-generation LAI
(Lafeulle et al., 2013). This study suggested that patients with schizophrenia were less likely to
be hospitalized or visit the ER if they were switched to a second-generation LAI from an oral
antipsychotic (Lafeulle et al., 2013).
Poloni et al. (2019) conducted a unique mirror analysis study that examined the length
and number of hospitalizations and the number of ER visits one year before and one year
following initiation of a LAI in 153 patients in Italy with a schizophrenia spectrum disorder. The
study showed that in the same group of patients, there was a decrease in the number and length
of hospitalizations and the number of ER visits during the 12 months following the introduction
of a LAI (Poloni et al., 2019). The findings highlighted the benefit of a LAI over an oral
antipsychotic within the same patient in decreasing ER visits and the number and length of
hospitalizations.
Relapse/Psychotic Symptom Severity
The PROACTIVE (Preventing Relapse Oral Antipsychotic Compared to Injectable
Evaluating Efficacy) study by Buckley et al. (2015) was a randomized clinical trial that studied
276 patients with schizophrenia or schizoaffective disorder over 30 months at 8 academic centers
in the United States and compared the rates of relapse in those that were taking a secondgeneration oral antipsychotic to those taking the second-generation LAI, Risperdal Consta. The
primary outcome was time to relapse, and the secondary outcomes were psychiatric symptom
severity and level of functioning (Buckley et al., 2015). The study concluded no significant
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difference in relapse rates between the LAI and oral groups (Buckley et al., 2015). However, the
LAI group showed a greater reduction in psychotic symptom severity over time (Buckley et al.,
2015). This study did not find LAIs to be more advantageous than oral antipsychotics in
preventing relapse but did reveal their superiority in reducing the severity of psychotic symptoms
over time.
Subotnik et al. (2015) conducted a randomized clinical trial comparing the effectiveness
of LAI Risperidone with oral Risperidone over 12 months in 86 patients with recent-onset
schizophrenia. Effectiveness was measured by psychotic exacerbation or relapse, and secondary
outcomes measured were psychiatric hospitalization, psychotic symptom control, and drug
discontinuation (Subotnik et al., 2015). Psychotic exacerbation or relapse rates were 5% in those
on LAI Risperidone compare to 33% in those on oral Risperidone (Subotnik et al., 2015). LAI
Risperidone was also associated with greater medication adherence and psychotic symptom
control than oral Risperidone (Subotnik et al., 2015). This study supported a LAI's superiority in
adherence, control of psychotic symptoms, and prevention of relapse.
Adherence
Lafeuille et al. (2016) conducted a longitudinal, retrospective, cohort study of 12,990
patients with schizophrenia, identified by Medicaid claim data, and assessed the effect baseline
characteristics had on medication adherence. Adherence was defined as attainment of the
Healthcare Effectiveness Data and Information Set (HEDIS) measure, which was considered the
proportion of days covered (PDC) with antipsychotic medication as more than or equal to 80%
(Lafeuille et al., 2016). Approximately 49% of study participants achieved defined adherence
over a year (Lafeuille et al., 2016). The baseline characteristic of being prescribed the LAI
Invega Sustenna was associated with a 26% increase in medication adherence (Lafeuille et al.,
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2016). This study showed that many patients on oral antipsychotics are non-adherent, and LAIs
are superior in attaining medication adherence.
The various studies reviewed show that LAIs are as effective as oral antipsychotics and,
in many cases, are more effective at increasing adherence and decreasing relapse,
hospitalizations, ER visits, and psychotic symptoms. However, in clinical practice, oral
antipsychotics are used more frequently than LAIs. More naturalistic studies need to be
conducted to establish the real utility of LAIs compared to oral antipsychotics.
P chia ic P e c ibe
K
ledge, A i de , a d P ac ice Rega di g L
g-Acting
Injectable Antipsychotics
Underutilization of LAIs in clinical practice is believed to be due in part to psychiatric
prescribers' attitudes toward LAIs (Miles et al., 2011), which are based on their knowledge and
affect their prescribing practices. A limited number of studies have investigated the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs. Understanding the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs is instrumental in determining
their influence on the underutilization of LAIs.
Ciglar et al.(2016) noted the underutilization of LAIs in clinical practice despite their
advantages and theorized that psychiatrists' attitudes likely impacted their prescribing practices.
They investigated 48 psychiatrists' attitudes in Croatia regarding LAIs via a questionnaire (Ciglar
et al., 2016). General attitudes toward LAIs were positive; 81.25% reported a tendency to
prescribe LAIs, and 91.66% considered LAIs to significantly contribute to the treatment of
schizophrenia (Ciglar et al., 2016). However, only 37.5% said they preferred LAIs over oral
antipsychotics, and 66.67 % believed patients preferred oral antipsychotics over LAIs (Ciglar et
al., 2016). Researchers concluded that even though psychiatric prescribers had positive attitudes
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toward LAIs, they also had unsupported beliefs about LAIs and limited utilization (Ciglar et al.,
2016).
Heres et al. (2006) conducted a survey study on 246 psychiatrists that examined why
LAIs were not chosen as a treatment option for those with schizophrenia or schizoaffective
disorder. Reasons for not prescribing LAIs included concern for extrapyramidal symptoms,
patient refusal, and beliefs that patients were adherent to their oral antipsychotic medication
(Heres et al., 2006). The survey also revealed that 64.5% of the psychiatrists e g b e a e
had never been offered a LAI (Heres et al., 2006). Researchers concluded that the reported
reasons for not prescribing LAIs were unsupported by evidence-based knowledge (Heres et al.,
2006).
In the first part of a two-part qualitative study by Iyer et al. (2013b), the attitudes of 24
psychiatrists from Canada regarding LAIs were explored through a questionnaire and focus
group. Information gleaned from the questionnaires revealed that psychiatrists prescribed oral
antipsychotics more than LAIs, did not frequently offer LAIs as a treatment option, had limited
LAI prescribing experience, and would only prescribe a LAI if there were no other option (Iyer
et al., 2013b). Psychiatrists reported believing that patients would refuse LAIs, be unconvinced
about their benefits, fear pain, be aversive to needles, and interpret the suggestion of their use as
a lack of trust by the psychiatrist (Iyer et al., 2013b). Researchers hypothesized that psychiatric
prescribers' lack of knowledge and experience with LAIs, lack of offering of LAIs to patients,
and personal biases about LAIs might contribute to their underutilization of LAIs (Iyer et al.,
2013b).
In the second part of the two-part qualitative study by Iyer et al. (2013a), patients with
psychosis in Canada were examined to determine their perceptions about LAIs. Thirty-four
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patients at multiple sites provided their views on LAIs through a questionnaire and focus group
(Iyer et al., 2013a). Patient perspective themes identified were unawareness and lack of
understanding of LAIs, negative perceptions of LAIs, cost and convenience issues, and coercion
involved with the presentation of LAI treatment (Iyer et al., 2013a). This study identified patient
barriers to the use of LAIs, which could be mitigated by educating psychiatric prescribers on the
improved prescribing practices of discussing and offering LAIs to patients through shared
decision-making.
Miles et al. (2011) conducted a two-phase, qualitative study that examined psychiatrists'
attitudes and knowledge from New Zealand regarding the LAI Risperdal Consta and the impact
of their attitudes upon their prescribing practices. Data in the first phase was gathered from 16
psychiatrists by utilizing a focus group, and in the second phase, data was collected from 35
psychiatrists through a focus group based on the results of the phase one data (Miles et al., 2011).
In both phases, a gap was identified between the psychiatrists' knowledge about best practices
regarding LAIs and their reported prescribing practices (Miles et al., 2011). There were
significant discrepancies in psychiatrists' initiation, dosing, titration, and monitoring strategies,
indicating that utilizing the LAI Risperdal Consta was needed (Miles et al., 2011). Many
psychiatrists reported negative perceptions of the LAI Risperdal Consta and described it as a last
resort option, harmful to the psychiatrist-patient relationship, and unpleasant due to needle
administration (Miles et al., 2011). This study revealed the varied and limited knowledge,
uninformed attitudes, and poor prescribing practices of psychiatric prescribers regarding the LAI
Risperdal Consta.
Patel et al. (2003) conducted a questionnaire study about the attitudes, beliefs, and
knowledge of 143 European psychiatrists regarding LAIs and how they impacted their utilization
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of LAIs. The study showed that 94% of psychiatrists surveyed knew LAIs prevented relapse,
91% knew they were as effective as oral antipsychotics, 81% knew they increased adherence,
69% believed they were not acceptable to patients, 48% thought they were stigmatizing, 40%
thought they were old fashioned, and 38% believed LAIs had more side effects than oral
antipsychotics (Patel et al., 2003). Researchers concluded that LAIs are underutilized in part due
to a dichotomy between psychiatric prescribers' knowledge and attitudes, which affects their
prescribing practices (Patel et al., 2003).
Patel et al. (2020) conducted a questionnaire study to investigate the beliefs and attitudes
of 136 European physicians regarding the acceptance and usage of LAIs for the treatment of
schizophrenia. Physicians reported an increase in their utilization of LAIs within the last five
years preceding the study but reported offering oral antipsychotic treatment more than LAIs
(Patel et al., 2020). The prescribing of LAIs was directly correlated to physician attitudes
regarding LAIs (Patel et al., 2020). The researchers concluded that psychiatric prescribers' poor
attitudes regarding LAIs influence patient acceptance of LAIs and, ultimately, psychiatric
prescriber usage (Patel et al., 2020).
Weiden et al. (2015) conducted an observational study that examined 33 psychiatristpatient conversations in which psychiatrists offered LAI therapy to determine if the conversation
impacted patient acceptance or refusal of a LAI. Analyses of the conversations revealed that 91%
focused on the actual injection or mode of delivery, and 9 % focused on the benefits of the LAI
(Weiden et al., 2015). Researchers also noted a tentative offer presented as an inconvenience and
not a beneficial treatment option (Weiden et al., 2015). Of the 33 offers to start a LAI, 67% of
the patients had a neutral or positive reaction; but only 50% of those with a positive or neutral
reaction agreed to start a LAI (Weiden et al., 2015). The study concluded that the low use of
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LAIs could be partially related to the ambivalence exhibited by psychiatric prescribers when
offering LAIs.
The research studies investigating the knowledge, attitudes, and practices of psychiatric
prescribers regarding LAIs revealed valuable information regarding the underutilization of LAIs
in clinical practice. Psychiatric prescribers have limited knowledge about and experience with
initiating, titrating, and managing LAIs. The attitudes held by psychiatric prescribers about LAIs
are often negative and associated with coercion, patient rejection, and harm to the prescriberpatient relationship. The prescribing practices of psychiatric prescribers are affected by their
attitudes and knowledge regarding LAIs. Oral antipsychotics are prescribed and offered more
than LAIs. Many psychiatric prescribers have never educated or offered those with schizophrenia
a LAI. If psychiatric prescribers offer LAIs, the benefits of the option are not highlighted.
Barriers to the use of LAIs are the knowledge deficits, uninformed attitudes, and poor
prescribing practices of psychiatric prescribers. Patients' choice of treatment and acceptance of
treatment is largely influenced by psychiatric prescribers' knowledge, attitudes, and practices.
Gap in the Literature Regarding Interventions to Improve the Knowledge, Attitudes, and
Practices of Psychiatric Prescribers Regarding LAIs
A gap in the literature exists between the knowledge deficits, uninformed attitudes, and
poor prescribing practices of psychiatric prescribers, which are barriers to the use of LAIs in
clinical practice, and interventions that could alleviate them. Psychiatric prescribers need
education about LAIs to correct their knowledge deficits, uninformed attitudes, and poor
prescribing practices that contribute to the underutilization of LAIs in clinical practice. The
management of LAIs can be complicated and requires specific knowledge about practical issues
such as dosing and switching to a LAI (Correll et al., 2016); there are insufficient data and
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recommendations within the literature (Llorca et al., 2013). "Tailored education about LAIs
should be developed for different groups of professionals who interact with patients, including
physicians, nurse practitioners, nurses, physician assistants, pharmacists, social workers,
residents, peer counselors, and others" (Correll et al., 2016, p. 21). Psychiatric prescribers should
have easy access and evidence-based education about LAIs to offer and prescribe them as
treatment options for those with schizophrenia. Development of education to address psychiatric
prescribers' knowledge deficits, uninformed attitudes, and poor prescribing practices that prevent
LAIs from being utilized as a treatment option in those with schizophrenia is needed.
Development and Implementation of a Toolkit
Abdulrehman et al. (2019) addressed the problem of unrecognized and untreated iron
deficiency in pregnancy with the development and implementation of a toolkit for prescribers to
enhance iron deficiency identification and treatment in pregnancy (Abulrehman et al., 2019). The
toolkit's implementation resulted in improved study outcome measures (Abulrehman et al.,
2019). This study demonstrated the effectiveness of an educational toolkit for prescribers in
promoting positive practice changes.
Yamada et al. (2015) conducted a systematic review of the literature on toolkits to
evaluate their effectiveness as a knowledge translation strategy. The review included 39 research
studies, all of which used a toolkit as a knowledge translation strategy, but all had varying
methodologies and content (Yamada et al., 2015). Researchers concluded that a toolkit could be
an effective strategy to translate evidence into practice if the toolkit's content is based on
evidence, and the evaluation is thorough (Yamada et al., 2015).
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Web-Based Education for Prescribers
Madsen et al. (2014) investigated the effects of a web-based educational module on
pediatric emergency medicine physicians' knowledge, attitudes, and behaviors regarding youth
violence. Researchers developed a short, web-based educational program about youth violence
(Madsen et al., 2014). The 18 participating pediatric emergency department physicians
completed a pre-module assessment, and one month later, a post booster module and postmodule assessment (Madsen et al., 2014). The pre and post-module assessments examined
knowledge and attitudes, and behavior changes were measured by a pre and post-module chart
review of youth violence patients for specific discharge instructions (Madsen et al., 2014).
Results indicated a significant increase in physician knowledge and attitudes regarding youth
violence (Madsen et al., 2014). Before the module, 1.6% of youths treated for violence-related
injuries were discharged with violence discharge instructions, and one month following the webbased module, 15.7% received youth violence discharge instructions (Madsen et al., 2014). This
study proved the utility of web-based education as a method that can positively affect physicians'
knowledge, attitudes, and behaviors.
Oliveira et al. (2017) conducted a study to evaluate the impact of an e-learning pediatric
cardiology course on the knowledge and user satisfaction of 62 doctors, nurses, and medical
students (Oliveira et al., 2017). The impact of the e-learning course using the learning platform,
Moodle®, was measured using a pretest and posttest; and user satisfaction was evaluated using a
questionnaire (Oliveira et al., 2017). The mean satisfaction rating of the e-learning course was
87% (Oliveira et al., 2017). In pretest scores, 67% passed, and in the posttest scores, 100%
passed (Oliveira et al., 2017). This study supported using an e-learning course on Moodle® as a
useful method to increase knowledge in health care providers.
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Theoretical Framework: Knowledge to Action (KTA) Framework
The Knowledge to Action (KTA) Framework was the foundation of this DNP research
project. Graham et al. (2006) developed the KTA Framework as a guide to maximizing the
transfer of research findings into practice so patients receive the best evidence-based treatment.
Field et al. (2014) conducted a systematic review study about the KTA Framework. Ten studies
were identified and evaluated that utilized the framework to implemented health-focused
evidence-based treatment (Field et al., 2014). Researchers concluded that the KTA conceptual
framework could help facilitate bringing evidence into practice within the healthcare arena (Field
et al., 2014). The KTA process is flexible yet complex (Graham et al., 2006). It is composed of
two concepts, the knowledge creation and the action cycle (Graham et al., 2006). Illustration of
the framework shows the phases of the knowledge creation concept encircled by the action cycle
concept (Figure 1).
Knowledge Creation
This concept funnels through three phases. It begins with knowledge inquiry, moves to
knowledge synthesis, and ends with knowledge tools or products. The funneling reflects the
synthesis of knowledge to a useful product that meets identified needs (Graham et al., 2006).
Knowledge Inquiry. Knowledge inquiry represents "first-generation knowledge" or
primary studies on the problem being explored (Graham et al., 2006). Following an extensive
review of the literature obtained from the knowledge inquiry, it was found that the knowledge
deficits, uninformed attitudes, and poor prescribing practices of psychiatric prescribers contribute
to the underutilization of LAIs.
Knowledge Creation. Knowledge creation is considered "second generation knowledge"
and is a synthesis of all the information about the problem being explored in the knowledge
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inquiry; it is typically composed of meta-analyses and systematic reviews (Graham et al., 2006).
The review of literature represents the knowledge creation phase.
Knowledge Tools or Products. Knowledge tools or products are considered "thirdgeneration knowledge" and are typically practice guidelines, protocols, and clinical pathways
(Graham et al., 2006). They are customized to meet the needs of those that will use the
knowledge tool (Graham et al., 2006). The web-based educational toolkit development regarding
LAIs was based upon information obtained from the knowledge inquiry and the knowledge
creation phases and served as a knowledge tool.
Action Cycle
This concept is a feedback loop that cycles through activities leading to implementing the
knowledge tool or product (Graham et al., 2006). The phases of the action cycle are the
identification of the problem; identification, review, and selection of knowledge, adapt
knowledge to the context, access barriers to use of the knowledge, monitor knowledge use,
evaluate outcomes, and sustain the knowledge use (Graham et al., 2006).
Identify Problem. Identification of the problem results from the knowledge inquiry and
determines if there is a gap in the literature that needs to be filled (Graham et al., 2006). For this
research project, the clinical problem identified was the underutilization of LAIs due to
knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers. A gap was identified in the literature regarding interventions to address the barriers
to the use of LAIs perpetuated by psychiatric prescribers, which led to this project's conception.
Adapt Knowledge to the Local Context. Adapting knowledge to a context involves
determining the importance of knowledge to a group and tailoring it to meet the group's needs
(Graham et al., 2006). Barriers to the use of LAIs perpetuated by psychiatric prescribers were
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identified in the literature as knowledge deficits, uninformed attitudes, and poor prescribing
practices. Psychiatric prescribers have limited access to evidence-based education about the
complexities of prescribing LAIs, and the toolkit was developed by a psychiatric prescriber for
psychiatric prescribers.
Assess Barriers to Knowledge Use. Assessment of barriers to using the created
knowledge encourages targeting and overcoming barriers to disseminating the new knowledge
(Graham et al., 2006). Determining how to make psychiatric prescribers aware of the web-based
educational toolkit about LAIs was the primary barrier to dissemination. Using a network of
psychiatric prescribers through an online professional nursing organization member forum and
emails to known psychiatric prescribers found by word of mouth were chosen as means of
dissemination.
Select, Tailor, Implement Intervention. Selecting, tailoring, and implementing the
intervention based on the target group successfully implements and disseminates the new
knowledge based on the audience (Graham et al., 2006). The web-based educational toolkit was
tailored to target and overcome the knowledge deficits, uninformed attitudes, and poor
prescribing practices of psychiatric prescribers that contribute to the underutilization of LAIs.
Monitor Knowledge Use. Monitoring knowledge use is focused on determining if there
was a transfer of knowledge and is typically measured by a change in knowledge, attitudes, and
practices (Graham et al., 2006). This research project evaluated the toolkit's effectiveness by
measuring a change in knowledge, attitudes, and practices of psychiatric prescribers.
Evaluate Outcomes. Evaluating outcomes determines the impact of the new knowledge
on the problem identified (Graham et al., 2006). This project evaluated the impact of a webbased educational toolkit on psychiatric prescribers' knowledge, attitudes, and practices. Due to
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the project's time constraints, the long-term outcome of a change in the utilization of LAIs in
clinical practice was not part of this project. However, changes to prescribing rates of LAIs by
psychiatric prescribers could be considered for investigation in the future.
Sustain Knowledge Use. Sustaining the use of the new knowledge created requires
evaluation of barriers to its use (Graham et al., 2006). Continued use of this web-based
educational toolkit would include incorporation into the curriculum of psychiatric prescriber
programs and endorsement by a professional practice organization. The toolkit would need to be
updated yearly to ensure that all the information is up to date, considering the rapid increase in
available LAIs over the last several years.
This review of literature detailed the KTA theoretical framework and themes of this
interventional DNP research project. Themes included benefits of LAIs over oral antipsychotics,
the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs, a gap in the
literature regarding interventions to eliminate barriers to the use of LAIs perpetuated by
psychiatric prescribers, web-based education, and toolkits. The themes and framework support
the importance of developing and evaluating a web-based educational toolkit aimed at improving
the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs.
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Chapter 3
Methodology
The design and methods of this DNP research project, based on the KTA framework, will
be discussed. This DNP research project developed and evaluated the impact of a web-based
educational toolkit on psychiatric prescribers' knowledge, attitudes, and practices regarding
LAIs. The design and methods of this DNP research project assisted in answering the research
question, which asked if a web-based educational toolkit would have an effect on the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs. Participants took part in a webbased module composed of seven-parts. The setting, sample, ethical considerations,
instrumentation, data collection, and data analysis of this DNP research project will be detailed
in this chapter.
Research Design
This DNP research project had an interventional, one-group, before and after, quasiexperimental design. A web-based educational toolkit was developed to improve the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs. The intervention, a web-based
educational toolkit, was presented. A knowledge, attitudes, and practices (KAP) questionnaire
was conducted before and then after to determine the effect on participating psychiatric
prescribers' KAP questionnaire scores.
Setting
A seven-part web-based module, including the intervention and accompanying before
and after KAP questionnaire, was housed on the open-source learning management system,
Moodle®. The setting was any location where participants could access and complete the webbased module.
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Sample
A convenience, purposive sample of psychiatric prescribers, recruited through an
invitation posted to an online professional nursing organization member forum and sent to the
email accounts of psychiatric prescribers found through word of mouth, was utilized. The only
criterion required to participate was a professional designation as a prescriber of psychiatric
medication. The only criterion that excluded an individual from participating was not being a
prescriber of psychiatric medication. A DNP research project recruitment announcement and
invitation were posted on an online professional nursing organization member forum and sent via
email to psychiatric prescribers located through word of mouth to recruit participants. The
invitation included the purpose of the DNP research project, a brief description of this DNP
research project, and a URL link to the open-source learning management system, Moodle®,
where the seven- part web-based module was housed.
Ethical Considerations
The Institutional Review Board of Edinboro University reviewed this DNP research
project before initiation and found it to be exempt. Permission was obtained from the
organization that governs the online professional nursing membership forum where the
recruitment announcement and invitation for participation in this DNP research project were
posted. All participants were voluntary, and online consent and verification as a prescriber of
psychiatric medication were obtained before the initiation of the web-based intervention.
Participants self-enrolled in the web-based module through Moodle®, which required the
provision of a personal email address, username, password, and acceptance of the Moodle® user
agreement. The demographic information collected was a range of years prescribing
medications, sex, age range, practice setting, and professional designation. Data retrieved from
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participants was stored in the student researcher's password-protected Moodle® site, and a
personal email address identified the data. The data from Moodle® was de-identified from each
participant's email by assigning each email address a unique number from 1-100 before being
stored in an Excel and a Statistical Package for Social Science (SPSS) file on the student
researcher's password-protected computer. The Moodle® site and all data collected will be
retained for three years. No risks or discomfort were anticipated for participants except for the
time associated with completing the module, which was estimated to be approximately 30
minutes.
Instrumentation
To study the impact of the web-based educational toolkit on the knowledge, attitudes, and
practices of psychiatric prescribers regarding LAIs, the following tools were developed by the
student researcher:
(i). A web-based educational LAI toolkit and presentation were created using PowerPoint
and evidence-based information to enhance psychiatric prescribers' knowledge, attitudes, and
practices regarding LAIs. The toolkit was comprised of the following elements: an overview of
LAIs, review of evidence-based literature about LAIs, prescribing tables for each of the nine
LAIs available in the United States based on information from the manufacturers, websites
containing guidelines and an algorithm for the treatment of schizophrenia, manufacturer
websites, myths about LAIs, resources for psychiatric prescribers, advantages of LAIs,
disadvantages of LAIs, patient resources, and tips on how to engage patients in shared decisionmaking conversations about LAIs. The web-based educational toolkit and presentation were
housed on the open-source learning management system, Moodle®. Content validity of the webbased educational toolkit was established by submission to experts for evaluation and was based
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on content, clarity, and organization. The consulted experts were a board-certified psychiatrist
and board-certified psychiatric mental health nurse practitioner. The toolkit was finalized
following suggested modifications from the consulted experts.
(ii). A 20-item KAP questionnaire was created using the content of the web-based
educational LAI toolkit (Appendix A). The KAP questionnaire was comprised of three subscales.
The first subscale included 11 knowledge questions. The second subscale included six attitude
questions. The third subscale included three practice questions. All questions were true or false.
The 20-item KAP questionnaire was based on a 56-item, pre-existing knowledge and attitudes
questionnaire regarding LAIs. Eleven of the 20-items in the KAP questionnaire were directly
used or modified from the pre-existing knowledge and attitudes questionnaire. The 56-item
questionnaire was based on and modified from a previous 44-item knowledge and attitudes
questionnaire, which had excellent reliability based on the test-retest method and moderate
internal reliability (Bawo, Omoaregba, Okonoda, Otefe, & Patel, 2012). Permission was obtained
from the author to utilize the knowledge and attitudes questionnaire. The content validity of the
newly created 20-item KAP questionnaire was established by submission to the previously
mentioned experts for suggestions and modifications. The questionnaire was tested for reliability
before its use by the test-retest method with a one-week interval and was found to have a good
intraclass correlation coefficient of .816.
(iii). A web-based module that consisted of seven-parts was created using the open-source
learning management system, Moodle®. Included in the web-based module was a brief
description of the research project and intervention, a question to verify each participant as a
prescriber of psychiatric medication with a yes or no option, a consent form with a yes or no
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option, five multiple-choice demographic questions, the 20-item before KAP questionnaire, the
presentation of the web-based educational LAI toolkit, and the 20-item after KAP questionnaire.
Data Collection
Data was collected using the web-based, 20-item KAP questionnaire administered before
and after participants received access to the web-based educational toolkit presentation about
LAIs. In the KAP questionnaire, there were 20 questions, all true or false, correct answers got
one point, and incorrect answers got zero points. Knowledge questions were 1-11 (11 items),
attitudes questions were 12-17 (6 items), and practice questions were 18-20 (3 items). The range
for the total KAP score was 0-20, and the range for the three subscale scores were 0-11 for
knowledge KAP subscale score, 0-6 for attitudes KAP subscale score, and 0-3 for practices KAP
subscale score. Higher scores indicated better knowledge, more positive attitudes, and better
prescribing practices of the psychiatric prescribers regarding LAIs. Demographic data was
collected with five questions regarding age, sex, years prescribing medications, practice setting,
and professional designation (Appendix B). Verification that each participant consented to
participate and was a prescriber of psychiatric medication was completed by questions with a yes
or no response. All data was collected electronically by the web-based module created with and
housed on Moodle®.
The open announcement and invitation to participate in the DNP research project were
posted on the online professional nursing organization member forum and sent via email to
psychiatric prescribers found through word of mouth four times over three weeks. The
announcement and invitation provided a URL link to the web-based module on Moodle®, which
was available during the same three-week time frame. Before accessing the web-based module
on Moodle®, participants needed to become a registered user of Moodle® which required
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consent to their user agreement, and creation of a username and password. The web-based
module included: a brief description of this DNP research project, question verifying the
participant as a prescriber of psychiatric medication with a yes or no option, consent form with a
yes or no option, demographic questions, before KAP questionnaire, presentation of the webbased educational LAI toolkit, and after KAP questionnaire.
Data collection was concluded after three weeks. Verification as prescriber of psychiatric
medication, consent, de
ga
c da a a d c e f
eac
a c a
KAP
e
a e
before and after they viewed the web-based educational toolkit presentation was collected by
Moodle® and stored in the Moodle® module. A personal email address identified each
participant's data. Email addresses were then de-identified by assigning each a unique numeric
code from 1 to 100 before transferring the data to an Excel file. After the data was de-identified,
it was also stored in both an Excel and a SPSS f e
e
de
e ea c e
c
e . All data
was password protected.
Data Analysis
The purpose of this data analysis was two-fold. The first was to determine if there were
differences in the knowledge, attitudes, and practices of psychiatric prescribers (measured using
the total and three subscales KAP scores) before and after the presentation of the web-based
educational toolkit about LAIs. The second was to determine if there were relationships between
changes of knowledge, attitudes, and practices (measured as the differences in the after and
before total and three subscales KAP scores) of psychiatric prescribers and any of their
demographic factors.
The data was imported into and analyzed using the Statistical Package for Social Science
(SPSS) version 23 for Windows (IBM Corp., Armonk, NY). Frequency tables were used to
40
KAP OF PSYCHIATRIC PRESCRIBERS
summarize the KAP questionnaire responses and demographics of the participants. Descriptive
statistics, including mean, standard deviation, median, minimum, maximum, and range were
used to summarize the total and three subscales KAP scores before and after the presentation of
the web-based educational toolkit about LAIs.
Shapiro-Wilk tests were used to determine the normality of the data. As the data was not
normally distributed, non-parametric procedures, including Wilcoxon signed-rank tests, MannWhitney U tests, and Kruskal Wallis tests were applied (Field, 2013). Wilcoxon signed-rank
tests were performed to determine if there were differences in the knowledge, attitudes, and
practices (measured using the total and three subscales KAP scores) of psychiatric prescribers
before and then after the presentation of the web-based educational toolkit about LAIs. MannWhitney U tests (for categorical variables with two levels) and Kruskal Wallis tests (for
categorical variables with more than two levels) were used to determine if there were any
relationships between changes in knowledge, attitudes, and practices (measured as the
differences in the after intervention and the before intervention total and three subscales KAP
scores) of psychiatric prescribers and their demographic factors of age range, practice setting,
professional designation, range of years prescribing medications, and sex. For all the utilized
tests, a p-value of less than 0.05 indicated statistical significance. All p-values were two-sided.
Summary of Methodology
The design and methodology of this DNP research project, based on the KTA
Framework, were constructed to answer the research question that asked if the web-based
educational toolkit would have an effect on the knowledge, attitudes, and practices of psychiatric
prescribers regarding LAIs. The study was interventional with a quasi-experimental, one-group,
before and after design. Participants were a purposive, convenience sample of psychiatric
41
KAP OF PSYCHIATRIC PRESCRIBERS
prescribers recruited from an online professional nursing organization member forum and via
emails to psychiatric prescribers found through word of mouth. The module included a brief
description of the DNP research project, a question to verify each participant as a prescriber of
psychiatric medication, a consent form, demographic questions, before KAP questionnaire, a
presentation of the web-based educational LAI toolkit, and after KAP questionnaire. Data was
collected by the web-based module created with and housed on Moodle®. The data was analyzed
to determine if there were differences in the knowledge, attitudes, and practices of psychiatric
prescribers before and after the presentation of a web-based educational toolkit regarding LAIs
and to determine if there were relationships between changes in knowledge, attitudes, and
practices of the participants and their demographic factors.
42
KAP OF PSYCHIATRIC PRESCRIBERS
Chapter 4
Results and Discussion
In this chapter, this DNP research project's data analysis results will be presented and
discussed in detail. Justification of the sample size will be provided with the results of a priori
power analysis. The established research question will be answered based on the descriptive and
inferential statistical analysis of the obtained data. The results of the descriptive and inferential
statistical analysis will be displayed in tables. Discussion about the data and subsequent analysis
will include examining the findings in relation to the review of literature and the KTA
Framework of the study. The strengths and limitations of this DNP research project and its
implications for nursing practice will conclude this chapter.
Results
Power Analysis
A priori power analysis was conducted to determine the minimum number of participants
required for this DNP research project for a .80 power of finding statistically significant
differences in the knowledge, attitudes, and practices (measured using the total and three
subscales of KAP) of psychiatric prescribers before and after a presentation of the web-based
educational toolkit about LAIs, using the paired t-test family. The 0.80 for power analysis was
the desired power of the test, which means it was probable that the test would correctly reject the
null hypothesis when the null hypothesis was false (Cohen, 1988). The power analysis for the
paired t-test family was performed using G*power 3.1.9.4 (Faul et al., 2009) to determine the
minimum sample size that was needed for this DNP research project. For a large effect size of
0.8 (Cohen, 1988; Cohen, 1992) and an alpha level of 0.05, the minimum sample size needed to
achieve a 0.80 power was 15 participants. This DNP research project recruited 17 participants,
43
KAP OF PSYCHIATRIC PRESCRIBERS
which was greater than the minimum sample size needed according to the power analysis to
detect the effects hypothesized in this DNP research project, and hence this DNP research project
had an adequate sample size.
Participant Demographics
A total of 25 participants registered for the study via Moodle®. Out of the 25 participants
that registered, eight were excluded from the data analysis. One participant completed data
collection but answered "no" to the question requesting consent to participate. Two participants
did not answer all the demographic questions. Lastly, five participants did not complete the after
KAP questionnaire. In the final data analysis, 17 participants were included after they consented
to participate, verified themselves as a prescriber of psychiatric medication, viewed the
intervention, and completed both the before and after KAP questionnaire.
Table 1 shows the demographics of the participants. Nearly 60% of the participants
(58.8%) were psychiatric nurse practitioners. Slightly over half of the participants (52.9%) were
51-65 years old. Most of the participants were female (76.5%) and practiced in outpatient
settings (88.2%). Over 40% of the participants (41.2%) had prescribed medications for 11-20
years.
Table 1
Demographics of the Participants
Variable
Professional designation
Age
N
%
Psychiatric nurse practitioner
10
58.8
Family nurse practitioner
6
35.3
Physician
1
5.9
20-35
2
11.8
44
KAP OF PSYCHIATRIC PRESCRIBERS
Sex
Years prescribing medications
Practice setting
36-50
4
23.5
51-65
9
52.9
66 and over
2
11.8
Female
13
76.5
Male
4
23.5
0-5
4
23.5
6-10
3
17.6
11-20
7
41.2
21 plus
3
17.6
Hospital
2
11.8
Outpatient
15
88.2
KAP Questionnaire Responses
Table 2 summarizes the percentage of participants with correct answers for each KAP
questionnaire item before and after the presentation of the web-based educational toolkit about
LAIs. For the knowledge KAP subscale (Q1-Q11), more participants had correctly answered six
questions (Q2, Q3, Q5, Q6, Q7, and Q11) after the intervention than before the intervention. Side
effects, initiation, plasma levels, duration of effect, pharmacokinetics, and advantages of LAIs
compared to oral antipsychotics were the content of the knowledge KAP subscale questions more
participants answered correctly after the intervention. One question, knowledge KAP subscale
(Q3), which asked about an opportune time to initiate a LAI, had the most remarkable
improvement in scores, with 35.3 % of participants answering the question correctly before the
intervention and 88.2% answering the question correctly after the intervention. Three questions
(Q1, Q9, Q10) had more participants answer incorrectly after the intervention than before the
45
KAP OF PSYCHIATRIC PRESCRIBERS
intervention. The questions pertained to patients that should be offered a LAI, expert
recommendations for the use of LAIs, and the steady state of a LAI.
For the attitudes KAP subscale (Q12-Q17), more participants had correctly answered 1
question (Q12) after the intervention than before the intervention. The content of the question
was regarding the patient preference of oral antipsychotics over LAIs. Before the intervention,
88.2% of participants correctly answered the question compared to 94.1% after the intervention.
For the practices KAP subscale (Q18-Q20), more participants had correctly answered two
questions (Q19 and Q20) after the intervention compared to before the intervention. Question 19
was related to the offering of LAIs to patients with a fear of needles. Before the presentation of
the web-based educational toolkit, 94.1% of participants answered the question correctly and
after 100% of participants answered correctly. Question 20 was regarding patients being offered
a LAI from the first episode of schizophrenia through recovery. Correct responses by
participants increased by 17.6 % after the presentation of the web-based educational toolkit
regarding LAIs.
Table 2
Percentage of Participants with Correct Answers for Each KAP Item
Item
Before the intervention
After the intervention
% change
Q1
17 (100)
16 (94.1)
-
Q2
16 (94.1)
17 (100)
+
Q3
6 (35.3)
15 (88.2)
+
Q4
17 (100)
17 (100)
Q5
15 (88.2)
16 (94.1)
+
Q6
16 (94.1)
17 (100)
+
46
KAP OF PSYCHIATRIC PRESCRIBERS
Q7
11 (64.7)
15 (88.2)
+
Q8
16 (94.1)
16 (94.1)
Q9
16 (94.1)
15 (88.2)
-
Q10
15 (88.2)
12 (70.6)
-
Q11
16 (94.1)
17 (100)
+
Q12
15 (88.2)
16 (94.1)
+
Q13
17 (100)
17 (100)
Q14
17 (100)
17 (100)
Q15
17 (100)
17 (100)
Q16
15 (88.2)
15 (88.2)
Q17
17 (100)
17 (100)
Q18
17 (100)
17 (100)
Q19
16 (94.1)
17 (100)
+
Q20
13 (76.5)
16 (94.1)
+
Note. Q1-Q11 are the knowledge KAP subscale questions, Q12-Q17 are the attitudes KAP
subscale questions, and Q18-Q20 are the practices KAP subscale questions. "% change"
quantifies the difference in the percentage of participants with correct answers before the
intervention and after the intervention, "-" indicating the percentage of participants with correct
answers before the intervention was greater than the percentage of participants with correct
answers after the intervention, "+" indicating the percentage of participants with correct answers
before the intervention was less than the percentage of participants with correct answers after the
e e
,ba
+
d ca
g e ce age f a c a
c
ec a
e bef e
e
47
KAP OF PSYCHIATRIC PRESCRIBERS
intervention was the same as the percentage of participants with correct answers after the
intervention.
Descriptive Statistics of KAP Questionnaire Data
Table 3 presents the descriptive statistics of the total and three KAP subscale scores
before and after the presentation of the web-based educational toolkit about LAIs. The results of
the Shapiro-Wilk tests indicated that except for the before total KAP scores (W = 0.919, p =
0.141), all the other data, including the before and the after knowledge KAP subscale scores, the
before and after attitudes KAP subscale scores, the before and after practices KAP subscale
scores, and the after total KAP scores, were not normally distributed (W ranged from 0.262 to
0.872, p < 0.05).
As not all data were normally distributed, median and range were used to summarize the
data. Median was used for the measure of central tendency, and range was used for the measure
of variation of the data. The median knowledge KAP subscale scores were 10 (range = 3) and 11
(range = 4) before and after the intervention, indicating participants had good knowledge
regarding LAIs before and after the intervention. The median attitudes KAP subscale scores were
6 (range = 2) and 6 (range = 2) before and after the intervention, indicating participants had
positive attitudes regarding LAIs before and after the intervention. The median practices KAP
subscale scores were 3 (range = 1) and 3 (range = 1) before and after the intervention, indicating
participants had good prescribing practices regarding LAIs before and after the intervention. The
median total KAP scores were 18 (range = 5) and 19 (range = 5) before and after the
intervention, indicating participants had good cumulative knowledge, attitudes, and practices
regarding LAIs before and after the intervention.
48
KAP OF PSYCHIATRIC PRESCRIBERS
Table 3
Descriptive Statistics of the Total KAP and Three KAP Subscales Scores
Shapiro-Wilk test
KAP scale
Knowledge
Attitudes
Practices
Total KAP
M
SD
Mdn
Range
Min
Max
W
df
P
Pre
9.59
0.80
10
3
8
11
0.872
17
0.024
Post
10.18
1.19
11
4
7
11
0.729
17
< 0.001
Pre
5.76
0.56
6
2
4
6
0.490
17
< 0.001
Post
5.82
0.53
6
2
4
6
0.391
17
< 0.001
Pre
2.71
0.47
3
1
2
3
0.579
17
< 0.001
Post
2.94
0.24
3
1
2
3
0.262
17
< 0.001
Pre
17.94
1.25
18
5
15
20
0.919
17
0.141
Post
18.94
1.43
19
5
15
20
0.758
17
0.001
Note. M=mean; SD=standard deviation; Mdn=median; Min=minimum Max=maximum; W=
Shapiro-Wilk test statistic ; df=degrees of freedom; P=p-value
Impact of the Web-Based Educational Toolkit on KAP Questionnaire Scores
Wilcoxon signed-rank tests were performed to determine if there were differences in the
knowledge, attitudes, and practices (measured using the total and three subscales scores of the
KAP questionnaire) of psychiatric prescribers before and after the presentation of the web-based
educational toolkit about LAIs. The results are presented in Table 4.
There was no statistically significant differences in the knowledge KAP subscale scores
(T = 81.50, Z = 1.904, p = 0.057, r = 0.461), attitudes KAP subscale scores (T = 1.00, Z = 1.000,
p = 0.317, r = 0.243), and practices KAP subscale scores (T = 1.00, Z = 1.000, p = 0.317, r =
0.243) before and after the presentation of the web-based educational toolkit about LAIs (Table
49
KAP OF PSYCHIATRIC PRESCRIBERS
4). However, there was a statistically significant difference in the total KAP scores before and
after the presentation of the web-based educational toolkit about LAIs (T = 110.00, Z = 2.933, p
= 0.003, r = 0.711; Table 4). In particular, participants had statistically significant higher total
KAP scores after the intervention (Mdn = 19, Range = 5) than before the intervention (Mdn = 18,
Range = 5) (Table 3).
Table 4
Results of Wilcoxon Signed-Rank Tests
KAP scale
N
T
Z
P
R
Knowledge
17
81.50
1.904
0.057
0.461
Attitudes
17
1.00
1.000
0.317
0.243
Practices
17
10.00
2.000
0.125
0.485
Total KAP
17
110.00
2.933
0.003
0.711
Note. N = sample size; T = Wilcoxon signed-rank test statistic; Z = standardized test statistic; p =
p-value. r = effect size, computed as |Z|/√𝑁, where Z is the standardized test statistic, and N is
the number of total observations (Tomczak & Tomczak, 2014).
Association Between Change in KAP and Participant Demographics
Mann-Whitney U tests (for categorical variables with two levels) and Kruskal Wallis
tests (for categorical variables with more than two levels) were used to determine if there were
relationships between the changes in knowledge, attitudes, and practices (measured as the
differences in the after and the before intervention total and three subscales KAP scores) of
psychiatric prescribers and their demographic factors, such as age range, professional
designation, range of years prescribing medications, practice setting, and sex. The results are
presented in Tables 5-9.
50
KAP OF PSYCHIATRIC PRESCRIBERS
Table 5 presents the results of Mann-Whitney U tests for determining if differences in the
total and three KAP subscales scores (After-Before) were associated with a professional
designation. The median differences for after the intervention and the before the intervention
knowledge KAP subscale scores were 1 (range = 3) and 1 (range = 4) for psychiatric nurse
practitioners and family nurse practitioners. There was no association between professional
designation and differences in the after and the before intervention knowledge KAP subscale
scores (U = 27.50, Z = -0.285, p = 0.776, r= 0.071).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0 (range = 1) and 0 (range = 0) for psychiatric nurse practitioners and family nurse
practitioners. There was no association between professional designation and differences in the
after and the before intervention attitudes KAP subscale scores (U = 27.00, Z = -0.775, p =
0.439, r = 0.194).
The median differences for the after and the before intervention practices KAP subscale
scores were 0 (range = 1) and 0 (range = 1) for psychiatric nurse practitioners and family nurse
practitioners. There was no association between professional designation and differences in the
after and the before practices KAP subscale scores (U = 37.00, Z = 1.121, p = 0.262, r = 0.280).
The median differences for the after and the before intervention total KAP scores were 1
(range = 3) and 1 (range = 3) for psychiatric nurse practitioners and family nurse practitioners.
There was no association between professional designation and differences in the after and the
before intervention total KAP scores (U = 26.50, Z = -0.403, p = 0.687, r = 0.101).
51
KAP OF PSYCHIATRIC PRESCRIBERS
Table 5
Results of Mann-Whitney U Tests for Determining if Differences in Total and Three
Subscales KAP Scores (After - Before) Were Associated with Professional Designation
Median (Range)
KAP scale
PMHNP
Mean rank
FNP
PMHNP
FNP
U
Knowledge 1 (3)
1 (4)
8.75
8.08
Attitudes
0 (1)
0 (0)
8.80
Practices
0 (1)
0 (1)
Total KAP
1 (3)
1 (3)
Z
P
R
27.50 -0.285
0.776
0.071
8.00
27.00 -0.775
0.439
0.194
9.67
7.80
37.00 1.121
0.262
0.280
8.85
7.92
26.50 -0.403
0.687
0.101
Note. PMHNP = Psychiatric NP, FNP = Family NP. n = 10 for PMHNP, n = 6 for FNP. U =
Mann-Whitney U test statistic; Z = standardized test statistic; p = p-value. r = effect size,
computed as |z|/√𝑁, where z is the standardized test statistic and N is the number of total
observations (Tomczak & Tomczak, 2014).
Table 6 presents the results of Kruskal-Wallis tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with age group. The median
differences for the after and the before knowledge KAP subscale scores were 1 (range = 2), 1
(range = 2), 1 (range = 3), and -0.5 (range = 3), for age group 20-35, 36-50, 51-65, and 66+.
There was no association between age group and differences in the after and the before
intervention knowledge KAP subscale scores (H(3) = 1.563, p = 0.668, ε2 = 0.098).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0 (range = 0), 0 (range = 0), 0 (range = 1), and 0 (range = 0), for age group 20-35,
36-50, 51-65, and 66+. There was no association between age group and differences in the after
and the before intervention attitudes KAP subscale scores (H(3) = 0.889, p = 0.828, ε2 = 0.056).
52
KAP OF PSYCHIATRIC PRESCRIBERS
The median differences for the after and the before intervention practices KAP subscale
scores were 0 (range = 0), 0 (range = 1), 0 (range = 1), and 0.5 (range = 1), for age group 20-35,
36-50, 51-65, and 66+. There was no association between age group and differences in the after
and the before intervention practices KAP subscale scores (H(3) = 1.325, p = 0.723, ε2 = 0.083).
The median differences for the after and the before intervention total KAP scores were 1
(range = 2), 1.5 (range = 2), 1 (range = 3), and 0 (range = 2), for age group 20-35, 36-50, 51-65,
and 66+. There was no association between age group and differences in the after and the before
intervention total KAP scores (H(3) = 1.902, p = 0.593, ε2 = 0.119).
Table 6
Results of Kruskal-Wallis Tests for Determining if Differences in Total and Three Subscales
KAP Scores (After - Before) Were Associated with Age Group
Median (Range)
KAP scale
20-35
ε2
36-50
51-65
66+
H
df
p
Knowledge 1 (2)
1 (2)
1 (3)
-0.5 (3)
1.563
3
0.668 0.098
Attitudes
0 (0)
0 (0)
0 (1)
0 (0)
0.889
3
0.828 0.056
Practices
0 (0)
0 (1)
0 (1)
0.5 (1)
1.325
3
0.723 0.083
Total KAP
1 (2)
1.5 (2)
1 (3)
0 (2)
1.902
3
0.593 0.119
Note. n = 2 for age group 20-35, n = 4 for age group 36-50, n = 9 for age group 51-65, and n = 2
for age group 66+. H = Kruskal Wallis test statistic; df = degrees of freedom; p = p-value. ε2 =
effect size, computed as H/((N2-1)/(N+1)), where H is the Kruskal Wallis test statistic and N is
the total number of observations (Tomczak & Tomczak, 2014).
Table 7 presents the results of Mann-Whitney U tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with sex. The median
53
KAP OF PSYCHIATRIC PRESCRIBERS
differences for the after and the before intervention KAP knowledge scores were 1 (range = 4)
and 0.5 (range = 3) for female and male. There was no association between sex and differences
in the after and the before intervention knowledge KAP subscale scores (U = 24.00, Z = -0.241, p
= 0.871, r = 0.014).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0 (range = 1) and 0 (range = 0) for female and male. There was no association
between sex and differences in the after and the before intervention attitudes KAP subscale
scores (U = 24.00, Z = -0.241, p = 0.871, r = 0.014).
The median differences for the after and the before intervention KAP practices scores
were 0 (range = 1) and 0 (range = 1) for female and male. There was no association between sex
and differences in the after and the before intervention practices KAP subscale scores (U =
26.50, Z = 0.077, p = 1.000, r = 0.005).
The median differences for the after and the before intervention total KAP scores were 1
(range = 3) and 1 (range = 3) for female and male. There was no association between sex and
differences in the after and the before intervention total KAP scores (U = 24.00, Z = -0.241, p =
0.871, r = 0.014).
Table 7
Results of Mann-Whitney U tests for Determining if Differences in Total and Three Subscales
KAP Scores (After-Before) Were Associated with Sex
Median (Range)
Mean rank
KAP scale
Female
Male
Female
Male
U
Z
P
R
Knowledge
1 (4)
0.5 (3)
9.15
8.50
24.00
-0.241
0.871
0.014
Attitudes
0 (1)
0 (0)
9.15
8.50
24.00
-0.241
0.871
0.014
54
KAP OF PSYCHIATRIC PRESCRIBERS
Practices
0 (1)
0 (1)
8.96
9.12
26.50
0.077
1.000
0.005
Total KAP
1 (3)
1 (3)
9.15
8.50
24.00
-0.241
0.871
0.014
Note. n = 13 for female, n = 4 for male. U = Mann-Whitney U test statistic; z = standardized test
statistic; p = p-value. r = effect size, computed as |z|/√𝑁, where z is the standardized test statistic,
and N is the number of total observations (Tomczak & Tomczak, 2014). * indicates significance
at the 0.05 level.
Table 8 presents the results of Kruskal-Wallis tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with years prescribing
medications. The median differences for the after and the before intervention knowledge KAP
subscale scores were 1 (range = 2), 1 (range = 1), 1 (range = 4), and 1 (range = 0), for years
prescribing medications 0-5, 6-10, 11-20, and 21+. There was no association between years of
prescribing medications and differences in the after and the before intervention knowledge KAP
subscale scores (H(3) = 3.379, p = 0.337, ε2 = 0.211).
The median differences for the after and the before intervention attitudes KAP scores
were 0 (range = 1), 0 (range = 0), 0 (range = 0), and 0 (range = 0), for years of prescribing
medications 0-5, 6-10, 11-20, and 21+. There was no association between years of prescribing
medications and differences in the after and the before intervention attitudes KAP subscale
scores (H(3) = 3.250, p = 0.355, ε2 = 0.203).
The median differences for the after and the before intervention practices KAP subscale
scores were 0 (range = 0), 0 (range = 1), 0 (range = 1), and 1 (range = 1), for years of practice 05, 6-10, 11-20, and 21+. There was no association between years of prescribing medications and
differences in the after and the before intervention practices KAP subscale scores (H(3) = 4.542,
p = 0.209, ε2 = 0.284).
55
KAP OF PSYCHIATRIC PRESCRIBERS
The median differences for the after and the before intervention total KAP scores were
1.5 (range = 2), 2 (range = 1), 1 (range = 3), and 1 (range = 1), for years of practice 0-5, 6-10,
11-20, and 21+. There was no association between years of prescribing medications and
differences in the after and the before intervention total KAP scores (H(3) = 3.929, p = 0.269, ε2
= 0.246).
Table 8
Results of Kruskal-Wallis Tests for Determining if Differences in Total and Three Subscales
KAP Scores (After - Before) Were Associated with Years of Prescribing medications
Median (Range)
KAP scale
0-5
6-10
11-20
21+
H
df
P
ε2
Knowledge
1 (2)
1 (1)
1 (4)
1 (0)
3.379
3
0.337
0.211
Attitudes
0 (1)
0 (0)
0 (0)
0 (0)
3.250
3
0.355
0.203
Practices
0 (0)
0 (1)
0 (1)
1 (1)
4.542
3
0.209
0.284
Total KAP
1.5 (2)
2 (1)
1 (3)
1 (1)
3.929
3
0.269
0.246
Note. n = 4 for years of practice 0-5, n = 3 for years of practice 6-10, n = 7 for years of practice
11-20, and n = 3 for years of practice 21+. H = Kruskal Wallis test statistic; df = degrees of
freedom; p = p-value. ε2 = effect size, computed as H/((N2-1)/(N+1)), where H is the Kruskal
Wallis test statistic, and N is the total number of observations (Tomczak & Tomczak, 2014).
Table 9 presents the results of Mann-Whitney U tests for determining if differences in the
total and three subscales KAP scores (After-Before) were associated with practice setting. The
median differences for the after and the before intervention knowledge KAP subscale scores
were 1 (range = 0) and 1 (range = 4) for hospital and outpatient settings. There was no
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association between practice setting and differences in the after and the before intervention
knowledge KAP subscale scores (U = 12.00, Z = -0.475, p = 0.635, r = 0.115).
The median differences for the after and the before intervention attitudes KAP subscale
scores were 0.5 (range = 1) and 0 (range = 0) for hospital and outpatient settings. There was an
association between practice setting and differences in the after and the before intervention
attitudes KAP subscale scores (U = 7.50, Z = -2.739, p = 0.006, r = 0.664). Those participants
who practiced in a hospital setting had a statistically significant increase in attitudes KAP
subscale scores from before to after the web-based educational toolkit presentation compared to
the participants that practiced in outpatient settings.
The median differences for the after and the before intervention practices KAP subscale
scores were 0.5 (range = 1) and 0 (range = 1) for hospital and outpatient settings. There was no
association between practice setting and differences in the after and the before intervention
practices KAP subscale scores (U = 10.50, Z = -0.911, p = 0.362, r = 0.221).
The median differences for the after and the before intervention total KAP scores were 2
(range = 0) and 1 (range = 3) for hospital and outpatient settings. There was no association
between practice setting and differences in the after and the before intervention total KAP scores
(U = 4.00, Z = -1.742, p = 0.081, r = 0.422).
Table 9
Results of Mann-Whitney U Tests for Determining if Differences in Total and Three
Subscales KAP Scores (After-Before) Were Associated with Practice Setting
Median (Range)
KAP scale
Mean rank
Hospital Outpatient Hospital Outpatient U
Knowledge 1 (0)
1 (4)
10.50
8.80
12.00
Z
P
R
-0.475 0.635 0.115
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Attitudes
0.5 (1)
0 (0)
12.75
8.50
7.50
-2.739 0.006 0.664
Practices
0.5 (1)
0 (1)
11.25
8.70
10.50
-0.911 0.362 0.221
Total KAP
2 (0)
1 (3)
14.50
8.27
4.00
-1.742 0.081 0.422
Note. n = 2 for hospital, n = 15 for outpatient. U = Mann-Whitney U test statistic; z =
standardized test statistic; p = p-value. r = effect size, computed as |z|/√𝑁, where z is the
standardized test statistic, and N is the number of total observations (Tomczak & Tomczak,
2014). * indicates significance at the 0.05 level.
Discussion
The knowledge, attitudes, and practices of psychiatric prescribers play a vital role in
utilizing LAIs in clinical practice. Barriers to the use of LAIs in clinical practice are believed to
be the knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers (Ciglar et al., 2016; Correll et al., 2016; Heres et al., 2006, Iyer et al., 2013a; Iyer et
al., 2013b; Llorca et al., 2013; Miles et al., 2011; Patel et al., 2003; Patel et al., 2020; Sajatovic et
al., 2018a; Sajatovic et al., 2018b; Samalin et al., 2013; Weiden et al., 2015). There is a gap in
the literature regarding educational interventions to address the knowledge deficits, uninformed
attitudes, and poor prescribing practices of psychiatric prescribers. This DNP research project
was designed to develop and evaluate the impact of a web-based educational toolkit on
psychiatric prescribers' knowledge, attitudes, and practices regarding LAIs. The aim of this DNP
research project was to develop a web-based educational toolkit for psychiatric prescribers that
would improve their knowledge, attitudes, and practices regarding LAIs.
The research question of this DNP research project asked if the web-based educational
toolkit would have an effect on the knowledge, attitudes, and practices of psychiatric prescribers
regarding LAIs. The independent variable of this DNP research project was the presentation of
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the web-based educational toolkit regarding LAIs. The dependent variables were the knowledge,
attitudes, and practices of psychiatric prescribers. The outcome measures were the differences in
the median total and three KAP subscales scores of participants before and after the presentation
of the web-based educational toolkit regarding LAIs. It was hypothesized that the web-based
educational toolkit would have a positive effect on the knowledge, attitudes, and practices of
psychiatric prescribers regarding LAIs.
The data analysis of this DNP research project revealed that the web-based educational
toolkit regarding LAIs slightly improved the total and three subscales KAP scores of
participants. It also showed that the total and three subscales KAP scores were adequate before
and after the presentation of the web-based educational toolkit about LAIs (Table 3). The
improvement in the total KAP score was statistically significant, with a p-value of 0.003, but the
improvements in the three subscales KAP scores were not statistically significant (Table 4).
Changes in the total and three subscales KAP scores from before to after the web-based
educational toolkit presentation had no association with the participants' demographic factors
except for a relationship found between practice setting and changes in attitudes KAP subscale
scores of participants. Attitudes regarding LAIs had a statistically significant improvement
(p=0.006) for participants working in hospitals compared to participants practicing in an
outpatient setting following the presentation of the web-based educational toolkit about LAIs.
The findings of this DNP research project answered the research question and supported
the hypothesis. The web-based educational toolkit had a positive effect on the knowledge,
attitudes, and practices of psychiatric prescribers regarding LAIs, as evidenced by the outcomes
of the improved total and three subscales KAP scores. However, improvements were slight and
only statistically significant when the totality of the improvements to knowledge, attitudes, and
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practices was combined as a total KAP score. Knowledge, attitudes, and practices are separate
concepts but culminate to have an overall impact on the utilization of LAIs by psychiatric
prescribers in clinical practice.
Even though baseline knowledge, attitudes, and practices of participants were adequate
before and after the intervention, the examination of the participants' KAP questionnaire
responses revealed specific areas of knowledge, attitudes, and practices regarding LAIs that were
impacted by the web-based educational toolkit. There was an improvement in knowledge KAP
subscale scores regarding side effects, plasma levels, duration of effect, pharmacokinetics, and
advantages of LAIs over oral antipsychotics. Several areas of knowledge deteriorated following
the presentation of the toolkit. Participants struggled with complex knowledge regarding expert
recommendations for the use of LAIs, steady states of LAIs, and appropriate patient candidates
for LAIs. If the toolkit were to be utilized in the future, changes would be made to focus on
knowledge areas that deteriorated since the content was complicated. The area of knowledge that
showed the greatest improvement by participants after the presentation of the web-based
educational toolkit was regarding initiation of a LAI before transitioning from a higher level of
care to a lower level of care. Only one area of improvement in attitudes was noted. Following the
web-based educational toolkit presentation, participants' attitudes improved concerning the belief
that patients only prefer oral antipsychotics. Prescribing practices improved related to the
practice of offering a LAI to a patient regardless of a fear of needles or their phase of illness.
In many ways, the results of this DNP research project supported aspects of the review of
literature, but in many ways, they contradicted the review of literature. The review of literature
revealed knowledge deficits, uninformed attitudes, and poor prescribing practices of psychiatric
prescribers regarding LAIs (Ciglar et al., 2016; Correll et al., 2016; Heres et al., 2006; Iyer et al.,
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2013a; Iyer et al., 2013b; Llorca et al., 2013; Miles et al., 2011; Patel et al., 2003; Patel et al.,
2020; Sajatovic et al., 2018a; Sajatovic et al., 2018b; Samalin et al., 2013; Weiden et al., 2015).
Contrary to the review of literature, the psychiatric prescribers of this DNP research project had
adequate knowledge, attitudes, and practices regarding LAIs, which may be related to the fact
that the sample of psychiatric prescribers within the review of literature were all psychiatrists and
in this DNP research project, most participants were primarily experienced nurse practitioners. It
raises questions about possible differences in education and training between psychiatrists and
nurse practitioners regarding LAIs. Other confounding factors that may have contributed to the
unexpected good baseline knowledge, attitudes, and practices of psychiatric prescribers
regarding LAIs in this DNP research study include the date of and the various countries' medical
culture in which the studies within the review of literature were conducted. This DNP research
project was based on a few studies from various countries conducted greater than five years ago.
The time-lapse may have led to improved knowledge, attitudes, and practice of psychiatric
prescribers. The difference in the medical culture in the United States compared to the medical
culture of other countries could result in differences in knowledge, attitudes, and practices
regarding LAIs amongst psychiatric prescribers.
The results indicated that web-based education and toolkits were effective methods to
transfer knowledge to psychiatric prescribers. It also demonstrated that the KTA Framework
assists in translating evidence into practice through the development of tailored educational
materials. The KAP questionnaire responses revealed specific deficits in knowledge, attitudes,
and practices of psychiatric prescribers that were supported by the review of literature.
Knowledge deficits identified by this DNP research project were related to side effects, plasma
levels, duration of effect, pharmacokinetics, advantages of LAIs over oral antipsychotics, and
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appropriate patient candidates for LAIs. Similar knowledge deficits regarding initiation, dosing,
titration, and monitoring of the LAI, Risperdal Consta, were identified in the study by Miles et
al. (2011). The only attitude that improved was the belief that patients always preferred oral
antipsychotics over LAIs. The belief that patients preferred oral antipsychotics was also found in
studies by Ciglar et al. (2016), Iyer et al. (2013b), and Patel et al. (2003). The prescribing
practice of psychiatric prescribers that was found to be poor based on the KAP questionnaire
responses was related to the practice of not offering LAIs due to fear of needles and the phase of
illness of the patient. This finding is similar to studies by Iyer et al. (2013b), Heres et al. (2006),
and Weiden et al. (2015) because they discovered that a lack of offering LAIs was a poor
prescribing practice of physicians that contributed to the underuse of LAIs in clinical practice.
Strengths and Limitations
The strength of this DNP research project is that if served to fill gaps in the literature
regarding LAIs. Few studies evaluated the knowledge, attitudes, and practice of psychiatric
prescribers regarding LAIs, and those that did only evaluated only psychiatrists and excluded all
other psychiatric prescribers. With the shortage of psychiatrists in the United States, many family
nurse practitioners, physician assistants, certified nurse specialists, and psychiatric nurse
practitioners prescribe psychiatric medications to treat those who have schizophrenia. To the
knowledge of this writer, this DNP research project serves as the first study to examine the
knowledge, attitudes, and practices of psychiatric prescribers other than psychiatrists. And there
has been no prior study that attempted to develop and evaluate an educational intervention to
address the gap in the literature regarding the knowledge deficits, uninformed attitudes, and poor
prescribing practices of psychiatric prescribers that are barriers to the utilization of LAIs in
clinical practice.
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Several limitations were associated with this DNP research project. The limitations were
related to the design, process, and recruitment strategy of the project. Any of the limitations may
have affected the results of the data analysis. Limitations within the project design included the
lack of a comparison group. The inclusion of a comparison group in the project's design would
have resulted in data that was representative of the intervention's effectiveness. Also, using one
group with one KAP questionnaire both before and after the intervention may have subjected
participants to sensitization and not revealed the true effect of the web-based educational toolkit
presentation about LAIs, but rather of the exposure to the KAP questionnaire.
The study's process was complex. Participants were required to have access to a
computer with internet capabilities and register as a Moodle® user. Independent completion of
multiple steps by the participants was necessary to finish the module and all data collection.
Many participants were excluded from data analysis due to missing portions of the required data
collection. This most likely occurred because participants were not automatically advanced but
rather had to advance to the next portion of data collection manually. Thus, making it easy to
skip portions of the data collection inadvertently. In addition, the process necessitated a
significant time commitment of at least 30 minutes.
Recruitment endeavors were unsuccessful and not representative of all psychiatric
prescribers. Efforts were made to maximize this DNP research project's visibility to potential
participants but were largely unsuccessful. Recruitment opportunities for psychiatric prescribers
other than nurse practitioners were limited and resulted in a sample that was not diverse. In
addition, the time frame and the specificity of the topic may have contributed to the lack of
participation and resultant small sample size. Those who participated in the DNP research project
were likely highly motivated, desirous of continuing education, and not fully representative of all
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psychiatric prescribers. Due to the limited number of participants and the sample not being
representative of all psychiatric prescribers, this DNP research project's generalizability is
limited.
Implications for Nursing Practice
This DNP research project contributes to the limited body of knowledge regarding LAIs
in many unique ways. It is significant to the profession of psychiatric nursing since it is the first
study that examined nurse practitioners' knowledge, attitudes, and practices regarding LAIs. It is
the only known study that developed a toolkit that targets the knowledge, attitudes, and practices
of psychiatric prescribers regarding LAIs. The developed web-based educational toolkit is
evidence-based and provides a useful resource for psychiatric prescribers regarding the
utilization of LAIs. It stands as a practical reference tool to guide psychiatric prescribers in the
process of prescribing a LAI. It supports web-based education and toolkits as effective
educational interventions to positively affect the knowledge, attitudes, and practices of
prescribers. Web-based education is a convenient, flexible, and effective form of education for
medical professionals. During the current COVID-19 pandemic, it has become necessary to
practice social distancing, making distance learning through web-based education essential.
Lastly, the completion of this DNP research project highlighted areas needing further
investigation regarding the underutilization of LAIs and acts as a catalyst for research regarding
LAIs.
This chapter reviewed the research question and answered it through the data analysis of
this DNP research project. This project aimed to develop and evaluate the impact of a web-based
educational toolkit on psychiatric prescribers' knowledge, attitudes, and practices regarding
LAIs. There were several limitations to this DNP research project, but the project's aim was
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obtained and resulted in several positive implications for psychiatric nursing. Several DNP
Essentials established by the American Association of Colleges of Nursing were utilized
throughout the planning, implementation, and analysis of this project.
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Chapter 5
Summary, Conclusions, and Recommendations
The DNP research project will be summarized in this chapter. Conclusions about this
project and the findings of the data analysis will be drawn. Dissemination strategies of the results
will be discussed. Recommendations for future research based on the findings of this DNP
research project will conclude this final chapter.
Summary of Findings
LAIs are useful pharmacologic tools in the fight against schizophrenia. Still, they are
underutilized in clinical practice due in part to the knowledge deficits, uninformed attitudes, and
poor prescribing practices of psychiatric prescribers (Ciglar et al., 2016; Correll et al., 2016;
Heres et al., 2006, Iyer et al., 2013a; Iyer et al., 2013b; Llorca et al., 2013; Miles et al., 2011;
Patel et al., 2003; Patel et al., 2020; Sajatovic et al., 2018a; Sajatovic et al., 2018b; Samalin et al.,
2013; Weiden et al., 2015). A review of the literature revealed few studies investigating the
issue. Studies that did examine the issue highlighted the specific unmet educational needs of
psychiatric prescribers regarding LAIs. There is a gap in the literature regarding effective
educational interventions to address the knowledge deficits, uninformed attitudes, and poor
prescribing practice of psychiatric prescribers that are barriers to the use of LAIs in clinical
practice. Toolkits and web-based education have shown promise in positively impacting
healthcare providers' knowledge, attitudes, and practices. Web-based education is convenient,
flexible, and necessary due to social distancing during the COVID-19 pandemic.
This DNP research project was based on the KTA Framework, which helped translate
evidence into practice through the knowledge creation and action cycle (Graham et al., 2006). It
was constructed to develop and evaluate the impact of a web-based educational toolkit on
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psychiatric prescribers' knowledge, attitudes, and practices regarding LAIs. The project aimed to
develop an effective educational intervention to eliminate barriers to the use of LAIs by
improving the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. It
was hypothesized that the web-based educational toolkit would have a positive effect on the
knowledge, attitudes, and practices of psychiatric prescribers. Findings of the data analysis of
this DNP research project indicated a slight improvement in knowledge, attitudes, and practices
of psychiatric prescribers following a presentation of the web-based educational toolkit regarding
LAIs, as evidenced by a difference in the before and the after total and three subscales KAP
scores. However, the only statistically significant difference was seen in the total KAP scores of
participants. There were not statistically significant differences in the before and the after three
subscales KAP scores. Changes in knowledge, attitudes, and practices of participants following
the presentation of the web-based educational toolkit had no association with participants'
demographic factors except for an associaition between improvement in attitudes amongst
participants practicing in a hospital compared to those practicing in an outpatient setting.
In assessing the baseline knowledge, attitudes, and practices of psychiatric prescribers
regarding LAIs, it revealed that contrary to the review of literature, psychiatric prescribers had
adequate baseline knowledge, attitudes, and practices regarding LAIs. However, the KAP
questionnaire examination indicated participants of this DNP research study had specific deficits
in their knowledge, attitudes, and practices regarding LAIs that were compatible with previous
studies. Due to the small sample that was not fully representative of all psychiatric prescribers
and its lack of a control group, this DNP research project's results have limited generalizability.
Despite this DNP research project's limitations, it was important to the body of knowledge
regarding LAIs. Although it wasn't the study's purpose, it stands as the only known study that has
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examined the knowledge, attitudes, and practices of psychiatric prescribers other than
psychiatrists. This DNP research project is also the first known study that attempted to create an
educational intervention aimed at improving the knowledge, attitudes, and practices of
psychiatric prescribers to eliminate barriers to the use of LAIs. The results of this DNP research
project indicated the effectiveness of the developed web-based educational toolkit at improving
the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. The web-based
educational toolkit regarding LAIs stands as an effective resource and support tool for
psychiatric prescribers.
Conclusions
In conclusion, this DNP research project answered the established research question.
Findings revealed that the developed and evaluated web-based educational toolkit could
eliminate barriers to the use of LAIs by providing a foundation for positive change to psychiatric
prescribers' knowledge, attitudes, and practices regarding LAIs. It contributed to the limited body
of knowledge regarding LAIs in unique ways by filling gaps in the literature. This DNP research
project is the first study that attempted to develop and evaluate an educational intervention
focused on eliminating the knowledge deficits, uninformed attitudes, and poor prescribing
practices of psychiatric prescribers that contribute to the underutilization of LAIs in clinical
practice. This DNP research project also stands as the only known study that investigated the
knowledge, attitudes, and practices of psychiatric prescribers other than psychiatrists and
revealed differences worthy of further investigation. Although the DNP research project
generated unique information with some significant findings, it is important to note that the
project had flaws that limit generalization. The study sample was small and not representative of
all psychiatric prescribers, and the design was not randomized. Still, this DNP research project
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serves as a platform for further investigation to guide research regarding knowledge, attitudes,
practices, web-based education, toolkits, and LAIs.
Recommendations for Further Research and Dissemination of Findings
This DNP research project indicated that the web-based educational toolkit slightly
improved the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. The
project can be considered feasible and should be implemented in a large randomized control trial
with a more diverse sample to validate the findings. A rigorous study with a control group would
more clearly demonstrate the independent effects of the web-based educational toolkit on the
knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs.
Based on this DNP research project's findings, additional gaps in the literature regarding
LAIs were identified and should be explored. This DNP research project was the first study that
examined the knowledge, attitudes, and practices of psychiatric prescribers other than
psychiatrists. The findings of this DNP research project did not agree with the review of
literature, which indicated that psychiatric prescribers had knowledge deficits, uninformed
attitudes, and poor prescribing practices regarding LAIs. Instead, the results of this DNP research
project showed that psychiatric prescribers had adequate baseline knowledge, attitudes, and
practices regarding LAIs. Since the psychiatric prescribers that comprised the participants of this
DNP research project were primarily nurse practitioners and not psychiatrists, it indicates a
possible difference in education and experience regarding LAIs amongst psychiatrists and nurse
practitioners. Further examination for differences in the knowledge, attitudes, and practices of
various psychiatric prescribers regarding LAIs should be pursued. Most importantly, research
exploring the low utilization rate of LAIs despite adequate knowledge, attitudes, and practices of
psychiatric prescribers could reveal valuable information in the pursuit of maximizing the use of
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LAIs in clinical practice. Lastly, a specific investigation into the practical application of the webbased educational toolkit should be conducted to determine if it influences psychiatric
prescribers' use of LAIs in clinical practice. The web-based educational toolkit could be used as
part of a protocol in a quality improvement project to maximize the use of LAIs in appropriate
patients.
This DNP research project supports web-based education and toolkits as methods to
increase the knowledge, attitudes, and practices of prescribers. Web-based education is valuable
for busy clinicians related to the convenience of asynchronous learning. Due to the COVID-19
pandemic, which necessitates social distancing, web-based education is a practical necessity.
Another advantage of web-based education in the form of a toolkit is that it can be widely and
rapidly disseminated through online resources and platforms. The web-based educational toolkit
about LAIs could easily be integrated into an existing curriculum for psychiatric prescribers.
This study serves as a model for future web-based medical education that supports evidencebased practice.
This DNP research study is a culmination of knowledge and experiences. It reflected the
AACN DNP essentials and was an attempt to improve healthcare indirectly through the
education of psychiatric prescribers. The intent was to positively impact the lives of those with
schizophrenia by educating the psychiatric prescribers that care for them.
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References
Abdulrehman, J., Lausman, A., Tang, G., Nisenbaum, R., Petrucci, J., Pavenski, K., Hicks, L., &
Sholzberg, M. (2019). Development and implementation of a quality improvement
toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A
before-and-after study. PLOS Medicine, 16(8), 1-12.
https://doi.org/10.1371/journal.pmed.1002867
American Psychiatric Association (APA). (2019). The American Psychiatric Association
practice guideline for the treatment of patients with schizophrenia.
https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guide
lines/schizophrenia.pdf
Attitude. (2020). In Merriam-Webser.com dictionary. https://www.merriamwebster.com/dictionary/attitude
Bawo, J., Omoaregba, J., Okonoda, K., Otefe, E., & Patel, M. (2012). The knowledge and
attitudes of psychiatrists towards antipsychotic long-acting injections in Nigeria.
Therapeutic Advances in Psychopharmacology, 2(5), 169-177.
Buckley, P., Schooler, N., Goff, D., Hsiao, J., Kopelowicz, A., Lauriello, J., Manschreck, T.,
Mendelowitz, A., Miller, D., Severe, J., Wilson, D., Ames, D., Bustillo, J., Mintz, J.,
&Kane, J. (2015). Comparison of SGA oral medications and long-acting injectable SGA:
The PROACTIVE study. Schizophrenia Bulletin, 41(2), 449-459.
Ciglar, M., Bjedov, S., & Malekovic, H. (2016). Attitudes of Croatian psychiatrists
towards long-acting injectable antipsychotics. Psychiatria Danubina, 28(3), 273-277.
71
KAP OF PSYCHIATRIC PRESCRIBERS
Cloutier, M., Aigbogun, M., Gueria, A., Nituleseu, R., Ramanakumar, A. Kanah, S., DeLuca,
M., Duffy, R., Legacy, S., Henderson, C., Francois, C., & Wu, E. (2013). The economic
burden of schizophrenia in the United States in 2013. The Journal of Clinical Psychiatry,
77(6), 764-771.
Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences. New York: Routledge.
Cohen, J. (1992). A power primer. Psychological bulletin, 112(1), 155-159.
Correll, C.U., Citrome, L., Haddad, P.M., Lauriello, J., Olfson, M., Calloway, S.M., & Kane,
J.M. (2016). The use of long-acting injectable antipsychotics in schizophrenia: evaluating
the evidence. Journal of Clinical Psychiatry, 77(supplement 3), 1-24.
Dx.doi.org/10.4088/JCP.15032su1
Desai, R., & Nayak, R. (2019). Effects of medication non-adherence and comorbidity on health
resource utilization in schizophrenia. Journal of Managed Care Spec Pharm, 25(1), 37-34.
Emsley, R., Chiliza, B., Asmal, L., & Harvey, B.H. (2013). The nature of relapse in
schizophrenia. BioMed Central Psychiatry, 13(50), 1- 8.
http://www.biomedcentral.com/1471-244x/13/50
Faul, F., Erdfelder, E., Buchner, A., & Lang, A.G. (2009). Statistical power analyses using
G*Power 3.1: Tests for correlation and regression analyses. Behavior Research
Methods, 41, 1149-1160.
Field, A. (2013). Discovering statistics using IBM SPSS statistics. Washington, DC: Sage.
Field, B., Booth, A., Llott, I., & Gerrish, K. (2014). Using the knowledge to action
framework in practice: a citation analysis and systematic review. BioMed Central, 9(172)
http://www.implementationsciende.com/content/9/1/172
72
KAP OF PSYCHIATRIC PRESCRIBERS
Florida Medication Drug Therapy Management Program for Behavioral Health. (2018). Florida
best practice psychotherapeutic medications: Guidelines for adults.
http://www.medicaidmentalhealth.org/_assets/file/Guidelines/2018Psychotherapeutic%20Medication%20Guidelines%20for%20Adults%20wit
h%20References.pdf
Graham, I.D., Logan, J., Harrison, M.B., Straus, S.E., Tetroe, J., Caswell, W., & Robinson, N.
(2006). Lost in knowledge translation: Time for a map? The Journal of Continuing
Education in the Health Professions, 26, 13-24.
Haddad, P., Brain, C., & Scott, J. (2014). Nonadherence with antipsychotic medication in
schizophrenia: challenges and management strategies. Patient-Related Outcome
Measures, 5, 43-62.
Hamer, A. (2006). Medication noncompliance and partial compliance: Identifying
contributing factors methods for improvement. Psychiatric Times, (April), 1-4.
Hasan, A., Falka, P., Wobrock, T., Liebernar, J., Glenthoj, B., Gattaz, W.F., Thibaut, F., &
Moller, H, J. (2013). World Federation of Societies of Biological Psychiatry (WFSBP)
guidelines for biological treatment of schizophrenia, part 2: Update 2012 on the longterm treatment of schizophrenia and management of antipsychotic-induced side-effects.
The World Journal of Biological Psychiatry, 14, 2-44.
Heres, S., Hamann, J., Kissling, W., & Leucht, S. (2006). Attitudes of psychiatrists toward
antipsychotic depot medication. Journal of Clinical Psychiatry,67(12), 1948-1953.
73
KAP OF PSYCHIATRIC PRESCRIBERS
Iyer, S., Banks, N., Roy, M., Tibbo, P., Williams, R., Manchanda, R., Chue, P., & Malla, A.
(2013a). A qualitative study of experiences with and perceptions regarding long-acting
injectable antipsychotics: Part -patient perspectives. Canadian Journal of Psychiatry,
58(5 supplement 1), 14S-22S.
Iyer, S., Banks, N., Roy, M., Tibbo, P., Williams, R., Manchanda, R., Chue, P., & Malla, A.
(2013b). A qualitative study of experiences with and perceptions regarding long-acting
injectable antipsychotics: Part 2-physician perspectives. Canadian Journal of Psychiatry,
58(5 supplement 1), 22S-29S
Kane, J. M., Aguglia, E., Altamura, A. C., Ayuso Gutierrez, J. L., Brunello, N., Fleischhacker,
W. W., Gaebel, W., Gerlach, J., Guelfi, J. D., Kissling, W., Lapierre, Y. D., Lindström,
E., Mendlewicz, J., Racagni, G., Carulla, L. S., & Schooler, N. R. (1998). Guidelines for
depot antipsychotic treatment in schizophrenia. European Neuropsychopharmacology
Consensus Conference in Siena, Italy. European Neuropsychopharmacology : the
Journal of the European College of Neuropsychopharmacology, 8(1), 55 66.
https://doi.org/10.1016/s0924-977x(97)00045-x
Kaplan, G., Casoy, J., & Zummo, J. (2013). Impact of long-acting injectable antipsychotics on
medication adherence and clinical, functional, and economic outcomes of schizophrenia.
Patient Preference and Adherence, 7, 1171-1180.
Knowledge. (2020). In Merriam-Webster.com dictionary. https://www.merriamwebster.com/dictionary/knowledge
74
KAP OF PSYCHIATRIC PRESCRIBERS
Lafeulle, M., Laliberte-Auger, F., Lefebvre, P., Frois, C., Fastenau, & Duh, M. (2013). Impact
of atypical long-acting injectable versus oral antipsychotics on rehospitalization rates and
emergency room visits among relapsed schizophrenia patients: a retrospective database
analysis. BioMed Central, 13(221), 1-11. http://www.biomedcentral.com/1471244x/13/221.
Lafeulle, M., Frois, C., Cloutier, M., Duh, M., Lefebrve, P., Pesa, J., Clancy, Z., Fastenau, J., &
Durkin, M. (2016). Factors associated with adherence to the HEDIS quality measure in
Medicaid patients with schizophrenia. American Health & Drug Benefits, 9(7), 399-409.
Lasser, R.A., Schooler, N.R., Kujawa, M., Jarboe, K., Docherty, J., & Weiden, P. (2009). A new
psychosocial tool for gaining patient understanding and acceptance of long-acting
injectable antipsychotic therapy. Psychiatry, 6(4), 22-27.
Limandri, B. (2019). Long-acting injectable antipsychotic medications: Why aren't they used as
often as oral formulations? Journal of Psychosocial Nursing, 57(3), 7-10.
Lin, C., Chen, F., Chan, H., & Hsu, C. (2019). Time to rehospitalization in patients with
schizophrenia receiving long-acting injectable antipsychotics. International Journal of
Neuropsychopharmacology, 22(9), 541-547.
Llorca, P.M., Abbar, M., Courtet, P., Guillaume, S., Lancrenon, S., & Samalin, L.(2013).
Guidelines for the use and management of long-acting injectable antipsychotics in serious
mental illness. BioMed Central, 13(340), 1-17.
Madsen, T.E., Riese, A., Choo, E.K., & Ranney, M.L. (2014). Effects of a web-based
educational module on pediatric emergency medicine physicians' knowledge, attitudes,
and behaviors regarding youth violence. Western Journal of Emergency Medicine, 15(5),
615-622.
75
KAP OF PSYCHIATRIC PRESCRIBERS
Miles, S.W., Wheeler, A., & Davies, K. (2011). Determining what practicing clinicians believe
about long-acting injectable antipsychotic medication. International Journal of
Psychiatry in Clinical Practice, 15, 135-144.
Miyamoto, S., & Wolfgang-Fleischhacker, W. (2017). The use of long-acting injectable
antipsychotics in schizophrenia. Current Treatment Options in Psychiatry, 4(2), 117-126.
Morrissette, D.A., & Stahl, S.M. (2012). Optimizing outcomes in schizophrenia: long-acting
depots and long-term treatment. CNS Spectrums, 17, 10-21.
doi:10.1017/S1092852912000739
Nasrallah, H.A. (2018). Triple advantages of injectable long-acting second-generation
antipsychotics: Relapse prevention, neuroprotection, and lower mortality. Schizophrenia
Research, 197, 69-70. doi:10.1016/j.schres.2018.02.004
National Institute for Mental Health (NIMH). (2018). Schizophrenia.
https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml#part_154881
National Institute for Health and Care Excellence (NICE). (2014). Psychosis and schizophrenia
in adults: Prevention and management clinical guidelines.
https://www.nice.org.uk/guidance/cg178
Oliveira, A.C., Mattos, S., Coimbra, M. (2017). Development and assessment of an e-learning
course on pediatric cardiology basics. JMIR Medical Education, 3(1):e10. doi:
10.2196/mededu.5434
Patel, M.X., Bent-Ennakhil, N., Sapin, C., Di Nicola, S., Loze, J.Y., Nylander, A.G., & Heres, S.
(2020). Attitudes of European physicians towards the use of long-acting injectable
antipsychotics. BMC Psychiatry, 20(123) 1-11. https://doi.org/10/.1186/s12888-02002530-2
76
KAP OF PSYCHIATRIC PRESCRIBERS
Patel, M., & David, A. (2005). Why aren't depot antipsychotics prescribed more often, and
what can be done about it? Advances in Psychiatric Treatment, 11, 203-211.
http://apt.rcpsych.org/
Patel, M.X., Nikolaou, V., & David, A.S. (2003). Psychiatrists' attitudes to maintenance
medication for patients with schizophrenia. Psychological Medicine, 33, 83-89.
Poloni, N., Ielmini, M., Caselli, I., Lucca, G., Gasparini, A., Lorenzoli, G., & Callegari, C.
(2019). Oral antipsychotic versus long-acting injections antipsychotic in schizophrenia
spectrum disorder: a mirror analysis in a real-world clinical setting. Psychopharmacology
Bulletin, 49(2), 17-27.
Potkin, S., Bera, R., Zybek, D., & Lau, G. (2013). Patient and prescriber perspectives on longacting injectable (LAI) antipsychotics and analysis of in-office discussion regarding LAI
treatment for schizophrenia. BioMed Central, 13(261), 1-11.
http://www.biomedcenteral.com/1471-244x/13/261
Practice. (2020). In Merriam-Webster.com dictionary. https://www.merriamwebster.com/dictionary/practice
Prescriber. (2020). In Merriam-Webster.com dictionary. https://www.merriamwebster.com/medical/prescriber
Psychiatric nurse practitioner. (2020). In Wikipedia.com.
https://en.wikipedia.org/wiki/Psychiatric-mental_health_nurse_practitioner
Sajatovic, M., Ross, R., Legacy, S., Byerly, M., Kane, J., DiBiasi, F., Fitzgerald, H., Correll, C.,
(2018a). Initiating/maintaining long-acting injectable antipsychotics in
schizophrenia/schizoaffective or bipolar disorder-expert consensus survey part 2.
Neuropsychiatric Disease and Treatment, 14, 1475-1492.
77
KAP OF PSYCHIATRIC PRESCRIBERS
Sajatovic, M., Ross, R., Legacy, S., Correll, C., Kane, J., DiBiasi, F., Fitzgerald, H., Byerly, M.
(2018b). Identifying patients and clinical scenarios for the use of long-acting injectable
antipsychotics-expert consensus survey part 1. Neuropsychiatric Disease and Treatment,
14, 1463-1474.
Samalin, L., Charpeaud, T., Blanc, O., Heres, S., & Llorca, P.M. (2013). Clinicians' attitudes
toward the use of long-acting injectable antipsychotics. The Journal of Nervous and
Mental Disease, 201(7),553-559.
Samalin, L., Garnier, M., Auclair, C., & Llorca, P. (2016). Clinical decision- making in the
treatment of schizophrenia: Focus on long-acting injectable antipsychotics. International
Journal of Molecular Sciences, 17(1935), 1-8. doi:10.3390/imjms17111935
Subotnik, K.L., Casaus, L.R., Ventura, J., Luo, J.S., Hellemann, G.S., Gretchen- Doorly, D.,
Marder, S., & Nuechterlein, K.H. (2015). Long-acting injectable Risperidone for relapse
prevention and control of breakthrough symptoms after a recent first episode of
schizophrenia: A randomized clinical trial. JAMA Psychiatry, 72(8), 822-829.
Taylor, D.M., Velaga, S., & Werneke, U. (2018). Reducing the stigma of long-acting injectable
antipsychotics-current concepts and future developments. Nordic Journal of Psychiatry,
72(51), 536-539.
Texas Medication Algorithm Project (TMAP). (2008). Schizophrenia algorithm procedural
manual. https://www.cdphp.com/-/media/files/providers/behavioral-health/hedis-toolkitand-bh-guidelines/tmap-schizophrenia.pdf?la=en
Web-based. (2020). In dictionary.com. https://www.dictionary.com/browse/web-based
Tomczak, M., & Tomczak, E. (2014). The need to report effect size estimates revisited. An
overview of some recommended measures of effect size. TSS, 21(1), 19-25.
78
KAP OF PSYCHIATRIC PRESCRIBERS
Weiden, P.J., Roma, R.S., Velligan, D.I., Alphs, L., DiChiara, M., & Davidson, B. (2015). The
challenge of offering long-acting injectable antipsychotic therapies: A preliminary
discourse analysis of psychiatrist recommendations for Injectable therapy to patients with
schizophrenia. Journal of Clinical Psychiatry,76(6), 684-690.
Yamada, J., Shorkey, A., Barwick, M., Widger, K., Stevens, B.J. (2015). The effectiveness of
toolkits as knowledge translation strategies for integrating evidence into clinical care: a
systematic review. BMJ Open, 5, 1- 10. doi:10.1136/bmjopen-2014-006808
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APPENDIX A
Knowledge
1. Long-acting injectable antipsychotics are only for patients that have a history of medication
non-adherence. T or F
2. A long-acting injectable version of an antipsychotic causes more side effects than its oral
equivalent. T or F
3. A preferred time to start a long-acting injectable antipsychotic is during a transition from a
higher level to a lower level of care. T or F
4. If long-term use of an antipsychotic is necessary, a long-acting injectable antipsychotic should
be considered. T or F
5. There is less individual variation in plasma levels with a long-acting injectable antipsychotic
than an oral antipsychotic. T or F
6. In an adverse event, the duration of a long-acting injectable antipsychotic is a disadvantage. T
or F
7. The pharmacokinetics of long-acting injectable antipsychotics are based on elimination
pharmacokinetics as opposed to absorption pharmacokinetics. T or F
8. Long-acting injectable antipsychotics offer a practical solution for the common problem of
medication non-adherence in those with schizophrenia. T or F
9. Experts recommend limited use of long-acting injectable antipsychotics. T or F
10. An advantage of long-acting injectable antipsychotics is that they typically take a longer time
to reach a steady-state. T or F
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11. Long-acting injectable antipsychotics are more effective than oral antipsychotics at
decreasing rehospitalization rates, relapse rates, psychotic symptom severity, and ER visits. T or
F
Attitudes
12. Patients always prefer an oral antipsychotic over a long-acting injectable antipsychotic. T or
F
13. The practice of prescribing a long-acting injectable antipsychotic is coercive. T or F
14. Prescribing a long-acting injectable antipsychotic is not part of patient-centered care or
shared decision-making. T or F
15. Discussing a long-acting injectable antipsychotic will harm the established relationship with
a patient. T or F
16. Patients prescribed a long-acting injectable antipsychotic usually have a history of
noncompliance and incarceration. T or F
17. A long-acting injectable antipsychotic is an outdated form of pharmacological treatment for
those with schizophrenia. T or F
Practices
18. When discussing a long-acting injectable antipsychotic, both the advantages and
disadvantages should be discussed with the patient. T or F
19. If a patient has a fear of needles, a long-acting injectable antipsychotic should not be offered
as a treatment option. T or F
20. A long-acting injectable antipsychotic should be offered as a treatment option for those with
schizophrenia from the first episode of schizophrenia to those in recovery. T or F
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APPENDIX B
1. What is your age?
a. 20-35
b. 36-50
c. 51-65
d. 66 and over
2. What is your sex?
a. Male
b. Female
3. What is the number of years you have been prescribing medications?
a. 0-5
b. 6-10
c. 10-20
d. 21 plus years
4. What is your professional designation?
a. Physician
b. Psychiatric Nurse Practitioner
c. Physician Assistant
d. Nurse Specialist
e. Family Nurse Practitioner
5. What is your place of practice?
a. Hospital
b. College/University
c. Outpatient practice
d. Long-term care
e. Home care
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Figure 1. The Knowledge to Action Framework. From Graham I, Logan J, Harrison M,
Strauss S, Tetroe J, Caswell W, Robinson N: Lost in knowledge translation: Time for a
map? The Journal of Continuing Education in the Health Professions 2006, 26, (1), p. 19.