Reducing Suicide by Providing Cognitive Behavioral Therapy for Suicide Prevention

Veteran suicide is a serious and persistent national problem, which demands an effective treatment intervention. This Evidence-Based Practice project (EBP) addressed the question: Do patients with a psychiatric in-patient admitting diagnosis of suicidal ideation, who after discharge self-elect outpatient Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP) treatment over a 6-week time frame, reduce the likelihood of hospital readmission for suicidal ideation vs. patients who decline CBT-SP treatment and elect Treatment as Usual (TAU)? The literature is prolific in validating that CBT-SP is successful in determining the effectiveness of CBT-SP versus TAU in reducing suicidal behaviors in adults. Hospital re-admission data were collected on both the CBT-SP and the TAU groups. The CBT-SP group collected a further measure utilizing the Quality of Life (QOL) Scale pre and post CBT-SP group intervention. Demographic variables of age, sex, and homelessness were compared to assess variability between the two groups. The CBT-SP and the TAU groups were compared for rehospitalization utilizing the Fisher exact test, which was statistically significant at p < 0.05 for no rehospitalizations in the CBT-SP group and six rehospitalizations in the TAU group over a 6-week period. The Wilcoxon Signed Rank Test was used to analyze the difference between the pre and post QOL scores within the CBT-SP group and the results demonstrated a statistically significant positive increase in QOL scores at p < 0.004. The only difference in the group demographic variables was for age, after utilizing a non-paired t-test results produced a significance at p < 0.03, with the CBT group mean age being approximately ten years younger than the TAU group. Evaluation of outcome measures confirmed a decrease in hospital readmissions for suicide ideation and/or attempt and an increase in quality of life scores for the CBT-SP group. REDUCING SUICIDE BY PROVIDING COGNITIVE BEHAVIORAL THERAPY 1 Reducing Suicide by Providing Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) in the Out-Patient Setting Suicide rates in America are increasing. Suicide is now the 10th leading cause of death in America, claiming more lives than traffic accidents and twice as many lives as homicides (Sentinel Alert Event, 2016). Alarmingly, suicide rates have increased by 33% from 1999 through 2017 (Center for Disease Control and Prevention: National Center for Health Statistics, 2019). Veteran suicide is also on the increase with 13.5% of Veterans accounting for all deaths by suicide in 2017 in the U.S. and constituted 7.9% of the U.S. adult population (US Department of Veteran Affairs, 2019) Hence, suicide prevention is a national Veteran Health Administration (VHA) priority and mission. Cognitive behavioral therapy for suicide prevention (CBT-SP) is theoretically grounded and incorporates evidence-based practice principles of psychological therapy. CBT-SP is a 6-12 week therapy aimed to understand problems associated with the relationship between thoughts, physiological sensations, emotions, and behaviors (Bryan et al., 2018). This Doctor of Nursing Practice (DNP) project proposed a practice change for implementing evidence-based CBT-SP in the outpatient setting at a large East Coast VA hospital. This 6-week EBP intervention compared CBT-SP versus Treatment as Usual (TAU) with post discharged psychiatric patients with an admitting diagnosis of suicidal ideation or attempt. The intervention involved an interprofessional team of mental health nurses, advance practice nurses, psychologists, licensed mental health counselors, and two DNP preceptors. The intervention explored the rehospitalization rates of the CBT-SP versus the TAU groups and the Quality of Life pre and post measures of the CBT-SP group. REDUCING SUICIDE BY PROVIDING COGNITIVE BEHAVIORAL THERAPY 2 Significance of the Practice Problem In 2017, United States Veteran suicide deaths were 6,139 (National Veteran Suicide Prevention Annual Report, 2019). According to the National Veteran Suicide Prevention Annual Report (2019), the number of Veteran suicide deaths has exceeded 6,000 each year from 2008 to 2017. Suicide prevention is a national VHA priority and mission. The most recent VHA campaign to prevent Veteran suicide was the executive order, President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS), signed in March 2019 (National Veteran Suicide Prevention Annual Report, 2019). For the Veteran Health Administration (VHA) the statistical data for Veteran suicide increased from 15.9% in 2005 to 16.8% in 2017 (National Veteran Suicide Prevention Annual Report, 2019). Among U.S. adults, the average number of suicides per day rose from 86.6 in 2005 to 124.4 in 2017. These numbers included 15.9 Veteran suicides per day in 2005 and 16.8 in 2017. The suicide rate for Veterans, in 2017 was 1.5 times the rate for non-Veteran adults, after adjusting for population differences in age and sex (National Veteran Suicide Prevention Annual Report, 2019). The U.S. Department of Veterans Affairs (VA) National Strategy for Preventing Veteran Suicide: 2018-2028, is very clear in its mission. The VHA is treating suicide as a national public health tragedy that impacts not only Veterans but also people from all walks of life (Office of Mental Health and Suicide Prevention, 2018). The VHA has embraced a comprehensive public health model, that while remains evidenced based, it seeks to reach beyond the traditional medical model of prevention by ensuring interprofessional, family, and community active participation nationwide (Office of Mental Health and Suicide Prevention,


Significance of the Practice Problem
In 2017, United States Veteran suicide deaths were 6,139 (National Veteran Suicide Prevention Annual Report, 2019). According to the National Veteran Suicide Prevention Annual Report (2019), the number of Veteran suicide deaths has exceeded 6,000 each year from 2008 to 2017. Suicide prevention is a national VHA priority and mission. The most recent VHA campaign to prevent Veteran suicide was the executive order, President's Roadmap to Empower

Framework and Change Theory
The organization was assessed and deemed ready for practice change with leadership in full support. The theoretical framework that best fit this project was The Stevens' ACE STAR Model of Knowledge Transformation and it was selected as the framework due to its systematic integration of evidence into daily practice (Stevens, 2010) (see Figure 1). Stevens' ACE STAR model is comprised of five major stages for hastening healthcare improvements in science and is known as one of the most used frameworks to transform improvement science into safe patient clinical practice (Correa-de-Araujo, 2016). Stevens' theory is also considered a paradigm of continual monitoring of changes evidence-based practice has on patient care in order to evaluate its effectiveness at achieving the right patient outcomes (Bonis et al., 2007).
DMAIC is an acronym for a five-part process used to Define, Measure, Analyze, Improve, and Control improvement performance and is an approach of Lean Six Sigma (LSS).
Its value in healthcare focuses on improving the patient experience by making sure that quality processes consistently deliver the desired positive patient outcome results. It also helps service providers to reduce waste and variation in the service processes (Ahmed, 2019) (See Figure 3).
The DMAIC model was used to effectively implement a timeline to monitor and expedite the change project. DMAIC was used in the change project as a framework to improve existing programs or process. The Stevens' Model and the DMAIC processes aligns well with the VHA's dedication to educational, teaching, and patient improvement outcome endeavors designed at achieving the highest level of quality healthcare and performance improvements. The organization, interprofessional team, and the Mental Health and Behavioral Sciences (MH&BS) was assessed as ready for practice change. The VHA Hospital and MH&BS leadership support was attained.

PICOT Question
Do patients with an admitting diagnosis of suicidal ideation and a psychiatric inpatient introduction to Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP) and who consequently after discharging self-elect outpatient CBT-SP treatment, reduce the likelihood of readmission for suicidal ideation vs. patients who decline CBT-SP treatment and elect Treatment as Usual (TAU) over a six-week period?

Population
The population included a convenience sample, from a large VA Hospital Emergency Department in the southeast, comprised of adult men and women, ages 18-90 years of age who are Veterans from all wars and experienced suicidal ideation and/or suicide attempts. These individuals had multiple mental health diagnoses and were admitted with suicide ideation and identified by a positive Columbia-Suicide Severity Rating Scale (C-SSRS).

Intervention
The project's change intervention was to roll-out CBT-SP within the outpatient department of the designated VA hospital. Multiple mental health professionals provided a CBT-SP for 6-weeks. Patients who were interested and agreed to participate in CBT-SP and the change project were tracked and data analytics maintained.

Comparison
There was a comparison of patients between the CBT-SP and the TAU groups regarding hospital readmissions and a pre and post score comparison on the Quality of Life Scale (Burckhardt & Anderson, 2003) (see Appendix A) for the CBT-SP group only. The demographic variables of age, sex, and homelessness was also compared to check for variability.

Outcome
The outcomes measured were the rehospitalization rate and shifts in patient perception of Quality of Life. Any decrease in rehospitalization rate or improvement in Quality of Life denoted clinical significance. A p <0.05 is required for statistical significance.

Timeline
The DNP scholarly change project timeline was approximately 6-weeks of outpatient CBT-SP therapy. Once the University of St. Augustine and a large VA hospital in the southeast conducted and approved the EBP processes, implementation of the change project began . setting; outpatient care settings and (c) reports objectively measured patient health-related outcome. Forty evidenced-based, peer reviewed research articles were obtained. The studies were randomized controlled trials (RCT), systematic reviews, meta-analysis, qualitative and quantitative and mixed methodology. The articles were reviewed for level and quality by using the Johns Hopkins Nursing Evidence-Based Practice Level and Quality Guide (Dearholt & Dang, 2012). The articles included a combination of Level 1-3 and Grade High-Moderate.

Literature Search Strategy
Exclusion criterion was student participation and age under 18.

Literature Search Results and Evaluation
The online search resulted in 106 citations from CINAHL, 21 citations from Medline, 193 citations from PubMed, and 53 citations from ProQuest. The total number of articles were reduced when duplicate articles were excluded. Inclusion criteria allowed (1) suicide and selfinjury; (2) suicide meta-analysis and meta-regression literature; (3) retrospective study of Root Cause Analysis literature; (4) allowance of various settings/environments outpatient mental health follow-up utilizing CBT-SP occurred. Exclusion criteria restricted database search to (1) adults 18 years and older; (2) peer-reviewed research and journal articles earlier than 2005 were restricted except for the two historical articles dated 2005. All other articles were 2014-present.
Hence the relevant studies were narrowed to the 12 shown in the evidence table (see Figure 2).
The Johns Hopkins Nursing Evidence-Based Practice Rating Scale (Dearholt & Dang, 2012) was used to determine the table of the evidence. There were 12 Randomized Controlled Trial (RCT) studies included in the search of the literature. Of the studies, six were single study RCTs, of which five were of level I quality and five were Grade A and the sixth was Grade B (see Table 1). The search of literature produced six systematic reviews, which were a level II and had an overall strength of evidence grade high to moderate. The overall strength of the aggregate evidence had a high to moderate grade (see Table 1). A summary of primary resources and systematic reviews included themes of the efficacy of CBT versus TAU, efficacy of CBT for suicide ideation and attempts, and CBT-SP in reducing suicide ideation and attempts with Veteran populations (see Table 1).

Themes from the Evidence
The primary themes found in the literature were compared with non-VHA and VHA national protocols, regulations, and directives. A summary of the thematic primary resources and systematic reviews summary is contained in Appendix B. The Johns Hopkins Evidence Level and Quality Guide was used to identify high-quality, evidence-based resources from peer reviewed journals. The literature included three themes: cognitive behavioral therapy versus treatment as usual, effectiveness of cognitive behavioral therapy in reducing suicidal ideation, and the effectiveness of cognitive behavioral therapy in reducing suicidal ideation in the veteran population.

Cognitive Behavioral Therapy versus Treatment as Usual
Cognitive Behavioral Therapy (CBT) versus Treatment as Usual (TAU) emerged from four studies; two primary RCT (Bryan et al., 2018;Haddock et al., 2016) and three systematic reviews, RCTs (Gotzsche & Gotzsche, 2017;Watts et al., 2014;Witt et al., 2018). The three primary reviews were longitudinal RCTs, varying from six months and two years, in which all demonstrated CBT-SP versus Treatment as Usual (TAU) was superior (Brown et al., 2005;Bryan et al., 2018;Rudd et al., 2015). One systematic review demonstrated a 60% decrease in suicide ideation (Bryan et al., 2018;Haddock et al., 2016). The strength of the three systematic studies was the adherence to the CONSORT principles. Another strength of these studies was that participants completed interview assessments at serial times post baseline by an independent evaluator who was blinded to the treatment conditions. The three systematic review studies were large reviews. One had 18 RCTs and the other 48 RCTs, and the last had 7 RCTs. Two studies had large sample participant numbers in the thousands which strengthened the studies. However, there was considerable variability amongst the studies. In all three systematic studies CBT was found to be significantly superior to TAU (Gotzsche & Gotzsche, 2017;Watts et al., 2014;Witt et al., 2018). All studies are outlined in Appendix B. An overall weakness in the three systematic reviews was TAU was often operationally not well defined and this contributed to the limitation of many of the studies.

Effectiveness of Cognitive Behavioral Therapy in Reducing Suicidal Ideation
Effectiveness of Cognitive Behavioral Therapy in Reducing Suicidal Ideation emerged from two primary source studies, one RCT and one retrospective report review respectively (Brown et al., 2005;Riblet et al., 2017). The RCT was an 18-month longitudinal study and CBT-SP proved more effective, but its weakness as compared to the Theme I longitudinal studies is that it did not have comparably large sample sizes. The retrospective report of root cause analysis (RCA) of deaths within seven days of discharge from an inpatient psychiatric hospital for suicide ideation or attempt was longitudinal, like those in Theme I, over an eight years' timeframe.
There were five systematic reviews (Brown & Jager-Hyman, 2014;Calati & Courtet, 2016;Ghahramanlou-Holloway et al., 2015;Mewton & Andrews, 2016;Tarrier et al., 2008). The five systematic reviews all had large RCT reviews ranging from 16 to 32. One RCT systematic review had randomized patients greater than 4,000 in number (Calati & Courtet, 2016). All reviews were successful in determining the effectiveness of CBT-SP versus TAU in reducing suicidal behaviors in adults. All five systematic reviews identified studies from PsycINFO, Cochrane Library and/or Web of Science databases. One systematic review cited the intervention of reducing suicide ideation and attempts by introducing CBT-SP while patients are on the acute in-patient psychiatric units (Ghahramanlou-Holloway et al., 2015). The strength of all five systematic reviews was each had serial monitoring of the effectiveness of CBT-SP. Sources are depicted in Appendix B. Unfortunately, all five had enormous variability across the studies in both method and treatment techniques, which was considered a limitation.

Veteran Population
Effectiveness of Cognitive Behavioral Therapy in Reducing Suicidal Ideation in the Veteran Population was developed from three primary source studies (Brown et al., 2016;Bryan, Rozek et al., 2019;Rudd et al., 2015). The evidence search bore an RCT evaluating the effects of CBT-SP versus TAU in a longitudinal study with two-year follow-up (Rudd et al., 2015). One study was of a Veteran Training Program with a sample size of 900 plus Veterans evaluating the effectiveness of CBT for depression and suicide (Brown et al., 2016) and lastly there was a study evaluating the patterns of change and fluid vulnerability of suicide ideation in high-risk suicidal military soldiers (Bryan et al., 2019). The three studies had results that indicated CBT-SP and depression treatment was effective in reducing suicide ideation and re-attempt episodes. One study cited the odds of suicide re-attempts decreased by 64% at final assessment (Brown et al., 2016) (see Appendix B).

Practice Recommendations
A methodical review of the literature answered the PICOT question by establishing that the implementation of Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP) was effective for reducing the likelihood of readmission for suicidal ideation versus patients who decline CBT-SP treatment and elect Treatment as Usual (TAU). The Johns Hopkins Nursing Evidence-Based Practice Level and Quality Guide was used to verify the quality and level of evidence-based literature (Dearholt, & Dang, 2012). The strength of the literature substantiated the practice change recommendation. A synthesis of evidence found in the literature revealed the conclusion that implementation of the intervention of CBT-SP reduced hospital re-admission for suicide ideation and/or suicide attempts.
Most of the primary studies utilized a measurement tool. The Beck Depression Inventory-II (BDI-II), was a common tool used and has high validity and reliability. The BDI-II has a reliability range of 0.73 to 0.96 and validity showed good sensitivity and specificity in the detection of depression (Wang & Gorenstein, 2013). The Hamilton Rating Scale for Depression (HRSD) was another common tool used and has a test-retest reliability rage of 0.65 to 0.98 (Trajkovic et al., 2011). The primary studies also utilized other quality of life assessment tools.
The integrity of the research design was addressed in all the research studies. Three of the RCT primary studies were longitudinal in design with high sample size, Level 1, and Grade A.
The Brown et al., (2005) 18-month longitudinal study for example found that patients that presented to the hospital following a suicide attempt and who received CBT-SP were 50% less likely to reattempt suicide during the follow-up period than those in the TAU group. The Rudd et al., (2015) two-year longitudinal study showed military personnel who were in the CBT-SP were 60% less likely to attempt suicide than those who were TAU. The primary studies had variability pertaining to the Clinical Trial Assessment Measure (CTAM) [sample size and recruitment method, assignment to treatment, assessment of outcome, control group, description of treatment and statistical analyses] (Lobban et al., 2013), but overall found in favor of CBT-SP as opposed to TAU.
The systematic reviews adhered to the CONSORT principles in choosing the studies for review inclusion. There are six of the eight systematic reviews from the Cochrane Library database for a total of 183 RCTs with a Grade of High to Moderate. Although there were a few mixed findings and some limitations within the selected RCTs; overall, there is moderate to high evidence that CBT-SP based interventions focused on suicide prevention are effective at reducing repeat suicide occurrences. These findings align with the VA/DoD Clinical Practice Guideline (CPG) for the Assessment and Management of Patients at Risk for Suicide (2019).
The CPG reviewed eleven studies of which eight were primary sources and three systematic reviews. This DNP scholarly review has four of the eleven CPG studies, one of which is a systematic review (Gotzsche & Gotzsche, 2017) and three primary sources (Brown et al., 2005;Riblet et al., 2017;Rudd et al., 2015). The strength of the overall evidence supports the implementation of CBT-SP as an effective intervention for the reduction of suicide ideation and reattempts. CBT-SP is considered a strong recommendation by the CPG with little to no risk to patient well-being. Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP) is effective for reducing the likelihood of readmission for suicidal ideation versus patients who decline CBT-SP treatment and elect Treatment as Usual (TAU).

Project Setting
The location for this DNP scholarly project was the mental health out-patient clinic setting of a large adult tertiary care level-1 415 bed hospital on the southwest coast of Florida, which is part of a much larger VHA organization. The facility provides Veteran care for primary care, tertiary care, and long-term care in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, spinal cord injury, neurology, oncology, dentistry, geriatrics, and Details regarding the organizational structure, culture, needs assessment, stakeholders, project support and sustainability, interprofessional collaboration, and a SWOT analysis were discussed below (see Appendix C).

Organizational Structure
The project setting was a large VHA health care network. The care model includes multiple health care settings, including acute care, urgent care, community-based out-patient clinics (CBOCs), specialty care, and long-term care nursing centers. The business model is a notfor-profit quality healthcare organization. The organizational structure included a Pentad consisting of a Director, which is the equivalent of a CEO, a Deputy Director the equivalent of a

Organizational Culture
The VHA organization is a culture of diversity and inclusion both with patients and staff. The patient culture is patient-centered with an overlay of a military culture that is on the journey of becoming a High Reliability Organization (HRO). VHA nurses becomes adept in recognizing symptoms and sequelae of posttraumatic stress disorder, traumatic brain injury, and military sexual trauma that lead to suicide ideation and suicide attempts. There are increased risks among veterans for suicidality and substance abuse, and nurses are taught to screen accordingly.

Organizational Need
An organizational needs assessment was completed. Variable cost per bed per day of care for inpatient psychiatry is approximately $1,242.00 and the length of stay is approximately five to seven days, providing there is no other psychiatric co-morbidity (B. Konkel, personal communication, January 20, 2020;W. Levy, personal communication, January 25, 2020). A review of the group programming in the out-patient psychiatric setting revealed that while Cognitive Behavioral Therapy (CBT) was being conducted there was no specific group that addressed CBT for suicidal ideation. Psychiatric leadership then gave the approval and support needed to conduct this DNP scholarly project utilizing CBT-SP.

Organizational Support
The Chief of Psychiatry was the first administrator to provide support for this DNP scholarly project and encouraged other staff members to lend their support. The physician Suicide Prevention Coordinator and psychologist Suicide Prevention Team Leader also had been a tremendous support in providing information and guidance on this project. The in-patient psychiatrists as well as the two DNP preceptors were extremely implemental in working on this change project.

Stakeholders
Brainstorming was the tool used to identify those individuals whose interests are affected by the DNP scholarly project of CBT-SP. A simple three column chart was used to brainstorm to identify the criteria needed to determine the appropriate stakeholders (see Appendix D). While the Input, Tools & Techniques, and Output were used to brainstorm, the initial stakeholders were identified as the Chief of Psychiatry, psychiatrist, psychologist, admitting emergency department psychiatrist, nursing service, social work service, two DNP preceptors, and a data/IT. It was critical for the success of the project to have key stakeholders.

Sustainability
Sustainability is the successful outcome of process and practice improvements over time.
In a High Reliability Organization (HRO), a culture of safety is critical for sustainability (Agency for Healthcare Research and Quality, 2019). The VHA is on the journey of becoming an HRO. VHA is a highly complex healthcare system and culture change can be difficult. Yet, based on the fluidity of healthcare, changes must be made. Shifting to the culture of HRO can assist all staff with accepting and adapting to continuous change. The first pillar is leadership commitment, which provides facility leaders and frontline staff the education regarding the importance of leadership support (Andriulo et al., 2015). Essentially, an organizational change that incorporates safety and resilience will be reflected in the vision, mission, and actions of leadership. The second pillar is the implementation of a safety culture. According to Sullivan (2019), implementing a culture of safety will encourage all employees in the organization to implement safety values and practices to assist with the prevention of harm to patients. A culture of safety, that is just, also allows organizational employees the ability to learn from errors to continuously make process improvement, which is the third pillar (

Interprofessional Collaboration
Interprofessional collaboration is fundamentally necessary. Interprofessional teams or multidisciplinary teams are not new to the VHA (VHA Locations, n.d.). The Interprofessional Professionalism Assessment (IPA) tool is a five principle, 26 item "observational rating tool used by faculty/preceptors to assess learners' professionalism when working with members of other health professions" (National Center for Interprofessional Practice and Education, 2018). There are five principles of the IPA that resonate as extremely important to interprofessional teamwork: 1) Communication, 2) Respect, 3) Altruism and Caring, 4) Excellence, and 5) Ethics.
Psychometric properties were tested with 10 health professions to determine its reliability and validity across multiple health care professions (National Center for Interprofessional Practice and Education, 2018). Patients were identified as suicidal on the inpatient psychiatric unit by nursing/data team member. Education on the benefits of CBT-SP was offered to patients at discharge by the DNP student and/or psychologist. Those accepting outpatient 6-week CBT-SP therapy was followed as well as the TAU group by the interprofessional team.

Strengths, Weaknesses, Opportunities and Threat Analysis (SWOT)
The SWOT analysis identified that the organization has competitive strengths with their organization's core values and mission directives towards quality care (see Appendix C).
Weaknesses stem from external directives from Congress through national mandates that are not quality or evidence based. Opportunities for evidence-based clinical practice are supported and readily available to staff that are willing to take the initiative. Threats to clinical practice are very real and not easily remedied. Pay scales are dictated externally by the VISN. They are reviewed every two years and are very resistant to increases in comparison to the private sector. The Office of the Director is not supportive of flexible shifts. These are threats to maintaining the quality of our clinical practice. The organization has strengths, weaknesses, opportunities, and threats. Overall, they are aimed at quality care and evidence-based clinical practice and remain a desired organization to work for.

Project Vision and Mission
To provide veterans the world-class benefits and services they have earned and to do so by adhering to the highest standards of compassion, commitment, excellence, professionalism, integrity, accountability, and stewardship (James A. Haley VA Hospital & Clinics [JAHVAHC], personal communication, June 26, 2019). The vision of this project was to fully implement a CBT-SP 6-week outpatient program to reduce suicide attempts and suicide ideation by decreasing hospital admissions related to suicide. The project mission was the integration of CBT-SP, a theoretically grounded evidence-based practice principles of psychological therapy aimed to understand problems associated with the relationship between thoughts, physiological sensations, emotions, and behaviors (Bryan et al., 2018). The mission of the project aligns with VHAs mission of providing the highest standard of quality care to our Nation's Veterans.

Project Objectives
The U.S. Department of Veterans Affairs (VHA) National Strategy for Preventing Veteran Suicide: 2018-2028, is very clear in its mission of treating suicide as a national public health tragedy that impacts not only Veterans but also people from all walks of life. The objective of this project was to implement a 6-week therapy for prompt CBT-SP. Patients were identified on the inpatient psychiatric unit and offered outpatient CBT-SP therapy at discharge.
Early intervention of CBT-SP may reduce or prevent reattempts of suicide, both while inpatient and outpatient.

Short-Term Goals
A short-term goal of CBT-SP was identified and immediately assessed to provide suicide prevention therapy for newly discharged patients diagnosed with suicide ideation. Continuum of care from acute inpatient psychiatry to instant outpatient follow-up. The expected outcome of decrease suicide rates with active participation in outpatient CBT-SP should be evident within 6 weeks of treatment (Mewton et al., 2014).

Long-term Goals
Long term goal would be the culmination of the DNP scholarly change project with every aspect of the project process emphasizing the strength and recommendation of the project (Green, 2019). The expectation was the data results from this EBP project would fully support a practice change in the dissemination and spread of CBT-SP. The CBT-SP begins with identification on the inpatient psychiatric unit and continues with a 6-week outpatient CBT-SP therapy to optimize reduction in reattempts of suicide. Optimal long-term would be permanent incorporation of CBT-SP in the Mental Health & Behavioral Sciences Service.

Untended Consequences and Risks factors
Ethical aspects of implementing CBT-SP would pose little to no adverse impact to patients who currently receive some form of acute inpatient stabilization for SI and minimally TAU as an outpatient. This was an evidence-based project collecting and analyzing quantitative and qualitative data on the effectiveness of CBT-SP. VHA is a teaching organization and routinely conducts research and EBP projects and is familiar with protected health information (PHI). The EBP process was completely reviewed and sanctioned this project prior to implementation. All patients self-elected to participate in the project.

Evaluation of CBT-SP Integration with Existing Programs
Stevens' model was chosen for this project because it effectively and efficiently analyses positive CBT-SP interventions into clinical knowledge and practice (Stevens, 2011). New knowledge derived from CBT-SP and the Stevens ACE STAR Model must then be transformed into clinically useful protocols and evidence-based practice (Stevens, 2013). Lastly there was effective implementation across the entire interprofessional care team within a systems context (Stevens, 2013). By utilizing CBT-SP CPG, mental health providers were able to transform healthcare from a systems perspective, focus on EBP for clinical effectiveness and efficacy (Stevens, 2013). Ultimately, CBT-SP increased patient engagement, and patient survival outcomes.

Impact on Suicide Attempt Rates and Hospital Readmission for Suicide
The providers used cognitive restructuring strategies such as identifying and evaluating automatic thoughts from cognitive therapy (Brown & Jager-Hyman, 2014). TAU did not include CBT-SP but can include one or more of the following: multidisciplinary therapy, psychotherapy only, pharmacotherapy only, treatment by primary care provider, or minimal to no follow-up (Witt et al., 2018). It is only through enhancement of coping skills and reduction of isolation by providing support and stressing the importance of adherence to mental health and/or substance abuse disorder treatment, can the ultimate goal of reduced suicide attempts be met (Ghahramanlou-Holloway et al., 2015).

Create a Coalition
All efforts from key stakeholders were positive, enthusiastic, and marked with extreme support for the success of this EBP project. The two DNP preceptors were always available and receptive to endeavors to create a thorough and comprehensive project. The Chief of Psychiatry, nursing leadership, psychiatrists and psychologists all provided a leadership presence, provision, and accountability. There was a data mental health clinician and the project manager who identified and tracked the patients who elected CBT-SP and those who elected TAU. One DNP preceptor was on the inpatient psychiatric unit as a full-time employee and was able to monitor data collection, PHI, completion of C-SSRS and assist with education on CBT-SP using brochures designed for this educational purpose. Control of performance measures were frequently monitored to ensure reliability and validity and were controlled for risks, delays, and need for change adjustments (Sasal, 2018).

Develop a Project Vision
The Mental Health & Behavioral Sciences Service Chief of Psychiatry had concerns about implementing a practice, possibly program, and its sustainability after the DNP scholarly change project ends. According to Mewton & Andrews (2016), suicide prevention, both inpatient identification and outpatient interventions, is everyone's responsibility and there is indication that global suicide rates are decreasing due to the impact of suicide prevention strategies. The interview with Mental Health Leadership identified their concerns of lack of follow-up after hospital discharge with a diagnosis of suicide ideation with mental health outpatient CBT-SP providers. According to Kogon et al. (2015), maintaining shared vision is essential and instrumental to a successful project. Discharge follow-up appointments were made prior to the patient leaving the inpatient psychiatric unit. The challenge that this EBP project faced involved ensuring immediate buy-in by the patient for CBT-SP therapy, patient engagement for the 6week duration, and constant staff encouragement to adhere to the project vision (Kogon et al., 2015).

Communicate and Constantly Reiterate Project Vision
Attrition in drop-out rate was a potentially high factor with this population of patients.
The interprofessional team had a goal of admitting all suicidal participants in the DNP scholarly change project in order to obtain a sample size. CPRS was used following each weekly meeting and monitoring was done according to the Gantt Timeline (see Appendix E) to make appropriate project manager corrections needed to stay on course (Kogon et al., 2015). DMAIC, Stevens' ACE STAR Model for Knowledge Transformation, VHA CPG, Gantt Timeline and the Metric Metrix were all used to monitor project timeline, encourage staff continued engagement, update hospital and mental health leadership. Small wins were frequently discussed and shared with all interprofessional team members and leadership (Kogon et al., 2015).

Barriers and Obstacle Removal While Empowering Facilitators
A healthcare failure mode effective analysis (HFMEA) was conducted to identify patients with suicide ideation early in the emergency department to inpatient psychiatry admission process. The HFMEA was also utilized to identify and mitigate obstacles determined by the interprofessional team (Kogan et al., 2015). The DMAIC Model was used to improve project dissemination processes and begin sustainment of improvement efforts (Kumar & McKewen, 2011).

Project Schedule
The Gantt Timeline Chart and the Metric Matrix detailed a schedule of activities and check points used to monitor EBP project progress as indicated in the project manager timeline (see Appendix E and F). Data collection occurred as stated on the Gantt Timeline Chart and Metric Matrix. Data were analyzed at the end of the 6-week CBT-SP intervention. Continuous staff education and checks for competency, pre/post-test, documented patient instruction and education on CBT-SP, documented descriptive data from the Columbia-Suicide Severity Rating Scale (C-SSRS) assessment of severity of suicide ideation, indication CPG and hospital policy were followed, and audits of all data were collected.

Resources and Budget
The interprofessional team were the most valuable resource to this DNP Scholarly change project and its success. There would be no cost to the patients as CBT-SP was in addition to services provided by Mental Health & Behavioral Health Science Services. Educational costs for one hour of training for eight staff was provided and included in the budget. There were two DNP preceptors (average salary of $54 per hour), three psychologists ($100 per hour), four mental health counselors ($40 per hour), two data/IT technologist support ($25 per hour), and two nursing staff at $40 per hour. Additional organizational costs included educational materials/manual, educational pamphlets for patients and sundry ($300). Total project cost was approximately $998. A detailed budget breakdown is provided on the Budget Table (See Table   2).

Project Management Role and Leadership Skills.
According to Kogan et al. (2015), operative leadership skills and the ability to differentiate between optimal management to effect project management change begins with learned skills. Project management and leadership skills are very similar in both have input, tools & technology and outcome requirements to a consumer or patient (Kogan et al., 2015). There are deadlines, deliverables, patient care services, and patient outcomes that must be met. Managing this project required flexibility, strong leadership aids and resources, organization, and excellent communication skills (Kogan et al., 2015). This project required attention to detail and strict supervision of timelines and due dates.

Evaluation Plan
The Steven's ACE STAR Model and the DMAIC model guided the project evaluation.
The plan evaluated whether the implementation of CBT-SP therapy would decrease the number of readmissions of patients to an inpatient psychiatric unit for suicidal ideation, as compared to those patients who elected treatment as usual (TAU) for a 6-week time frame (Posner et al., 2014). Participant selection included a convenience sample based on self-selection. Both parametric and non-parametric statistical analysis methods were used to compare intervention variables. Secured, public health information (PHI) data collection tools were used to gather intervention data for comparison and statistical analysis testing as discussed below.
Participant selection and methodology involved CBT-SP success rate data and education, provided by a mental health licensed (MHL) provider and psychiatric nurses, to inpatient psychiatric patients who had a diagnosis of suicide ideation or attempts. Patients who elected CBT-SP and TAU were monitored for 6-weeks and the data were collected. The patient identification system included the last four from the social security number for tacking and monitoring for readmissions, for both groups, to inpatient psychiatry for suicide attempts and ideation. The tracking and monitoring system were inclusive of the principle VA hospital and any other community hospital within the region. Attrition of those no longer participating in either of the two groups (CBT-SP vs. TAU) was also monitored throughout the 6-week period by weekly audits for exclusion from the project.
Missing data were mitigated by use of electronic hospital record (EHR) that listed patients admitted every day with a diagnosis to one unit that treats psychiatric patients. The MHL provider, two DNP preceptors and the DNP project manager had full access to all inpatient psychiatric patient data. When the MHL provider was not available, the psychiatrist offered CBT-SP to the patient, at the time the last negative C-SSRS was completed at time of discharge.
All patients who screened positive on the C-SSRS and were admitted to the inpatient psychiatric unit and then subsequently discharged with a negative C-SSRS screen and chose to either enroll in the CBT-SP therapy or TAU for a completion of the 6-week period were included in the project. Primary data from the Quality of Life tool was collected from the CBT-SP patients themselves. The completion of both CBT-SP and TAU demographic and rehospitalization data were the secondary data extracted from a retrospective EHR review.
Upon discharge those patients who choose the CBT-SP therapy were surveyed with the Quality of Life Scale at week one and then again at week 6 to ascertain if there was a difference in their perceived satisfaction. Both groups then either received CBT-SP or TAU for a 6-week timeframe. At treatment conclusion, a chart audit was conducted to compare the number of hospital readmissions between the two groups CBT-SP and TAU for suicidal ideation or attempts. Patients who initially agreed to attend the CBT-SP group, but did not participate in the group were considered in the attrition rate and not part of the EBP project

Formative Evaluation
Formative evaluations were used to ensure that the project was progressing as scheduled and to determine if any changes were needed to improve the project. This process aligns with the DMAIC cycles for identifying opportunities to improve the project before initiating the next cycle. The C-SSRS tool was used to identify patients with suicidal ideation or attempts in the Emergency Department of the designated tertiary hospital. This tool is the screening tool of choice within the department and is an eight-item nominal yes/no question scale that screens for suicidal thoughts and behaviors over the past month to the past three months. If questions three, four, five, or eight are answered in the affirmative the screen is considered positive and the clinician would then proceed to conduct a comprehensive suicide assessment. However, the C-SSRS tool is used as a diagnostic tool by the tertiary hospital during normal operations and was collected for this project. Only those patients that screen positive on C-SSRS were included in the project.
The C-SSRS was developed by a team of investigators from Columbia University, the University of Pennsylvania, and the University of Pittsburgh (Posner et al., 2014). The C-SSRS is used to complete suicide risk assessments on all patients diagnosed with suicide ideation in the VHA (C-SSRS, 2019). The C-SSRS is a highly predictive measure of content and construct validity and reliability (see Appendix G). The C-SSRS has a reliability rate of .88 or higher and a high predictive validity rate due to its high reliability (C-SSRS, 2019). The C-SSRS is completed on ALL patients with admission diagnosis of suicidal ideation and at hospital discharge. At discharge, the C-SSRS MUST be negative or discharge does not occur without additional length of stay and interventions. Data were captured and collected, at week one and at end of therapy week 6 of the CBT-SP intervention group, via a Quality of Life Scale (see Appendix A). Data review and examination of variables were intently scrutinized to determine if CBT-SP was the actual intervention that affected change: 1) therapy/group attendance; 2) readmission rates for suicide ideation or suicide attempts to inpatient psychiatry; and 3) Quality of Life Scale (Burckhardt & Anderson, 2003).

Summative Evaluations
The Quality of Life (QOL) scale is a 16-item ordinal Likert scale with five domains of quality of life (material and physical well-being, relationships with other people, social, community, and civic activities, personal development and fulfillment, and recreation). The QOL scale ranges from one through seven, with one being terrible and seven being delighted on the aforementioned domains. The goal was for the C-SSRS nominal scale to remain negative and Quality of Life score to increase.

Variables and Other Measures
The independent variable in this project was the implementation of the CBT-SP therapy.
One related dependent variable was the number of patients who experienced CBT-SP therapy and were readmitted for suicide ideation or attempt post CBT-SP therapy. Another dependent variable is the number of patients who underwent CBT-SP therapy and experienced a perceived increase in satisfaction on the Quality of Life Scale (see Appendix A). The Matrix Metric (see Appendix F) outlined the outcomes, processes, balancing, financial, and sustainability factors.
There are no benchmarks for these measures.

Protection of Human Rights and Privacy
Ethical aspects of implementing CBT-SP posed little to no adverse impact to patients who currently receive some form of acute inpatient stabilization for SI and minimally TAU as an outpatient. This was an evidence-based project collecting and analyzing quantitative and qualitative data and not a research study and as such had little impact or adversely impacted those patients receiving TAU. VHA is a teaching organization and routinely conducts research and is familiar with Protected Health Information (PHI). The EBP process completely reviewed and sanctioned this project prior to implementation. All patients did consent for participation in the project. Patient information and data were secured by password and personal identification verification (PIV) card encryption as PHI controls on the Department of Veterans Affairs The data were collected by several project therapists and the data were transferred to the project manager via encrypted e-mail. The project manager then encoded the data within an Excel data base, which was stored and protected by use of a PIV card. The Quality of Life Scale was a hard copy and maintained in a locked, secure cabinet. Hard copy data were stored in a locked desk drawer in a locked office. Electronic data were stored in an Excel file on CPRS site with a strong password protection. Data were stored in a locked desk drawer and password protected Excel document and upon completion of the DNP degree the data were destroyed beyond reclamation.
In the interest of the EBP project integrity and patient safety the project manager submitted a DNP Scholarly Project Proposal Application for review by USAHS Nursing Evidence-Based

Practice Project Review Council (EPRC) and the organization site Institutional Review
Board/Evidence-Based Practice (IRB/EBP) review committee. The EBP project was approved by both entities without amendments.

Data Analysis
The IBM SPSS program analysis was utilized to analyze the data. Data were entered into the IBM SPSS system and checked for accuracy before calculating results using a standard 0.05 p-value for significance at 95% confidence level for both the non-parametric and parametric data. The eventual group compositions of both groups generated 14 members in the CBT-SP group and 22 members within the TAU group. However, two members within the TAU group went to residential treatment centers post discharge and were excluded from the project because the re-hospitalization data from this group would have been inaccurate. Hence, the total number of participants from the TAU group was 20 for a total of 34 participants combining both the CBT-SP and TAU groups. Variable and measures of demographic data (see Table 3) was collected on both the CBT-SP implementation group and the TAU group and used to compare both groups based on age, sex, and homelessness, since these demographics have a correlation with suicidal ideation (Huang et al., 2017). The was no missing data and the data were checked several times by the project manager and the DNP preceptor for accuracy.
The ratio variable on age between the CBT and the TAU groups was analyzed using a two tailed t-test for unequal variance. The results indicated that there was a significant difference between the two groups regarding age with the CBT group mean age being approximately ten years younger than the TAU group, with the p < 0.03 (see Table 4). This was a surprise finding and will be discussed in the Discussion and Implication section. The nominal variable on sex between the CBT and the TAU groups was compared using the non-parametric Fisher exact test and results indicated that there was no statistical significance between the groups in terms of sex with p > 0.68 (see Table 5). The difference between re-hospitalization within both groups was explored next. Due to an intervention truncated timeframe because of the COVID-19 virus, the amount of rehospitalizations may have been minimized (i.e., decreased re-admissions), thereby necessitating the use of a non-parametric statistic as opposed to a parametric test. There were no rehospitalizations within the CBT group and in order to determine if the six re-hospitalizations within the TAU group had any statistical significance it was necessary to treat the data as nominal (yes/no) in nature. A Fisher exact test was then used to analyze the data and the results were significant for TAU re-hospitalization with p < 0.03 (see Table 6).  Table 7). 11.5 1.5 3 9 11.5 11.5 11.5 6 4 1.5 7.5 7.5 5 -14 -11.5 1.5 -3 -9 -11.5 -11.5 -11.5 -6 4 1.5 -7.5 -7.5 -5 Note: Z-value: -2.8563, Mean (W): 52.5, Standard Deviation (W): 15.93, p < 0.00424 Sample size (N): 14

Impact
The clinical finding from this EBP project was that patients with an admitting diagnosis of suicidal ideation that elected CBT-SP vs. TAU did not have a rehospitalization during the 6-week period of the CBT-SP treatment. The project outcome is comparable to outcomes identified in the literature that demonstrated the use of CBT-SP reduced the number of rehospitalization admissions (Brown et al., 2016;Bryan et al., 2019;Rudd et al., 2015). Clinical significance was apparent in that of the 14 patients who received CBT-SP, none of them had a readmission to the hospital for suicide ideation or suicide attempts as opposed to six (30%) of the TAU patients who did. The use of CBT-SP in the outpatient setting has the possibility of effectively reducing the number of hospital re-admissions for suicide ideation or suicide attempts. The use of CBT-SP as an intervention to reduce suicide ideation and suicide attempts could facilitate a dramatic decrease in the overall rate of Veteran suicide. A decrease in hospital readmissions would decrease the financial burden on both the public and private funding resources (Bryan & Rudd, 2019).
Similarly, the Quality of Life Scale pre/post patient self-reported survey demonstrated a significant increase in quality of life satisfaction. This speaks to the impact of CBT-SP in improving an individual's life skills in coping with everyday life demands. This increased resilience helps to mitigate suicide ideation and suicide attempts (Ahmadizadeh et al., 2013;Cajanding, 2016). The seven mental health therapists reported that the patients enjoyed the structure of the CBT-SP modality, thereby increasing patient attendance and participation. This in turn sparked an interest by the therapists to inquire of the project manager how the EBP project could become a sustainable practice change. Plans are now underway to provide CBT-SP training to the entire Suicide Prevention Team at the VA EBP project site.
Limitations of this EBP project included a small sample population of participants. This was due to the COVID19 pandemic necessitating a truncated timeframe for the project, shortening the CBT-SP timeframe from the original 12 weeks to 6 weeks. However, literature does support the effectiveness of a brief CBT-SP (i.e. 6 weeks) (Bryan et al., 2018;Rudd et al., 2015). This population was also clinically stabilized by not being homeless. It remains to be seen if the CBT-SP would be as effective with a more destabilized or homeless population.
The demographics of age, sex, and homelessness were explored because of their correlation to suicide ideation and suicide attempts (Huang et al., 2017). While the demographics of sex and homelessness were found to have no statistical significance differences between the two groups, the variable of age did have a significant statistical finding. The TAU group was approximately ten years older that the CBT-SP group. It is speculated that the TAU group knowing that the CBT-SP modality would only be offered via telemental health, as a result of COVID19, and not face-to-face individual or group meeting were disinclined to participate. It could be further speculated that the TAU group did not have or lacked the electronic items or skills to participate in telemental health. The implication to further improve the EBP would be to look to the literature on telemental health, age, and access.
Suggestions for sustaining this EBP project includes training as many mental health practitioners in the CBT-SP modality practice change at the request of the Suicide Prevention Team Coordinator. Utilizing the DMAIC model data will continue to be collected for maintenance in order to enhance the sustainability of this EBP project. In summation, this EBP project has the potential to decrease suicidal symptomatology, increase the quality of life, and save lives.

Plans for Dissemination
The EBP change project validated the CBT-SP literature that the intervention decreases suicide ideation, suicide attempts, and self-harm injury as positive treatment outcomes. The results of the project were compared with evidence-based research literature, highlighting the positive impact of CBT-SP with Veteran populations. Lastly, at closure there will be discussion on access to training materials, Clinical Practice Guidelines (CPG), and Veterans' Health Administration (VHA) protocol resources for sustainment of the EBP project change. A comprehensive peer review of the EBP project's major components were reviewed and evaluated before dissemination of the results. This process included feedback from both preceptors, course instructor, and selected university peers.
Given the COVID19 pandemic circumstances, the results of the EBP project will be evidence-based interventions for Veterans and major health issues, such as decreasing rates of suicide. This EBP paper will be submitted, as a requirement, in full text to the institutional repository called SOAR@USA to improve the discoverability and availability of the EBP project. Finally, the EBP project will be submitted to The Virginia Henderson Global Nursing e-Repository to allow worldwide share of the project information.

Conclusion
Suicide and suicide prevention are a national health concern that affects Veterans and all Americans whether or not they have served in the military forces. Globally, it is everyone's responsibility to play a role in preventing suicide and the VHA has incorporated a comprehensive public health approach to reduce Veteran suicide rates (The National Strategy for Preventing Veteran Suicide, 2018-2028). Cognitive behavioral therapy for suicide prevention (CBT-SP) is theoretically grounded and incorporates evidence-based practice principles of psychological therapy aimed to understand problems associated with the relationship between thoughts, physiological sensations, emotions, and behaviors (Bryan et al., 2018). The primary goal of CBT-SP is to provide patients with education and coping mechanisms to prevent future suicidal acts and self-harm behaviors. This DNP scholarly change project examined evidencebased literature that emphasizes patients with suicide ideation and recent discharge from inpatient psychiatric hospitalization and who follow-up with outpatient mental health providers for CBT-SP versus TAU are less likely to attempt suicide. The results of this DNP scholarly change project were disseminated via a virtual PowerPoint presentation to varying hospital and nursing associations. Future implications, as a result of the EBP project, will provide opportunities for the CBT-SP endeavors. A major implication of this EBT change project is to empower the field of nursing care with the initiative necessary to continue such projects to potentially improve patient safety, increase optimal patient outcomes, and decrease patient mortality. Moderate Multiple studies. Strong designs for answering the question addressed. Some uncertainty due to either validity threats (generalizability, bias, design flaws or adequacy of statistical power) or inconsistency. Consistency.

Low
Health professional opinion is the only relevant published information. Local consensus is clear. Uncertainty due to either validity threats (generalizability, bias, design flaws or adequacy of statistical power). Inconsistency.

Grade not assignable
Studies have not been done, or published studies are seriously flawed, and/or published studies give inconsistent results. There is insufficient evidence and lack of consensus to answer the clinical question.

Figure 2
Prisma Model Summary

Figure 3
DMAIC Model