Abstract

This state-of-the-evidence review summarizes characteristics of intervention studies published from January 2000 through December 2005 in five psychiatric nursing journals. Intervention studies were defined as those evaluating the application of nursing strategies/procedures/practices for enhancing/promoting health or preventing disability/dysfunction. Of 486 research studies published in those journals, 77 were intervention studies, including 77% conducted in the United States. Interventions reflected psychological (57%), social (9%), and biological (12%) dimensions of the biopsychosocial model; 22% of the studies tested interventions with overlapping dimensions. Some studies included persons of various ages; however, 7 focused on adolescents, 36 on adults, and 10 on elders; 2 included children. The findings describe the current state of published intervention research in five psychiatric nursing journals and suggest the need for increased dissemination of intervention research, more rigorous testing of interventions, and more focused programs of research to build evidence for effective psychiatric nursing interventions across the lifespan and globally.

Citation: Zauszniewski, J., Suresky M.J., Bekhet, A., Kidd, L. (May 14, 2007)   "Moving from Tradition to Evidence: A Review of Psychiatric Nursing Intervention Studies" Online Journal of Issues in Nursing Vol.12 No.2

DOI: 10.3912/OJIN.Vol12No02HirshPsy01

Key words: best practices, evidence-based practice, psychiatric nursing journals, psychiatric nursing research, published research, research dissemination, research utilization, systematic review, tradition, intervention research

Psychiatric nursing has a long-established precedent of relying on tradition (Forchuk, 2001; Stuart, 2001). Few psychiatric nurses can articulate the empirical basis for their actions, and much of their care is based on centuries-old wisdom and experiences passed down through the generations by word of mouth or in classic textbooks. While traditional modes of intervention are sometimes successful and certainly sincere, such interventions are seldom based on sound scientific data and principles. Rather they often are based on trial and error, a response to authoritarian influences, or random application of methods that have worked for others in the past (Stuart, 2001). As a result, nurses' practices are sometimes questionable. Forward movement for psychiatric nursing requires increased research to identify evidence-based approaches, critique of the research data, and dissemination of the findings to the practice arena (Forchuk, 2001; Zauszniewski & Suresky, 2003).

Evidence-based practice is the systematic use of current best evidence to make clinical decisions for patient care (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Use of best evidence for clinical decision making improves patient outcomes, provides professional development opportunities, contributes to recruitment and retention of staff, and saves health care dollars (The Sarah Cole Hirsh Institute, 2005). Health care that is based on evidence has been found to lead to better clinical decisions and patient outcomes (Fineout-Overholt, Melnyk, & Schulz, 2005). Yet, although recognition of the importance of evidence-based practice dates back to the mid-1990s (Upton & Upton, 2006), only a small percentage of health care providers actually incorporate the latest evidence into their practice (Cretin, Farly, Dolter, & Nicholas, 2001; Jolley, 2002; Melnyk et al.,2004). For example, Cretin, Farly, Dolter, and Nicholas (2001) found that at least a third of health care providers did not follow evidence-based practice guidelines when making patient care decisions. Melnyk et al.,2004) reported that the implementation of evidence-based practice was strongly associated with providers knowledge of evidence for specific interventions.

Several recent landmark documents - the Report of the Surgeon General on Mental Health (1999), Healthy People 2010, the National Health Promotion and Disease Prevention Objectives (2000), and the President's New Freedom Commission on Mental Health (2003)- highlight the need for psychiatric nursing practice that is evidence based. All these documents point to the existence of established scientific approaches for the treatment of mental illnesses and set goals to use these approaches to decrease the prevalence of crisis states such as suicide, homelessness, and incarceration. Finally, the reports note the importance of delineating a needed transformation of the mental health system, including improved access and support at federal, state, and local levels. The documents also point to the need for mental health care based on excellence achieved through research. The most recent of these documents, The President's New Freedom Commission on Mental Health (2003), specifically recommends the dissemination of evidence-based practices and partnerships to guide implementation, as well as improvement and expansion of the workforce providing evidence-based mental health services and supports.

The future of psychiatric nursing thus depends on the development of evidence-based practice and its dissemination to all involved in implementation of care. As a step in this direction, this article reviews intervention studies published by psychiatric nurses in five peer-reviewed psychiatric nursing journals from January 2000 through December 2005.

Methods

This review of psychiatric nursing intervention studies was limited to peer-reviewed, psychiatric nursing journals that we believed were most likely to be read by practicing psychiatric/mental health nurses: Journal of Psychosocial and Mental Health Services; Archives of Psychiatric Nursing; Issues in Mental Health Nursing; Perspectives in Psychiatric Care; and Journal of the American Psychiatric Nurses Association. We focused on these journals with the assumption that the majority of practicing psychiatric nurses may not read nursing research journals. All five of the journals are provided with membership to professional organizations or by individual subscriptions. Our goal was to capture the types of research being disseminated to practicing psychiatric nurses through these five journals. However, we did not include subspecialty journals, such as those that address child and adolescent or geriatric psychiatry in our review.

Thus, the purpose of this analysis was to determine the extent to which intervention studies are published in psychiatric nursing journals that are most likely to be read by practicing nurses who are in the best position to implement the interventions. A hand search of the five journals was done by the four co-authors, who reached a joint consensus about which studies would be included as intervention studies, defined as studies in which the application of nursing strategies, procedures, or practices were examined for their effectiveness in enhancing or promoting health or preventing disability or dysfunction.

We found that 486 research studies, using either quantitative or qualitative data, were published from January 2000 through December 2005. However, of these studies, only 77, or 15.84% of them, evaluated or tested psychiatric nursing interventions. The remainder of this review is limited to these 77 intervention studies (referenced in Table 1) which were found in the five psychiatric nursing journals. Content analysis was used to identify the setting where each study was conducted, the targeted population, and the intervention domain. Both quantitative and qualitative methods for evaluating the interventions were considered acceptable.

Results

Research Settings

Fifty-nine of the 77 interventions studies (77% of the total) were done in the United States. Seven studies were done in Canada, representing 12% of the total. Only 14% of the studies were done outside North America, specifically 2 studies each were done in Taiwan, Hong Kong, and Sweden, and one study was done in each of the countries of Turkey, Korea, United Kingdom, Australia, and Thailand.

Studies were also classified according to whether they were done in an institution or the community. Institutional settings included hospitals, nursing homes, assisted living facilities, and jails or correctional facilities. Community settings encompassed outpatient hospital services and schools, as well as agencies outside acute care facilities and homes. Results showed that 48% or 37 studies were conducted in community settings; and 44% or 34 studies were conducted in an institutional setting. Mixed settings -institution and community-were used in 5% of the studies (n=4), and for two studies (3%), the setting could not be identified from the information provided.

Targeted Populations

The populations targeted included adults, elders (age 65 and over), adolescents, or a combination of age groups such as adults and elders or adolescents and elders. Studies included those who were mentally ill and those adolescents, adults, or elders who were not mentally ill but were experiencing stress, physical illness, pregnancy, incarceration, victimization, or bereavement. In the studies reviewed, 46.2% were adults and of this percentage, 75% were mentally ill. Studies involving both adults and elders represented 9% of the total studies. One study involved children and adults, another involved adolescents and elders, and a third involved all ages across the life span (3.9%). Overall, 50 studies or 64.1% were conducted on samples with mental illness (see Table 2 for details). In six studies (7.7%), it was not possible to determine the age of the sample with certainty. Either no age was specified, or age over 18 was the only detail provided by the authors.

Intervention Domains

The biopsychosocial model was used to organize the nursing interventions reviewed. This model uses a holistic approach, consisting of three separate but interdependent domains: biologic, psychological, and social (Boyd, 2002). Although the knowledge and focus of the domains differ, they can interact with each other.

Indeed, after considering patients' circumstances and other factors, selection of a nursing approach involves integrating biologic, psychological, and social interventions into a comprehensive plan of care. Nursing interventions are defined as activities that assess dysfunction, enhance and promote health, and assist patients to regain or improve their coping abilities and or prevent further disabilities (ANA, 2000). The sections below describe interventions in each domain and categorize the studies reviewed accordingly.

Interventions in the Biologic Domain. Biologic interventions focus on physical functioning and are directed toward the patient's self care, activities and exercise, sleep, nutrition, relaxation, hydration, thermoregulation and, finally, pain and medication management. For example, a study conducted by Logsdon, Wisner, Hanusa, and Phillips (2003) examined 61 women with post-partum depression who were randomly assigned to treatment with one of two anti-depressants. The study found that symptoms and most measures of functional status improved in both groups. Another study examined the effects of a 16-week walking program on mental and physical health parameters of outpatients diagnosed with schizophrenia (Beebe, Tian, Morris, Goodwin, Allen, & Kuldau, 2005). The experimental group showed significant reduction in body fat, greater aerobic fitness, lower body mass indexes, and fewer psychiatric symptoms than controls.

Interventions in the Psychological Domain. A major focus in psychiatric mental health nursing is on the psychological domain; namely, emotion, behavior, and cognition. The nurse-patient relationship acts as the basis for interventions in this domain. The psychological domain includes counseling, conflict resolution, bibliotherapy, reminiscence, behavior therapy (including behavior modification and token economy), cognitive interventions, psycho-education, health teaching, and spiritual interventions.

For example, a psychological intervention was used in the study by Boyd et al. (2005), which implemented a peer counseling intervention for substance abuse in a sample of 13 rural women with HIV. The intervention was effective in helping the women acknowledge their problems with alcohol and other substances. In another study, the long-term effects of a cognitive behavioral group intervention in reducing depressive symptoms, negative thinking, and chronic stressors were examined in low-income single mothers at risk for clinical depression (Peden, Rayens, & Hall, 2005). Findings were that women in the intervention group experienced a reduction in depressive symptoms, negative thinking, and chronic stressors, and these effects continued over a 12-month period.

Interventions in the Social Domain. The social domain can be viewed as including the patient's environment and its effect on the patient's reactions to disorders and stress. Interventions in the social domain are directed toward couples, families, friends, and social groups, with special attention to ethnicity and community interactions. Interventions that affect the patient's environment, such as modifying the environment to promote positive behavior or helping caregivers in decision making for a patient in a long term care, also fall in the social domain. Interventions in the social domain include milieu therapy, safety, home visits, group, family, and community actions. The key concepts of milieu therapy are containment, validation, structured interaction, and open communication. Interventions that are designed for patients' safety include observation, de-escalation, seclusion, and restraints.

A social intervention was tested in a study conducted by Holmes, Kennedy, and Perron (2004). Their purpose was to obtain an understanding of psychiatric patients' perception of the intervention, their experience of seclusion on an emotional level, and the way they coped during their stay in the seclusion room. The authors found that the experience of seclusion intensified pre-existing feelings of exclusion, rejection, abandonment, and isolation. In another study, an inpatient psychiatric unit was modified to reflect best practices in geropsychiatry. Results revealed a reduced fall rate, no mortality, and no restraint use among the older adults (Nadler-Moodie & Gold, 2005).

Combinations of Domains. Some studies used a combination of domains in their interventions. For example, some studies reported biopsychological, biosocial, psychosocial, or biopsychosocial interventions. One study that combined all three domains was conducted by Roper and Manela (2000), who examined whether interventions to alter the environment would reduce psychiatric patients' perceptions of waiting time in psychiatric emergency services. Interventions included the use of relaxing music, educational videos, and recreational activities. The study found that these interventions were helpful in reducing patients' perceived wait time and in conveying concern and caring.

Comparisons across Interventions. Among the studies reviewed here, the most frequently used interventions were in the psychological domain; they were represented by 57% of the total or 44 studies. Psychological interventions included both psycho-education and cognitive-behavioral strategies. Combined interventions were used in 17 studies (22%). Among these, 53% used psychosocial strategies, while 47% used either bio-psychological or bio-psychosocial approaches (see Figure for details).

Research designs were primarily quantitative, with 49 studies or 64% of the total using a quantitative design. Qualitative studies comprised 26% of the total, or 20 studies. Four studies (5%) had unclear designs and another four studies (5%) used a mixed design. Twenty studies (25.6%) used a quasi-experimental design with a control group, while twenty-eight (35.9%) were quasi-experimental with no control group. Seven studies (9%) compared two or more intervention modalities.

We also examined number of intervention studies published yearly in the five journals combined. Interestingly, while the number of intervention studies remained essentially static between 2000 and 2004 (n =11, 11, 9, and 11 respectively), the number of intervention studies (n = 24) more than doubled in 2005.

Discussion and Recommendations

Psychiatric nursing practice is strongly influenced by tradition, unsystematic trial and error, and authority, not scientific evidence (Stuart, 2001; Zauszniewski, & Suresky, 2003). The need for quality psychiatric care that is based on the best and most current empirical research is well documented. Indeed, integration of the best evidence available into nursing practice would help ensure optimal nursing care, effective and efficient patient care delivery, and the achievement of goals recommended by the Report of the Surgeon General on Mental Health, Healthy People 2010, and the President's New Freedom Commission on Mental Health.

This review is the first attempt to examine psychiatric and mental health nursing intervention studies reported in the new millennium. While this review excluded nursing intervention studies published in research-oriented journals, restriction to these five psychiatric nursing journals was purposeful. Our intent was to focus on the "disconnect" between research and practice, which may be associated with limited dissemination of research findings in the journals that practicing psychiatric nurses may be more likely to subscribe to and read. However, a review of psychiatric nursing intervention studies published in research-oriented professional journals would provide more complete information regarding dissemination of evidence for psychiatric nursing practice.

Our results have demonstrated that, while progress has been made through the years in the publication and dissemination of evidence-based findings in these five psychiatric nursing journals, more work needs to be done to move psychiatric nursing forward in the new millennium. Our review found that the majority of nursing research studies reported in the five journals were based on the traditional medical model, or were illness-based: 75% of the studies targeted the mentally ill. While the need for evidence-based nursing interventions for persons with mental illness is clear, far less is known about mental health promotion (U.S. Department of Health and Human Services, 1999). More studies testing interventions directed toward primary prevention of mental health problems and promotion of mental health in persons with mental illness are needed.

Children were represented in only one study (1.3%); however, we did not review specialty journals and thus our ability to evaluate the research conducted with this vulnerable population is limited. A review of intervention studies in specialty journals is recommended. Another suggestion based on our review is that the ages of targeted populations be more clearly stated. Studies cannot be replicated with any degree of rigor if exact ages are not specified. In addition, findings cannot be generalized to specific populations if ages are unknown; thus, the benefits of the studies are limited.

Although the significant increase in the number of intervention studies published in the five psychiatric journals in 2005 is encouraging and may reflect a shift toward development of a stronger evidence base in mental health nursing, less than 16% of all the studies published over the five year period in these journals were intervention studies. More intervention studies would help to document the efficacy of evidence-based approaches implemented by psychiatric nurses and publication of this evidence in journals read by practicing psychiatric nurses is critical.

In summary, as psychiatric and mental health nursing moves to embrace evidence-based practice, there is work to be done in three major areas: personnel (researchers and clinicians), process (conduct and dissemination of evidence-based research), and product (change in practice based on evidence). Each will be discussed below.

Personnel

More researchers with both clinical knowledge and research expertise are needed, and these nurse researchers need to increase the depth and scope of their research. Challenges to increasing the number of nurse researchers include the current nursing shortage in all areas of nursing and the shortage of nursing faculty. Thus, those in practice and in academic settings must work together to encourage our youth to become nurses, and psychiatric and mental health nurses in particular. While an increase in the workforce of nurse researchers can help to increase the research produced in psychiatric nursing, it will not guarantee it. Not all psychiatric nurses who have knowledge/skills to conduct research will do so. Increasing the workforce of qualified psychiatric nurse researchers and practicing nurses is of vital importance.

Process

Development and rigorous testing of interventions and more focused research to build evidence for effective interventions are crucial, recognizing that not all the research conducted by psychiatric nurse researchers will be pertinent for practice as the research may not address clinically relevant issues or evaluate interventions used on a day-to-day basis. However, we must strive to engage psychiatric mental health nurses in discovering the value and relevance of evidence-based research. Research findings must be published in journals that are read by psychiatric nurses in clinical practice who can best use the evidence. Research should be reported in language that is understandable, not in complex research terminology and statistical jargon.

Product

We must implement change in nursing practice based on or guided by empirical evidence and break away from the routines and practices that are familiar and comfortable to us. Effecting practice change requires both institutional support and readiness for change on the part of practicing nurses. Change in practice is the final product derived from the evidence.

Conclusion

Quality care for consumers of mental health services will be best ensured through the implementation of best practices based on the most currently available empirical evidence. Moving from tradition to evidence-based practice will be of paramount importance to future mental health nurses. This transition can be supported by annual updates of this content analysis provided here to help keep psychiatric nurse researchers and clinicians informed of progress toward disseminating research for evidence-based psychiatric nursing practice.

Author note: The authors acknowledge the editorial assistance of Elizabeth M. Tornquist of the University of North Carolina at Chapel Hill.

Table 1.

Table 2: Distribution of studies by targeted population

AUTHORS

Jaclene A. Zauszniewski, PhD, RN-BC, FAAN
E-mail: jaz@case.edu

Jaclene A. Zauszniewski is the Kate Hanna Harvey Professor in Community Health Nursing and Associate Dean for Doctoral Education at the Frances Payne Bolton School of Nursing of Case Western Reserve University (Case), Cleveland, Ohio. She received a PhD and MSN from Case, Cleveland, Ohio; a MA in Counseling and Human Services from John Carroll University, Cleveland, Ohio; a BA in psychology from Cleveland State University, Cleveland, Ohio; and a diploma in nursing from St. Alexis Hospital School of Nursing, Cleveland, Ohio. With over 30 years of nursing practice, including 21 years in the field of psychiatric-mental health nursing, Dr. Zauszniewski has experience as a staff nurse, clinical preceptor, head nurse, supervisor, patient care coordinator, nurse educator, and nurse researcher. Her program of research focuses on the identification of factors and strategies to prevent depression and to preserve healthy functioning during depressive episodes across the lifespan. She is best known for her research examining the development and testing of nursing interventions to teach resourcefulness skills to elders with chronic illness. She has received research funding from the National Institutes of Nursing Research and Aging, National Institutes of Health, Sigma Theta Tau International, American Nurses Foundation, Midwest Nursing Research Society, and the State of Ohio Board of Regents.

Jane Suresky, ND, APRN, BC
E-mail: mjs5@case.edu

Jane Suresky is an Assistant Professor at the Frances Payne Bolton School of Nursing of Case Western Reserve University (Case), Cleveland, Ohio. She received an ND and MSN from Case, Cleveland, Ohio; and a BSN from Cleveland State University, Cleveland, Ohio. Her clinical experience in psychiatric nursing covers Psychobiological Research, Adolescent Dual Diagnosis, and Mood Disorders. She has taught psychiatric mental health nursing to undergraduate and graduate students. In addition, she has been involved in nursing research that focuses on stress of female family members of the severely mentally ill.

Abir K. Bekhet, PhD(c), MSN, RN
E-mail: akb7@case.edu

Abir Bekhet is an Assistant Lecturer at Alexandria University, Faculty of Nursing, Alexandria, Egypt, and a research assistant at the Frances Payne Bolton School of Nursing of Case Western Reserve University (Case), Cleveland, Ohio. She received her BSN and MSN (Excellent with honor degrees) from Alexandria University, Faculty of Nursing, Alexandria, Egypt. Her clinical experience in psychiatric nursing is with persons with schizophrenia, bipolar disorder, obsessive-compulsive disorder, and depressive disorder. She has taught clinical psychiatric mental health nursing to undergraduate students. She has co-authored many articles for publication. She has been awarded first place for two research presentations, one from the Midwest Nursing Research Society in 2003, and one from the International Society of Psychiatric Mental Health Nurses in 2005.

Lori Kidd, MSN, APRN, BC, RN, PhD student
E-mail: lori.kidd@case.edu

Lori Kidd is an Instructor at The University of Akron College of Nursing and a PhD student at the Frances Payne Bolton School of Nursing of Case Western Reserve University (Case), Cleveland, Ohio. She received her MSN from Case in Cleveland, Ohio, and her BSN from The University of Akron in Akron, Ohio. She has clinical experience as a staff nurse, nurse manager, clinical preceptor, nurse psychotherapist, and nurse educator in both adult and geriatric psychiatry.

The Sarah Cole Hirsh Institute for Best Nursing Practices of the Case Western Reserve University Frances Payne Bolton School of Nursing, Cleveland, Ohio, USA
http://fpb.cwru.edu/HirshInstitute

The Hirsh Institute's mission is to build a repository of best nursing practices based on research findings. Institute activities include: disseminating the most current scientific evidence on best nursing practices to clinicians, educators, administrators, and policy makers; guiding nursing research by identifying areas where scientific evidence is lacking; and conducting certificate programs for nursing staff to identify and implement evidence based practice.

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