The Sarah Cole Hirsh Institute for Best Nursing Practices of the Case Western Reserve University Frances Payne Bolton School of Nursing

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

Evidence for Psychiatric Nursing Practice: Wives’ Tales or Research

Historically, nursing practice has been influenced by traditional wisdom passed down through generations by word of mouth and in published textbooks. Without scientific evidence for practice, nurses have done the best they could in the patient’s interest. Much of the nursing care provided has been based on personal experience and the experiences of nurses and others who have gone before. Even today, much of psychiatric nursing practice is still grounded in tradition, unsystematic trial and error, and authority, rather than being based on sound empirical investigations (Wilson, 2004). Indeed, some psychiatric nursing knowledge comes from "Old Wives’ Tales," reflecting the perspectives of women from bygone days. This "received wisdom" is often taken for granted and passively implemented (Wilson). Although much of it is questionable, some of the wise sayings and beliefs passed down through the ages continue to contribute to many psychiatric nursing interventions.

Two landmark documents relevant for psychiatric nursing have recently been published by the U.S. Department of Health and Human Services (U.S. DHHS) Healthy People 2010, the National Health Promotion and Disease Prevention Objectives (2000), and the Report of the Surgeon General on Mental Health, submitted by David Satcher (1999). Both of these documents provide direction for psychiatric nursing and highlight the need for nursing practice based in evidence.

Many of the health care goals addressed within Healthy People 2010 (U.S. DHHS, 2000) are relevant to psychiatric mental health nursing. Objectives that are related to improvements in mental health include reduction of suicide rates in the general population, reduction of suicide attempts by adolescents, reduction in the number of homeless persons with severe mental illness, and increase in employment of persons with serious mental illness. Objectives related to expansion of treatment for the mentally ill include: reduction of relapse rates for persons with eating disorders; increase in mental health screening and assessment in primary care settings; increase in the numbers of children and adults with mental illness who receive treatment; increase in treatment for persons with dual diagnosis (including substance abuse); and increase in treatment for mentally ill persons in juvenile justice facilities and jails.

The Report of the Surgeon General on Mental Health (U.S. DHHS, 1999) was the first Surgeon General’s report ever published on the topic of mental health and mental illness. It was based on an extensive review of the scientific literature and consultation with mental health providers and consumers. This landmark document concluded that there are numerous effective treatments for most mental health disorders; but it also raises some questions for psychiatric nurses, including: (a) are psychiatric nurses aware of the efficacy of the treatments and interventions they provide? (b) are they truly practicing evidence-based psychiatric nursing? and (c) is there documentation of the nature and outcomes of the care they provide? (Stuart, 2000). The answers to these questions will shape the roles of nurses in a specialty area that is growing in its understanding of molecular and cell biology and genetics, as well as the cognitive and behavioral sciences.

Evidence-Based Practice

Evidence-based nursing practice has been defined as "the conscientious, explicit, and judicious use of the best evidence from systematic research to make decisions about the care of individual patients" (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Evidence-based practice involves putting the patient’s benefits first while continually striving to improve care through appropriate actions that are guided by scientific evidence (Gibbs, 2003).

Although evidence-based psychiatric care is relatively new for psychiatric nursing (Stuart, 2001), the notion of using scientific evidence in nursing practice dates back to the times of Florence Nightingale (1859/1969). Though not herself a psychiatric nurse, Florence Nightingale, the founder of the modern nursing profession, pioneered the use of statistics for evidence-based practice and used statistics to influence health care reform (Nightingale). In her early writings, Nightingale outlined the steps for assessing patient problems, developing hypotheses, collecting data, and analyzing it before designing nursing interventions (Nightingale). Like Nightingale, Hildegard Peplau (1952, 1988) believed that a scientific approach was essential to psychiatric nursing practice. Today, the development of evidence through clinical research is a high priority in psychiatric nursing (Haber, 2000).

The process of developing evidence-based nursing practice begins with a question about a specific patient problem or situation. A systematic search for evidence that could be used to answer the question follows. Once the evidence is obtained, its validity, relevance, and applicability are appraised. The evidence is then integrated with other information, including expert knowledge, patient preferences for alternative forms of care, and available resources. Taken together, these factors influence management of the clinical problem. Finally, the evidence-based practice decision is implemented and the outcome of the decision is evaluated (Stuart, 2001).

Five levels of evidence used in practice have been identified (Stuart, 2001). The lowest level and least powerful evidence is provided by opinions of reviewers that are based on their experience and knowledge and constitute clinical practice guidelines. Somewhat stronger evidence is derived from opinions that come from well-known experts and respected authorities. Even more compelling evidence comes from the results of research studies. There are three levels of evidence derived from research. Non-randomized controlled studies or cohort studies provide the weakest evidence, while small randomized controlled trials yield evidence that is stronger and more influential. Large randomized controlled trials and meta-analyses of studies providing evidence in a specific area are considered the "gold standards." These studies furnish the strongest and most powerful evidence for clinical practice. Unfortunately, there is currently little psychiatric nursing research that meets this "gold standard" (Stuart, 2001), and the need for clearly defined areas of research priority for the psychiatric nursing specialty are apparent (Pullen, Tuck, & Wallace, 1999).

Methods

To examine the quality of the currently available evidence for psychiatric and mental health nursing practice, we analyzed research conducted by psychiatric nurses and published in the five most commonly read psychiatric nursing journals published in the United States from January 2000 to January 2003. The five journals reviewed were: Archives of Psychiatric Nursing (Archives), Issues in Mental Health Nursing (Issues), Perspectives in Psychiatric Care (Perspectives), Journal of Psychosocial Nursing and Mental Health Services (JPNMHS), and the Journal of the American Psychiatric Nurses Association (JAPNA).Only data-based articles in these peer-reviewed journals were examined. The rationale for selecting the five most commonly read psychiatric specialty journals was to capture the types of research being disseminated to practicing psychiatric/mental health nurses. Our assumption was that nurses who were actively practicing in this field would be more likely to read these specialty journals than journals devoted specifically to research. Studies published in sub-specialty journals, such as those that address child and adolescent or geriatric psychiatry, were not included in the analysis.

Findings

Table 1 lists the numbers and categories of studies for the five psychiatric nursing journals from 2000-2003.

Global Perspectives

Between January 2000 and January 2003, a total of 227 databased articles were published in these five psychiatric journals. As would be expected, the majority of the studies were conducted in the US (n=201, 88%). Five percent of the studies (n=12) were conducted in Asian countries, including Korea, China, and Taiwan, while 2% (n=5) were conducted in Canada. The remaining 5% of the studies were divided among Australia (n=2), United Kingdom (n=2), Netherlands (n=2), Finland (n=1), Middle-east (n=1), and Africa (n=1).

The largest numbers of international studies were published in Archives and JPNMHS (9 and 7, respectively). Issues published 4, and Perspectives and JAPNA each published 3. However, the statistics also indicate that 25% of the published research studies in Perspectives between 2000 and 2003 were conducted outside of the United States, followed by JPNMHS (15%), Archives (14%), JAPNA (11%), and Issues (5%).

Research About Psychiatric Nurses

Of the 227 published studies, about 52 (23%) defined their study sample to include nurses, student nurses, and/or mental health care professionals. Of these 52 studies, 11 (21%) examined the effects of specific nursing interventions. However, the outcomes examined in these studies were nurse rather than patient-focused. Nine of the studies (17%) examined the effects of the nurse-patient relationship, but the outcomes measured were nurse rather than patient-related. Performance of the psychiatric nursing role, including decision making and ethical behavior, was investigated in 4 studies (8%).

Another 9 (17%) explored the effectiveness of curriculum or continuing education programs for nurses. Five studies (10%) explored role expectations, including staffing patterns and nursing functions. Studies of violence (n=4) in the workplace comprised about 8% of the research. The remaining studies related to psychiatric nursing practice examined case management (3, or 6%), prescribing practices (2, or 4%), collaboration with other mental health professionals (2, or 4%), and stress, role conflict, or burnout (2, or 4%). One study examined mental health promotion in psychiatric nurses and mental health professionals.

The largest numbers of studies about psychiatric nurses were published in Issues and JPNMHS (17 and 14 respectively). Archives published 9; JAPNA, 7; and Perspectives, 5. However, the statistics also indicate that 42% of the published research studies in Perspectives between 2000 and 2003 involved psychiatric nurses as their subjects, followed by JPNMHS (30%), JAPNA (25%), Issues (22%), and Archives (14%).

Studies of Caregivers

Thirty-two studies of caregivers were reported in the five psychiatric nursing journals over the past 3 years, or about 14% of the total number of published studies. Family caregivers that comprised the study samples were providing care to individuals across the life span. In 13 studies (41%) the care recipients were children or adolescents; the children were identified as healthy in 2 studies, at risk in 2 studies, and mentally ill in 9 of the 13 studies. In 4 studies (12%), adults with mental illness were the care recipients. The majority of the caregiver studies (n=15, 47%) involved caregivers of elders. While 5 of these studies involved care recipients with a physical condition, 10 involved caring for elders with mental illnesses, primarily depression and dementia.

The largest numbers of studies involving family caregivers were published in Issues and Archives (12 and 11 respectively). JPNMHS published 4; JAPNA, 3; and Perspectives, 2. However, the statistics relative to the number of published research studies within each of the respective journals indicate that the greatest percent of studies about family caregivers were published in Archives (18%), Perspectives (17%), and Issues (15%), followed by JAPNA and JPNMHS with 11% and 8% of their studies about family caregivers within the same time frame.

Research Across the Lifespan

While studies of nurses and family caregivers comprised 23% (n=52) and 14% (n=32) respectively of the total number of studies published in these five journals, studies of clients constituted the majority (63%, n=143) of the published research. Four of these studies (3%) involved children; 3 involved healthy children and 1 involved children with mental illness, specifically ADHD. Adolescents were sampled in 11 of the studies (8%), at-risk youth in 8 and mentally ill youth in 3 of the 11. At-risk youth were at risk for substance abuse and HIV, while adolescents classified as mentally ill were primarily depressed.

The largest numbers of studies about children and adolescents were published in Issues (n=10). JPNMHS and JAPNA published 2 each, Archives published 1, and none were published in Perspectives in this time period. In percentages, 13% of the published research studies in Perspectives involved children or adolescents. In JAPNA, 7% of the published studies were about children or adolescents, followed by JPNMHS with 4%, and Archives with 2%.

The majority of the studies (111, or 78%) included adults. Of those 111 studies, 41 (37%) involved mentally healthy adults, while 70 (63%) were studies of adults with mental illness. Of these, 17 studies involved elders. In 11 of those studies, the elders were mentally healthy but may have had physical disabilities or chronic conditions. Six studies involved elders with dementia, depression, or a combination of those diagnoses.

The largest numbers of studies about older adults were published in JPNMHS (n=6). Issues and Archives each published 5. Perspectives published one empirical study of elders and JAPNA had none. However, the statistics also indicated that 13% of the published studies in JPNMHS were of elderly persons, while both Archives and Perspectives published 8%, and Issues had 6%.

Studies of Adults Without Mental Illness

As noted above, there were 41 studies of mentally healthy adults, which constituted 37% of the 111 published studies involving adults. Of these 41 studies, a large percentage (46%, n=19) involved victims of violence, including persons who had been physically or sexually abused and those experiencing domestic violence. Studies of adults with physical illness represented nearly 20% of the studies of mentally healthy adults. These studies examined psychological outcomes in persons with acute and chronic cardiopulmonary conditions or HIV. Seven studies (17%) involved adults experiencing acute stress or crises, including life changes, career transitions, acute illness, trauma, or death of a family member. Four studies 10% involved healthy persons such as college students, healthy volunteers, or navy recruits, and 3 studies (7%) involved homeless adults.

The largest numbers of studies of adults without a diagnosis of a mental disorder were published in Issues (18), Archives (9) and JAPNA (7), followed by JPNMHS with 5 and Perspectives with 2. However, the statistics also indicated that 25% of the published research studies in JAPNA and 23% of the published studies in Issues between 2000 and 2003 involved non-mentally ill adults. The percentages for published research with adults without mental illness for the remaining journal were 17% for Perspectives, 14% for Archives, and 11% for JPNMHS.

Studies of Adults With Mental Disorders

There were 70 studies of adults with mental illness, which constituted 63% of the 111 published studies of adults. A large percentage of these studies were conducted in inpatient settings. In 26 of these 70 studies (37%), the adults in the sample were described as having a variety of mental disorders, including disorders of thought and mood, and substance abuse. Sixteen studies (23%) involved persons with substance abuse problems, including alcoholism and cocaine abuse. Another 12 (17%) were of adults with schizophrenia. Eleven studies (16%) involved adults with mood disorders, including 9 studies of persons with depression and 2 studies of adults with bipolar disorder. There were 3 studies of adults with eating disorders, and 1 study each of adults with post-traumatic stress disorder and borderline personality disorder.

The largest number of studies of adults who were diagnosed with a mental disorder was published in Archives (27). Issues and JPNMHS each published 16 studies of adults with mental illness during the same study period, while JAPNA published 9 and Perspectives published 2. However, the statistics showed that 44% of the published research studies in Archives were in samples of mentally ill adults. The next highest percentages were found for JPNMHS (34%) and JAPNA (32%). Fewer studies of adult with mental illness were found in Issues (20%) and Perspectives (17%).

Nursing Intervention Research

Of the 227 studies reviewed, only 25 (11%) examined the effectiveness of nursing interventions. This suggests that there is much work to be done to develop evidence for psychiatric nursing practice at the highest and most credible level, i.e., the randomized clinical trial. Over a third of the intervention studies (9, or 36%) examined the effectiveness of crisis intervention techniques. Another 5 (20%) examined the effectiveness of cognitive-behavioral therapy, while 3 (12%) evaluated the usefulness of psychodynamic therapies. Techniques for reducing and managing stress were tested in 3 intervention studies (12%) and methods of providing support to caregivers were investigated in another 3 of the studies (12%). Finally, the effectiveness of nursing observation of inpatients to promote their safety was measured in 2 of the available intervention studies (8%).

The largest numbers of intervention studies were published in Archives (12), Issues (11), and JPNMHS (11).JAPNA published 5 and Perspectives published 2 intervention studies. However, those numbers may be misleading given the varying number of published articles within each of the journals for the defined timeframe. For example, 23% of the published studies in JPNMHS examined psychiatric nursing interventions. This percent is closely followed by those of Archives (19%), JAPNA (18%), Perspectives (17%), and Issues (14%).

Summary and Conclusions

This review of psychiatric nursing research published in the five most commonly read American psychiatric nursing journals shows the numbers and types of studies that have recently been made available to practicing psychiatric and mental heath nurses. Evaluation of the 227 studies published in these journals from 2000 to 2003 identified five major areas of focus. These areas were: global perspectives, psychiatric nurses as subjects, studies of family caregivers, research with clients across the lifespan, and testing of nursing interventions. The great majority (201, or 88%) of the published studies were conducted in the United States. About 63% (143) involved recipients of mental health care services. Only 11% of the studies tested psychiatric nursing interventions.

As the psychiatric and mental health nursing specialty moves to embrace evidence-based practice, there is work to be done in three areas: personnel, process, and product. There is a need for more researchers who possess both clinical knowledge and research expertise (Tucker & Brust, 2000), and these nurse researchers need to increase the depth and scope of their research. With the current nursing shortage in all areas of nursing and the predicted shortage of nursing faculty, increasing the number of psychiatric nurse researchers is a challenge. Thus, those in practice and in academic settings must work together to encourage young men and women to become nurses and psychiatric and mental health nurses in particular.

While an increase in workforce numbers can help to augment the research produced in psychiatric nursing, it will not guarantee it. Not all psychiatric nurses who have the knowledge and skills to conduct research will do so. Moreover, not all the research conducted by psychiatric nurse researchers will be pertinent for practice: the research may not address clinically relevant issues (Parahoo, 1999). Finally, although categories into which psychiatric nursing research falls have been identified within this analysis and in the past (Pullen et al., 1999), such categories are very broad and yield little information on which solid evidence for clinical practice can be based.

Appropriate dissemination of research findings is also essential (Tucker & Brust, 2000). Research findings must be published in journals that are read by those who can use the evidence - psychiatric nurses in clinical practice. Research should be reported in language that is understandable, not in complex research terminology and statistical jargon.

Assuming that qualified psychiatric nurse researchers conduct research that is relevant to practice and appropriately disseminated to practicing nurses, a final issue of concern is the implementation of change in nursing practice based on or guided by empirical evidence. Change in practice is the final product derived from the evidence. Effecting change requires both institutional support and readiness for change on the part of practicing nurses (Parahoo, 1999; Tingle, 2002; Tucker & Brust, 2000). Breaking away from the routines and practices one is familiar and comfortable with is challenging. Many "Old Wives’ Tales" are still read and re-told today. However, 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.

Authors

Jaclene A. Zauszniewski, PhD, RNC
e-mail: jaz@cwru.edu

Jaclene A. Zauszniewski, PhD, RNC, is the Associate Dean for Doctoral Education and an Associate Professor at the Frances Payne Bolton School of Nursing of Case Western Reserve University in Cleveland, Ohio. She received a PhD and MSN from Case Western Reserve University, 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 28 years of nursing practice, including 18 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, RN, CS
e-mail: mjs5@cwru.edu

Jane Suresky, ND, RN, CS is an Assistant Professor at the Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. She received a ND and MSN from Case Western Reserve University, 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.

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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