Michael J. Rice

Evidence-Based Practice in Psychiatric and Mental Health Nursing: Qualitative Meta-Synthesis

A guiding principle of evidence-based practice (EBP) is use of the highest level of evidence available (FineoutOverholt, Hofstetter, Shell, & Johnston, 2005; Melnyk & Fineout-Overholt, 2002). Within the quantitative– numerical perspective, randomized controlled trials (RCTs) are considered the highest level of research evidence (Cochrane, 1972; Melnyk & FineoutOverholt, 2005). The results of the RCTs are considered even more supportive of an intervention if there are enough studies to conduct a meta-analysis (Crowther & Cook, 2007; Guyatt, Mills, & Elbourne, 2008). Meta-analysis follows rigorous statistical procedures to determine the effect of an intervention (Mundy & Stein, 2008) and often rely on funnel (Einarson & Einarson, 2005; Song, Khan, Dinnes, & Sutton, 2002; Souza, Pileggi, & Cecatti, 2007) and harvest plots (Hofmann & Smits, 2008; Ogilvie et al., 2008). The usefulness of a meta-analysis of quantitative data is generally accepted within the hierarchy of EBP (Rice, 2008). Less frequently used are the findings from qualitative research (Sandelowski, Trimble, Woodard, & Barroso, 2006). Qualitative research findings are generally not included in levels of scientific evidence, such as those offered by the Oxford Center for Evidence-Based Medicine (Phillips et al., 2001) or those systems addressed in the Agency for Healthcare Research and Quality (2002). Reasons why qualitative data are not included in some of the levels of evidence rating systems involve philosophical debates and the valuing of different types of research (Walsh & Downe, 2005). This debate is largely one of philosophical perspective and will not be addressed here. The goal of EBP is to provide a scientific basis for patient care using the highest level of evidence possible. In psychiatric care, the topics of concern are often phenomenon related to the human experience, such as stigma and experiences that are not easily quantified. Thus, it seems only appropriate to include a discussion on the application of qualitative studies to EBP interventions as this methodology is capable of addressing subjective issues encountered in providing direct care to psychiatric patients. Qualitative findings are included in some of the more recent levels of EBP models. Evidence levels including studies on an experience or the meaning of a life event, such as grieving, rate qualitative studies at a higher level than those reporting similar phenomenon occurring during RCTs (Fineout-Overholt, Melnyk, & Schultz, 2005). Within these evidence grading systems, analysis of multiple studies on phenomenon are considered to be a higher level for EBP interventions. Equivalent to meta-analysis conducted with multiple quantitative studies are analyses of multiple qualitative studies conducted using meta-synthesis (Sandelowski et al., 2006). The metasynthesis is the highest level of evidence that can be attained for application of qualitative studies to EBP.

Evidence-based practice in psychiatric care: defining levels of evidence.

Identification and application of the current research evidence to a clinical problem is a goal reflected in professional codes and institutional mission statements. The use of expert opinions and traditions is no longer clinically or legally defensible in an era of using emerging evidence. Application of current research evidence is the emerging standard of care for all health care personnel, including psychiatric mental health care. The emergence of evidence-based practice as the new standard of care obliges all health care providers to use the latest research evidence. The need to make an intervention based on the highest level of evidence mandates that clinicians understand levels of research evidence and how the different classification systems of evidence compare. In this article, the levels of research evidence are reviewed to provide a framework for determining the best evidence to use as a basis for clinical interventions. J Am Psychiatr Nurses Assoc, 2008; 14(3), 181–187. DOI: 10.1177/1078390308321220

The relationship between abuse, sexually transmitted diseases, & group B streptococcus in childbearing women.

Purpose To examine the relationship between abuse, sexually transmitted diseases (STDs) and group B Streptococcus (GBS) infection among childbearing women using Selye’s (1978) stress response theory. Design and Methods Retrospective chart review (n = 205) from two different clinical sites in Washington State, using the Childbearing Health Questionnaire to guide data collection. The women in the sample had an average age of 26.4 years and represented Anglo (81.4%), Hispanic (12%), Native American (3.9%), and African American (2.5%) ethnic groups. Thirty-eight percent (n = 78) reported experiencing physical and/or sexual abuse during their lifetimes and 31% had been diagnosed with an STD. Results Abuse was significantly related to STDs, and ethnicity emerged as a significant variable for the Hispanic women participating in this study. Findings indicated that infection with group B Streptococcus was also related to abuse status (r = .60, p ≤ .002) and to presence of herpes simplex virus-2 (r = .468, p ≤ .01). Total prevalence of STDs was positively related to abuse (r = .78, p ≤ .000). Abused Hispanic women were more likely to be positive for STDs than were their nonabused counterparts (p ≤ .03). Clinical Implications The findings support previously published results that abuse is widespread in the United States and that abused women are at increased risk for STDs. These results highlight the need for regular screenings for abuse during healthcare, for abuse is a critical variable to consider when screening for STDs and GBS. STD screening typically occurs during the first prenatal visit and may need to be repeated for high-risk groups.

Psychiatric Mental Health Evidence-Based Practice

This article is the first in a new column focusing on evidence-based practice (EBP) in psychiatric mental health nursing. The EBP movement was strongly influenced by a British epidemiologist, Dr. Cochrane, who advocated care based on randomized clinical controlled trials in the late 1900s. Although the majority of the EBP movement is directed toward developing clinical guidelines, the critical element focuses on the therapeutic relationship and clinical judgment associated with providing care. This column will address a clinical problem, define PICO questions, report knowledge base searches, and present existing evidence. Recommendations will be offered for potential interventions and suggestions for evaluating clinical outcomes. Nurses can no longer view clinical studies as academic exercises discarded on graduation and not applied to the clinical setting. Conscientiously applying what is known about treatments and interventions of ethical, if not legal, value is consistent with the professional definition of care. J Am Psychiatr Nurses Assoc, 2008; 14(2), 107-111. DOI: 10.1177/1078390308315798

APNA and ANCC Collaboration: Achieving Consensus on Future Credentialing for Advanced Practice Psychiatric and Mental Health Nursing

The American Psychiatric Nurses Association and the American Nurses Credentialing Center conducted a logical job analysis based on three recent role-delineation studies (RDSs) to determine whether there was enough commonality in the practice of psychiatric and mental health nursing by clinical nurse specialists (PMH-CS) and nurse practitioners (PMH-NP) to support the development of a single certification examination. Three hundred seventy-one work tasks gleaned from the three RDSs were presented for systematic review and discussion by the logical job analysis committee of 28 nurses certified in the specialty. Of the 371 work tasks, 332 (90%) were considered important enough to test for both the PMH-CS and PMH-NP. The results of the logical job analysis indicated that there was enough commonality in the practices of the PMH-CS and PMH-NP in psychiatric mental health nursing to warrant the development of one advanced practice examination for both roles. J Am Psychiatr Nurses Assoc, 2007; 13(3), 153-159.

Comparative analysis of physiological adaptation of neonates of abused and nonabused mothers

The investigators examined: (a) the relationships between the mothers abuse status and the newborns stress responses, and (b) differences in newborn stress responses of abused and nonabused mothers before and after a phenylketonuria (PKU) heel stick. The t-tests show a trend toward statistical significance. Abuse had strong effect sizes on cortisol and oxygen levels at 25 minutes. Findings support further research on the impact that maternal stress resulting from abuse has on neonatal outcomes.

Childbearing experiences of abused Hispanic women.

Previous research has documented that abused childbearing women have longer and more difficult labors than non-abused women. Prevalence of abuse differs depending on the ethnic group involved. Hispanic women experience higher rates of abuse and endure higher rates before reporting abuse than do Caucasian women. The purpose of this study was to explore the experience of childbearing for abused Hispanic women to provide guidance for clinical practice and further research. Cognitive dissonance theory guided the study. A sample of seven abused Hispanic women was recruited from a rural prenatal clinic. Criteria for selection of subjects included self-identification as Hispanic, less than 24 months postpartum, disclosure of abuse status, and willingness to be interviewed in English or Spanish. An acculturation scale and demographic form were completed. Interviews were conducted individually, and data were analyzed by using Van Kaams 12-step psychophenomenologic technique. Findings indicated that subjects experienced the normal responses associated with having a baby. However, the women also demonstrated a kindled neuroendocrine trauma response that was based on, and often similar to, their prior abuse experiences. The kindled emotional response was triggered by the normative events of childbearing. Understanding of the childbearing experiences of abused Hispanic women will facilitate the development of cultural-specific interventions that may ease the difficulties associated with birth for these women.

HIPAA's Preconsent: Impact on Study Validity

The Health Insurance Portability and Accountability Act (HIPAA) regulations added potential validity threats to clinical studies. The HIPAA regulations, using the principle of patient autonomy were designed to increase patients control over the all health related information. The Department of Health and Human Services did not identify rules related to research regulations believing HIPAA regulations facilitate investigations through use of de-identified information. Yet, under HIPAA guidelines, health care agencies can not allow access because of the need to obtain a patients prior permission to release raw data. The problem of how to conduct investigations in the face of the HIPAA “Privacy Rule” raises concerns for effects on subject recruitment and selection. This paper examines the impact of obtaining a HIPAA preconsent on subject recruitment, selection, and subject characteristics, and offers strategies for addressing the validity threats associated with the HIPAA regulations. J Am Psychiatr Nurses Assoc, 2008; 14(3), 225–230. DOI: 10.1177/1078390308319224