Learning Objectives
By the end of this section, you will be able to:
- Identify credible sources of research evidence for psychiatric-mental health nursing
- Apply concepts of evidence-based practice (EBP) to psychiatric-mental health nursing
- Locate evidence on representation and acceptance of mental health in the community
The foundation of any effective nursing practice is the use of evidence-based practice in caring for clients. Research completed by nurses contributes to the wealth of knowledge that forms evidence-based practice. Basing nursing practice on evidence leads to the most positive client outcomes.
Credible Sources and Types of Research
Throughout the nursing process, it is important to be sure to use evidence-based practice (EBP). The term evidence-based practice refers to:
A process used to review, analyze, and translate the latest scientific evidence with the goal of quickly incorporating the best available research, along with clinical experience and client preference, into clinical practice, so nurses can make informed client-care decisions (John Hopkins Medicine, 2023, para 1).
In this description, review means locate and study, analyze means determine the meaning, and translate means to move the evidence into practice.
Starting with a professional database is best to locate credible sources. Many databases require a subscription in order to access them. If the nurse works at a hospital or a university, then there is likely access to these sources. Popular databases include Cumulative Index to Nursing and Allied Health Literature (CINAHL) found within EBSCO (subscription needed), Agency for Healthcare Research and Quality (AHRQ) (available for free), MEDLINE (free online source), ERIC (provides links to sources available for free), PsychINFO (accessed through a vendor, such as OVID), and Cochrane Database of Systematic Reviews (contains free access to reviews).
The term empirical research refers to scholarly work from actual observation and measurement of experience, in contrast to theory. Empirical research is primary research, which means the authors of the study conducted the investigation. There are two basic types of research that fall under empirical research: qualitative and quantitative. Qualitative research pulls data from the subjective responses of the participants. It asks the questions of who, what, where, when, and how. Its goal is to determine how an individual or community feels about and is affected by a particular topic. Quantitative research deals with numbers and statistical data (McCusker & Gunaydin, 2015). Some studies combine aspects of qualitative and quantitative research called mixed method. The qualitative data can provide client insight into the statistical results from the quantitative data. Before selecting a research study for evidence-based practice, the nurse must determine which type best fits the problem being investigated.
Applying EBP to Psychiatric-Mental Health Nursing
Application of evidence-based practice (EBP) concepts to psychiatric-mental health nursing begins with definitions. In both the clinical and research settings, defining the question requires delineating a particular problem that has been identified by the nurse (Bermudez, 2021). In the research sector, the question arises after performing a thorough literature review and finding treatment gaps. In the clinical setting, the nurse develops the question first and then performs a literature review. Good research questions can be written using the FINER technique: “feasible, interesting, novel, ethical, and relevant” (Bermudez, 2021, p. 71).
Search Terms and Web Addresses
Effectively gathering data depends upon the search terms used. When choosing keywords, the focus should be on the main words or phrases that describe the research topic (American Psychological Association, 2020). For example, if a nurse is searching for information on barriers to care, they might use the words barriers to care, access, mental health care, medical care, and community health resources. As the search continues, the nurse can hone in on more terms based on what comes up in the search. Sometimes a good article will contain references that the nurse can access to find additional information.
Beyond using a database to locate professional journals and peer-reviewed articles, nurses can perform a general internet search. Extensions at the end of website names will help the nurse locate good sources. The most common extension is .com. This delegation is for businesses and news. Nonprofit organizations use .org. Higher education, such as colleges and universities, will have .edu. Government websites will use .gov. Military sites use .mil. With all sites, it is best to assess the source and the information for accuracy and bias before deciding to use it as a basis for research (Central Michigan Libraries, 2022).
Levels of Evidence
The levels of research evidence are organized below as lower-level evidence or higher-level evidence. This can be a guide for nurses who are beginners working on research and a reminder for more experienced nurses. Information across the levels can be combined to give a realistic view of the topic. These levels correspond to the types of items a nurse might find when conducting a literature review Table 1.3.
| Lower-level Sources of Research Evidence: | Higher-level Sources of Research Evidence: |
|---|---|
| Evidence from a cohort study, observational, nonexperimental | Systematic review/meta-analysis of RCTs (highest level) |
| Systematic review or meta-synthesis of qualitative studies | Evidence from a large randomized controlled trial (RCT) |
| One qualitative study or descriptive study, or a quality improvement project | Evidence from a nonrandomized controlled trial, quasi-experimental study or a mixed-method intervention study |
| Non-research source; expert opinion (lowest level) (Note: Expert opinion is valid data, especially in the PMH nursing specialty, though this level of evidence should be made clear in the research report.) |
Evidence-Based Practice in Psychiatric-Mental Health Nursing
It is vital for nurses to protect and promote the mental well-being of all individuals and address the needs of individuals with diagnosed mental disorders (World Health Organization, 2018). The World Health Organization (WHO) published the Mental Health Intervention Guide for nurses and primary health-care providers. It provides evidence-based guidance and tools for assessing and managing priority mental health and substance use disorders using clinical decision-making protocols. Essential principles for providing mental health care include promoting respect and dignity for the individuals seeking care; using effective communication skills to ensure care is nonjudgmental, nonstigmatizing, and supportive; and conducting comprehensive assessments (mhGAP Intervention Guide, 2016). Nurses can provide this care using the three components of EBP: best available research, tapping into client preferences, and applying their own expertise.
Best Available Research
Nurses may wonder, “How do I know what evidence-based nursing interventions to include in the nursing care plan regarding mental health care?” Finding the best available research may seem daunting to the new nurse, but it is as simple as consulting a current, evidence-based nursing care planning resource when planning nursing interventions individualized to each client’s needs. There are several sources nurses can reference to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the client chart. Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) maintains an evidence-based resource center (Substance Abuse and Mental Health Services Administration, n.d.).
Client Preferences
Within the evidence-based practice formula is the process of evaluating how well the new evidence works when applied to individual clients in a clinical setting. In other words, how do the evidence and the client’s preferences connect? It is important for clinicians to realize that although the evidence may point toward making a change, the client’s preferences may not. What modifications need to be made so that the new information is applicable to the client and accords with the client’s preferences? As with any nursing-client interaction, the goal is to reach the best client outcomes.
Nursing Expertise
There are different levels of mental health nursing expertise based on degree and licensing. The bachelor’s level nurse learns about evidence-based practice (EBP) through their own use of PICOT (Population/Problem, Intervention, Comparison, Outcomes, and Time) based projects, which translate their research into practice (Grys, 2022). According to Grys (2022), the PICOT format provides focus to the literature search and is key to clinical application of evidence.
Nurses prepared at the doctoral levels may perform actual research that translates into new approaches and changes to the knowledge base (Grys, 2022), as may those with a master of science in nursing (MSN). Nurses may become experienced at using the quality improvement (QI) process through the requirements of their degree program (Grys, 2022), or in the workplace. As the name implies, QI involves looking at a problem; utilizing data, decision-making tools, and testing; and making an improvement—this then becomes the new evidence-based practice (QSEN Institute, 2022). The results of QI and EBP research are used specifically at the client care level of practice.
Define a Clinical Question in PMH Nursing
As stated, professional databases and scholarly resources are available with evidence to answer clinical questions. Steps in the process are:
- Nursing recognition of a problem and nursing inquiry
- What contributes to client readmissions? Do they forget to pick up their medication, or miss their clinic appointments? Would it help for us to call and remind them?
- Phrase the inquiry as a clinical question
- For discharged clients, would follow-up phone calls result in higher percentage of adherence to post-hospital care?
- Format the question as PICOT
- P=discharged clients
- I=follow-up phone call within twenty-four hours to check on medications and clinic appointments
- C=no phone call
- O=readmissions reduced by 25 percent
- T=over six months
- Utilize the question and the PICOT to identify key search terms
- Follow-up phone calls; Readmissions
- Enter the terms in the Search field of the database
- On CINAHL, enter in the Search fields – nurse follow-up phone call AND reduce readmissions
- Select from the resulting list of articles
Evaluating Client Outcomes
After application of the EBP model, the nurse evaluates how the interventions worked for the client. At this time, adjustments can be made to the intervention to make the treatment plan most applicable to the individual. Again, the goal of the entire process is for the client to have the best possible outcomes based on the best evidence-based practice for their situation.
Link to Learning
Often, an evidence-based practice committee responds to client care questions that come up; members are assigned parts of the research process and share all of the information in order to make an informed decision. They can then base interventions on that new information, try them with the client, and evaluate outcomes for applicability and success. Johns Hopkins Nursing’s Center for Nursing Inquiry provides an Inquiry Toolkit for helping nurses and students during an inquiry project.
Research Evidence on Representation and Acceptance of Mental Health in the Community
Mental health practitioners, including psychiatrists, social workers, nurses, clinical psychologists, and therapists, are in a position to increase the representation and acceptance of mental health in the community. These professionals work with people and their mental health on a daily basis. Their job experiences, intellectual knowledge, research, and involvement in policy change make them “practical experts” (Morant 2006, p. 819) in mental health care.
Morant (2006) reminds us that over the last fifty years, much has changed in the way that society views mental health, with the move from institutional to community care of mental illness. A review of research in Morant’s article reveals that the differences in care provided can be partly attributed to age and location of the practitioner. Older practitioners were trained in the years of institutionalized clients so it may be difficult for them to transition to today’s treatment. Comparisons of the way that different communities represent and accept mental health can be seen across the globe. In France, long-term therapy and lack of community care are the norm, whereas in England, short-term therapy and lack of financial resources is more prominent. In the United States, it is evident that more research is needed in the area of mental health due to the increase in symptoms since the COVID-19 pandemic. The White House Report on Mental Health Research Priorities (2023) details the need for more U.S. research aimed at inequities, especially in areas with poorer mental health outcomes. This would include research to determine ways to create more community-based service areas.
Access to Care: Gaps in the System
Research conducted by the White House (2023) has identified several system gaps. The first is the need for better coordination of mental health and substance use services. The use of “wraparound services” (p. 14) for the acutely mentally ill client is effective because it involves engaging a multiple disciplinary approach to care. This includes training providers to be proficient in recognizing the signs and symptoms of mental illness and substance use disorder. This approach would also focus on the physical effects of substance use disorder across the life span.
The next big system gap relates to adolescents. Research has revealed a connection between mental illness and use of social media, particularly in the context of body image. More research is needed to determine ways that social media could be used to positively impact mental health of both individuals and communities. School systems have potential to create mental health teaching programs that would address the needs of children from elementary school through college, so there is a need for research on how to implement and what to include in such programs.
Societal View
Although stigma still exists surrounding mental health, there are more programs and resources available to educate the public. Through these efforts, it is becoming more widely accepted that prevention and early symptom recognition have positive effects on community mental health. Holt and DeTore (2021) share that the most promising preventive mental health efforts have been school-based. One such program is the Sandy Hook Promise (2023), which was developed after the December 2012 shootings at the Sandy Hook Elementary School in Newtown, Connecticut. This important program teaches young people to know the signs of potential gun violence.
Some workplaces have Employee Assistance Programs, which provide access to facilities providing time-limited free mental health services. Public service announcements on TV, radio, and social media provide information and resources to help reduce depression, anxiety, and suicidality. All of these resources help to increase general knowledge, decrease stigma, and promote a more positive societal view of mental health.
Link to Learning
This video provides mental health professionals with an introduction to evidence-based practice that can be used for better client care.