- Email: [email protected]
What is the Evidence for Evidence-Based Practice?
102
LETTERS TO THE EDITOR
nursing scholarship. It is critical that our specialty have a journal with a research focus not only for access to investigations but also one that holds the longitudinal perspective on the pace and direction of PMH research in particular areas. Of course, our other fine PMH journals contain valuable research but probably not the continuum of important programs of PMH research represented in Archives. Archives has also maintained a focus on issues in PMH education and the development of our workforce. The workforce studies and detailed description of innovative PMH programs has been vital to the efforts of the Society for Education in Psychiatric Nursing and all those involved in producing a workforce for the 21st century. As an inpatient psychiatric nurse, I believe that Archives publishes articles pertinent to many of the issues we face, dealing with violence, restraint, staff training, and most recently, patient outcomes. These articles provide a sense of the science in key areas of our practice. Although we might hope for a greater volume of investigations from the community of inpatient nurses, we must understand and accept the pace of clinical practice. Inpatient psychiatric systems often present nurse managers with unpredictable issues that demand immediate attention and fast-paced decision making. One could quite naturally raise the objection that other professions face similar work demands and manage to publish. But to unravel the distinct quality of how
a nurse manager holds together a system would require something akin to Meleis’s (1997) thoughtful exploration of nurses as scientists and theorists. Thus, for a specialty that has its energies radiating in multiple directions, it seems Archives does a good job of capturing the essence of our scholarship. Is it enough? Our efforts, whether academic, research, or clinical, are always in the service of our social mandate to care for the mentally ill. Keeping that in focus will always be the challenge. The fact that our dedication to this mandate goes unrecognized by the larger community because of our failure to publish is somewhat the unfortunate reality we operate in. Kathy Delaney Department of Community and Mental Health Nursing Rush University Medical Center Chicago, IL REFERENCE Meleis, A. F. (1997). From Kant to can’t. In A. F. Meleis (Ed.), Theoretical nursing: Development and progress (pp. 49 – 69). Philadelphia: Lippincott.
B 2005 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi:10.1016/j.apnu.2005.02.003
What is the Evidence for Evidence-Based Practice? To the Editor: Based on clinical practice, I would certainly concur with Krauss’s statement that bresearch alone does not and cannot define the entire domain of practiceQ (Archives of Psychiatric Nursing, p. 201). One of the major issues with evidence-based practice is that the majority of persons who participate in the research studies do not represent a large segment of persons who seek mental health services—specifically the poor and uninsured. I currently practice in a nurse-managed center located in a large inner-city area in the Midwest. The clients we see for mental health services are
the unemployed and working poor who are uninsured. Although evidence-based practice helps guide my treatment decisions, there are a multitude of other factors that are equally important, if not more important, when determining treatment options. These factors include (but are not limited to): 1. Does the person have the financial resources to purchase the medication recommended as first-line treatment choice, or do I need to prescribe a medication that is available in the pharmacy?
LETTERS TO THE EDITOR
2. Does the person have transportation for therapy and/or follow-up appointments? 3. What comorbidities (both medical and psychiatric) does the person have and how well are they managed? 4. Does the person have a social support system? 5. Does the person live in adequate, stable housing? 6. Does the person have difficulties paying their utilities, food, and clothing? 7. What resources are available for psychiatric consultation for persons presenting with more complex symptoms?
Although I am not naRve enough to think that a person with a job and insurance is not confronted with many of these same problems, such problems have a greater impact on those who are unemployed or working in low-paying jobs that do not provide insurance. For example, there is a large body of evidence for the treatment of unipolar depression. Research findings support the efficacy of antidepressant medications in improving mood state and decreasing the risk of relapse with SSRIs as the first-line treatment of choice. In additional, in persons who respond to medication, the combination of psychotherapy plus medication is often more effective in reducing relapse risk than medication alone (Thase, 2003). However, how effective are these treatments for persons who are depressed and have no job, no transportation, and no money? Might they be better served if we helped them obtain job skills that would result in earning a living wage? How effective is psychotherapy if someone has been in crisis for so long they have forgotten how to think about long term goals? My colleagues and I struggle with the challenge of how best to provide mental health services to those living on the edge; and, this challenge is not going away anytime soon. An estimated 43.6 million Americans (15.2% of the U.S. population) were uninsured in 2002, and this number increases if you include those who were uninsured for only part of the year—75 million were without coverage for all or part of 2001 and 2002, with two thirds uninsured for 6 months or more (U.S. Census, 2003). There is a large body of knowledge that describes the poor and uninsured and their
103
increased risk for physical and mental health problems, yet there is a paucity of knowledge and evidence about what is most helpful. Research in this area is slow in coming. I concur with Krauss who encourages practitioners to share their experiences of when and why they bdid not follow the linear path of evidenceQ (Archives of Psychiatric Nursing, p. 201). What intervention and treatment strategies have other practitioners used when their clients differ from the empirical norm? What evidence informs their decisions when empirical evidence does not yet exist? Do interventions for the poor and uninsured need to be different from those used with people who have a job and insurance? Clinical narratives and case studies have contributed great insights to psychiatric– mental health nursing in the past and hopefully will continue to inform our clinical judgment and practice now and in the future. Carla J. Groh, PhD, APRN, BC Associate Professor McAuley School of Nursing University of Detroit Mercy 4001 W. McNichols Road Detroit, MI 48221-3038 E-mail address: [email protected] REFERENCES Thase, M. E. (2003). Effectiveness of antidepressants: Comparative remission rates. Journal of Clinical Psychiatry, 64(Suppl. 2), 3 – 7. U.S. Census. (2003). Health insurance coverage in the United States: 2002. Retrieved January 23, 2005, from http:// www.census.gov/prod/2003pubs/p60-"223.pdf.
DOI of original article 10.1016/j.apnu.2004.09.002 B 2005 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi:10.1016/j.apnu.2005.03.003
To the Editor: I had to smile at your bGone Fishing Q editorial. I get every one of the journals you mentioned, and there are times when I wonder when I am going to read all of them. I hope you get the response you are looking for so that you will write again. It moved me to write this letter.
LETTERS TO THE EDITOR
nursing scholarship. It is critical that our specialty have a journal with a research focus not only for access to investigations but also one that holds the longitudinal perspective on the pace and direction of PMH research in particular areas. Of course, our other fine PMH journals contain valuable research but probably not the continuum of important programs of PMH research represented in Archives. Archives has also maintained a focus on issues in PMH education and the development of our workforce. The workforce studies and detailed description of innovative PMH programs has been vital to the efforts of the Society for Education in Psychiatric Nursing and all those involved in producing a workforce for the 21st century. As an inpatient psychiatric nurse, I believe that Archives publishes articles pertinent to many of the issues we face, dealing with violence, restraint, staff training, and most recently, patient outcomes. These articles provide a sense of the science in key areas of our practice. Although we might hope for a greater volume of investigations from the community of inpatient nurses, we must understand and accept the pace of clinical practice. Inpatient psychiatric systems often present nurse managers with unpredictable issues that demand immediate attention and fast-paced decision making. One could quite naturally raise the objection that other professions face similar work demands and manage to publish. But to unravel the distinct quality of how
a nurse manager holds together a system would require something akin to Meleis’s (1997) thoughtful exploration of nurses as scientists and theorists. Thus, for a specialty that has its energies radiating in multiple directions, it seems Archives does a good job of capturing the essence of our scholarship. Is it enough? Our efforts, whether academic, research, or clinical, are always in the service of our social mandate to care for the mentally ill. Keeping that in focus will always be the challenge. The fact that our dedication to this mandate goes unrecognized by the larger community because of our failure to publish is somewhat the unfortunate reality we operate in. Kathy Delaney Department of Community and Mental Health Nursing Rush University Medical Center Chicago, IL REFERENCE Meleis, A. F. (1997). From Kant to can’t. In A. F. Meleis (Ed.), Theoretical nursing: Development and progress (pp. 49 – 69). Philadelphia: Lippincott.
B 2005 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi:10.1016/j.apnu.2005.02.003
What is the Evidence for Evidence-Based Practice? To the Editor: Based on clinical practice, I would certainly concur with Krauss’s statement that bresearch alone does not and cannot define the entire domain of practiceQ (Archives of Psychiatric Nursing, p. 201). One of the major issues with evidence-based practice is that the majority of persons who participate in the research studies do not represent a large segment of persons who seek mental health services—specifically the poor and uninsured. I currently practice in a nurse-managed center located in a large inner-city area in the Midwest. The clients we see for mental health services are
the unemployed and working poor who are uninsured. Although evidence-based practice helps guide my treatment decisions, there are a multitude of other factors that are equally important, if not more important, when determining treatment options. These factors include (but are not limited to): 1. Does the person have the financial resources to purchase the medication recommended as first-line treatment choice, or do I need to prescribe a medication that is available in the pharmacy?
LETTERS TO THE EDITOR
2. Does the person have transportation for therapy and/or follow-up appointments? 3. What comorbidities (both medical and psychiatric) does the person have and how well are they managed? 4. Does the person have a social support system? 5. Does the person live in adequate, stable housing? 6. Does the person have difficulties paying their utilities, food, and clothing? 7. What resources are available for psychiatric consultation for persons presenting with more complex symptoms?
Although I am not naRve enough to think that a person with a job and insurance is not confronted with many of these same problems, such problems have a greater impact on those who are unemployed or working in low-paying jobs that do not provide insurance. For example, there is a large body of evidence for the treatment of unipolar depression. Research findings support the efficacy of antidepressant medications in improving mood state and decreasing the risk of relapse with SSRIs as the first-line treatment of choice. In additional, in persons who respond to medication, the combination of psychotherapy plus medication is often more effective in reducing relapse risk than medication alone (Thase, 2003). However, how effective are these treatments for persons who are depressed and have no job, no transportation, and no money? Might they be better served if we helped them obtain job skills that would result in earning a living wage? How effective is psychotherapy if someone has been in crisis for so long they have forgotten how to think about long term goals? My colleagues and I struggle with the challenge of how best to provide mental health services to those living on the edge; and, this challenge is not going away anytime soon. An estimated 43.6 million Americans (15.2% of the U.S. population) were uninsured in 2002, and this number increases if you include those who were uninsured for only part of the year—75 million were without coverage for all or part of 2001 and 2002, with two thirds uninsured for 6 months or more (U.S. Census, 2003). There is a large body of knowledge that describes the poor and uninsured and their
103
increased risk for physical and mental health problems, yet there is a paucity of knowledge and evidence about what is most helpful. Research in this area is slow in coming. I concur with Krauss who encourages practitioners to share their experiences of when and why they bdid not follow the linear path of evidenceQ (Archives of Psychiatric Nursing, p. 201). What intervention and treatment strategies have other practitioners used when their clients differ from the empirical norm? What evidence informs their decisions when empirical evidence does not yet exist? Do interventions for the poor and uninsured need to be different from those used with people who have a job and insurance? Clinical narratives and case studies have contributed great insights to psychiatric– mental health nursing in the past and hopefully will continue to inform our clinical judgment and practice now and in the future. Carla J. Groh, PhD, APRN, BC Associate Professor McAuley School of Nursing University of Detroit Mercy 4001 W. McNichols Road Detroit, MI 48221-3038 E-mail address: [email protected] REFERENCES Thase, M. E. (2003). Effectiveness of antidepressants: Comparative remission rates. Journal of Clinical Psychiatry, 64(Suppl. 2), 3 – 7. U.S. Census. (2003). Health insurance coverage in the United States: 2002. Retrieved January 23, 2005, from http:// www.census.gov/prod/2003pubs/p60-"223.pdf.
DOI of original article 10.1016/j.apnu.2004.09.002 B 2005 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi:10.1016/j.apnu.2005.03.003
To the Editor: I had to smile at your bGone Fishing Q editorial. I get every one of the journals you mentioned, and there are times when I wonder when I am going to read all of them. I hope you get the response you are looking for so that you will write again. It moved me to write this letter.