Evidence for Psychiatric Nursing Practice: An Analysis of Three Years of Published Research

Abstract

Psychiatric and mental health nursing practice continues to be strongly influenced by tradition, unsystematic trial and error, and authority. Yet the need for quality care that is based on the best and most current empirical research is well documented. Achieving evidence-based practice in the psychiatric nursing specialty will require that qualified nurse researchers conduct research relevant for practice and appropriately disseminate that research to those who can best use it, practicing nurses. This State of the Evidence Review analyzed the 227 data-based studies published in the five most commonly read American psychiatric nursing journals from January 2000 through December 2002. Five major research foci were found: global perspectives, psychiatric nurses as subjects, studies of family caregivers, research with clients across the life span, and testing of nursing interventions. About 88% of the studies were conducted in the United States; 63% involved recipients of mental health care services; but only 11% tested psychiatric nursing interventions. Promoting evidence-based practice in psychiatric nursing will require increasing the numbers of psychiatric nurse researchers, enriching the research process (i.e., increasing relevance and appropriate dissemination), and implementing changes in practice that are based on the best and most currently available evidence, rather than on the equivalents of "Old Wives' Tales."

Full text

Zauszniewski, J., Suresky, J. (December 19, 2003) Psychiatric/Mental Health Nursing -
"Evidence for Psychiatric Nursing Practice: An Analysis of Three Years of Published Research"
Online Journal of Issues in Nursing. Vol.#9 No.1 Available:
http://nursingworld.org/ojin/hirsh/topic4/tpc4_1.htm
© 2003 Online Journal of Issues in Nursing
December 19, 2003
EVIDENCE FOR PSYCHIATRIC NURSING
PRACTICE: AN ANALYSIS OF THREE YEARS OF
PUBLISHED RESEARCH
Jaclene A. Zauszniewski PhD, RNC
Jane Suresky ND, RN, CS
The Sarah Cole Hirsh Institute for Best Nursing Practices
of the Case Western Reserve University
Frances Payne Bolton School of Nursing
ABSTRACT
Psychiatric and mental health nursing practice continues to be strongly
influenced by tradition, unsystematic trial and error, and authority. Yet the need
for quality care that is based on the best and most current empirical research is
well documented. Achieving evidence-based practice in the psychiatric nursing
specialty will require that qualified nurse researchers conduct research relevant
for practice and appropriately disseminate that research to those who can best
use it, practicing nurses. This State of the Evidence Review analyzed the 227
data-based studies published in the five most commonly read American
psychiatric nursing journals from January 2000 through December 2002. Five
major research foci were found: global perspectives, psychiatric nurses as
subjects, studies of family caregivers, research with clients across the life span,
and testing of nursing interventions. About 88% of the studies were conducted
in the United States; 63% involved recipients of mental health care services; but
only 11% tested psychiatric nursing interventions. Promoting evidence-based
practice in psychiatric nursing will require increasing the numbers of psychiatric
nurse researchers, enriching the research process (i.e., increasing relevance and
appropriate dissemination), and implementing changes in practice that are based
on the best and most currently available evidence, rather than on the equivalents
of "Old Wives’ Tales."
Key words:
psychiatric nursing research, research dissemination, evidence-based practice,
systematic review, research utilization, published research, psychiatric nursing journals, best
p
ractices
Evidence for Psychiatric Nursing Practice: Wives’ Tales or Research
Historically, nursing practice has been influenced by traditional wisdom passed down
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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
N
ational Health Promotion and Disease Prevention Objectives
(2000
), and the
R
eport 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
p
ractice 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
p
rimary 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
j
ails.
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
p
sychiatric nurses, including: (a) are psychiatric nurses aware of the efficacy of the
treatments and interventions they provide? (b) are they truly practicing evidence-based
p
sychiatric 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
j
udicious 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).
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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
N
ightingale, 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
p
ractice. 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
N
ursing (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
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.
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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
p
ublished 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
P
erspectives
between 2000 and 2003 were conducted outside of the United States, followed
by
JPNMHS
(15%),
Archives
(14%),
JAPNA
(11%), and
Issues
(5%).
R
esearch About Ps
y
chiatric 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
p
atient-related. Performance of the psychiatric nursing role, including decision making and
ethical behavior, was investigated in 4 studies (8%).
Table 1. Number of studies published in five psychiatric nursing journals by
population (2000-2003)
Journal
Nurses
Caregivers
Youth
Elders
Healthy
Adults
Mentally Ill
Adults
Archives
9 11 1 5 9 27
Issues
17 12 10 5 18 16
Perspectives
5 2 0 1 2 2
JPNMHS
14 4 2 6 5 16
JAPNA
7 3 2 0 7 9
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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
J
PNMH
S
(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
P
erspectives
between 2000 and 2003 involved psychiatric nurses as their subjects, followed
by
JPNMHS
(30%),
JAPNA
(25%),
Issues
(22%), and
Archives
(14%).
S
tudies o
f
Care
g
ivers
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
A
rchives
(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
J
APNA
and
JPNMHS
with 11% and 8% of their studies about family caregivers within the
same time frame.
R
esearch Across the Li
f
espan
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
p
ublished 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 of clients
constituted the
majority...of the
published research.
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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
J
APNA
had none. However, the statistics also indicated that 13% of the published studies in
J
PNMH
S
were of elderly persons, while both
Archives
and
Perspectives
published 8%, and
Issues had 6%.
S
tudies o
f
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
p
sychological 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
p
ublished in
Issues
(18),
Archives
(9) and
JAPNA
(7), followed by
JPNMHS
with 5 and
P
erspectives
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
A
rchives
, and 11% for
JPNMHS
.
S
tudies o
f
Adults With Mental Disorders
There were 70 studies of adults with mental illness, which constituted 63% of the 111
p
ublished 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
p
ublished in
Archives
(27).
Issues
and
JPNMHS
each published 16 studies of adults with
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mental illness during the same study period, while
JAPNA
published 9 and
Perspectives
p
ublished 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
J
PNMH
S
(34%) and
JAPNA
(32%). Fewer studies of adult with mental illness were found in
I
ssues
(20%) and
Perspectives
(17%).
N
ursin
g
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
J
PNMH
S
(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
j
ournals 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,
p
sychiatric 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
p
ractice, 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
...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.
Research findings
must be published in
j
ournals that are read
b
y those who can use
the evidence -
psychiatric nurses in
clinical practice.
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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
p
articular.
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
p
ractice 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,
...a final issue of
concern is the
implementation of
change in nursing
practice based on or
guided by empirical
evidence.
...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.
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Cleveland, Ohio. With over 28 years of nursing practice, including 18 years in the field of
p
sychiatric-mental health nursing, Dr. Zauszniewski has experience as a staff nurse, clinical
p
receptor, head nurse, supervisor, patient care coordinator, nurse educator, and nurse
researcher. Her program of research focuses on the identification of factors and strategies to
p
revent 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 Nursin
g
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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Peplau, H. E. (1952).
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Stuart, G.W. (2000). Evidence Based Psychiatric Nursing Practice. In G.W. Stuart, & Laraia,
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U.S. Department of Health and Human Services. (1999).
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Wilson, H.S. (2004). Evidence-based practice in psychiatric – mental health nursing. In C.R.
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© 2003 Online Journal of Issues in Nursing
Article published December 19, 2003
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