Assignment: Evidence-Based Project, Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews

›Clinical issue of interest- nurse burnout

›Characteristics: fatigue, cognitive dysfunction, depression, and impaired sleep (Rudman et al., 2021).

›Causes: Job dissatisfaction, poor quality of the work environment, and unhealthy work relationships

›Implications: reduced output and high turnover (Rudman et al., 2021).

Nurses should work as comfortably as possible in order to maintain a healthy work environment and maximize patient outcomes. Nurse burnout, on the other hand, has a negative impact on nurses’ output and work relationships. It is also a major source of nurse turnover. According to Rudman et al. (2021), nurse burnout is characterized by fatigue, cognitive dysfunction, depression, and poor sleep. In this case, it affects multiple aspects of nurses’ health, implying that they are unable to provide efficient and effective care. Job dissatisfaction and increased workload are common causes. Evidence-based interventions are required due to the negative consequences of unhealthy workplaces and turnover. One of the most effective interventions is resilience training.

Burnout in nurses is a problem.

Resilience training is an intervention.

Contrast: no intervention

Reduced burnout as a result

Timeline: six months

The PICOT process aids in the development of a thoughtful question that will guide the search for evidence. I used the same method to create the PICOT question. The entire process begins with identifying the patient or problem that requires intervention. Nurses experiencing burnout are the target population in this scenario. Resilience training is the proposed intervention to improve nurses’ resilience to burnout. Other alternatives are considered in the comparison, but none have been considered. The result indicates the desired goal, which is to reduce nurse burnout. Because evidence-based practice projects must be completed within a specific time frame, the time required to achieve the desired outcome must be specified.

PICOT Question: Can resilience training (I) reduce nurse burnout (O) in six months (T) in nurses with burnout (P) compared to no intervention (C)?

Scholarly and peer-reviewed sources should be used to obtain evidence-based practice research. The university library has access to numerous nursing databases that contain numerous articles on a variety of topics. CINAHL Plus with Full Text, an extensive collection of journals and e-books on nursing topics, was one of the research databases I used. The Cochrane Database of Systematic Reviews contains full-text versions of evidence-based sources to help inform nursing and health-care decision-making. PubMed provides access to full-text journal articles. The CINAHL/MEDLINE Combined Search includes peer-reviewed articles from the nursing and allied health literature, as well as case studies, systematic reviews, and EBP reports.

Article
Focus Area

Deldar et al. (2018)
relationship between resiliency and burnout

Yu et al. (2019)
Personal and work-related factors associated with nurse resilience

De Oliveira et al. (2019)
prevention actions of burnout syndrome

Klein et al. (2019)
benefits of mindfulness-based interventions on burnout

The above four studies met the inclusion criteria for scholarly and peer-reviewed articles. Besides being scholarly and peer-reviewed, the studies recommend resilience training as an evidence-based strategy for addressing nurse burnout. Deldar et al. (2018) conducted a meta-analysis examining the effects of resiliency on nurse burnout. Yu et al. (2019) deduced that increased nurse resilience reduces emotional exhaustion and increases work engagement. Resilience is a key theme in de Oliveira et al. (2019) article, which can be taught or developed through coping skills training. Klein et al. (2019) examined the effectiveness of interventions that increase resilience, such as mindfulness-based activities. Their primary objective is to pursue a state of mind characterized by self-control and free from self-judgmental feelings.

Article
Type
Evidence Level

Deldar et al. (2018)
a systematic review and meta-analysis
Level 1

Yu et al. (2019)
a systematic review
Level 1

De Oliveira et al. (2019)
an integrating literature review
Level 1

Klein et al. (2019)
a systematic review
Level 1

In the evidence pyramid, systematic reviews and meta-analyses occupy the first level of evidence (Level 1). At this level, research studies contain evidence from systematic reviews or meta-analyses of good quality sources on a given topic. Systematic reviews provide a summary of the clinical literature. In this case, the chosen studies critically assess and evaluate many other research studies that address nurse burnout and resilience. On the other hand, a meta-analysis combines the results of independent studies. It also synthesizes summaries and conclusions from the same studies quantitatively. The defining element of a meta-analysis is being an overview of clinical trials, which differentiates such studies from systematic reviews.

›Answer a focused research question

›Clear and comprehensive evidence overview

›Identify research gaps

›Enhanced precision of effect estimate

›Minimal research bias

As sources of high level of evidence, systematic reviews are designed to answer a focused research question. In this process, researchers using the systematic review approach identify and synthesize the available scholarly research on a particular topic. For instance, Deldar et al. (2018) first extracted 227articles that were screened to end up with 108 studies for their review on resiliency and burnout. Such in-depth exploration of a nursing topic provides a clear and comprehensive overview of research evidence. The other dominant strength is identifying research gaps. After the synthesis and analysis, systematic reviews indicate areas where further research is required. Importantly, systematic reviews are associated with better precision of effect estimate and minimal bias compared to individual studies.

›de Oliveira, S. M., de Alcantara Sousa, L. V., Vieira Gadelha, M., & do Nascimento, V. B. (2019). Prevention Actions of Burnout Syndrome in Nurses: An Integrating Literature Review. Clinical Practice and Epidemiology in Mental Health : CP & EMH, 15, 64–73. https://doi.org/10.2174/1745017901915010064

›Deldar, K., Froutan, R., Dalvand, S., Gheshlagh, R. G., & Mazloum, S. R. (2018). The Relationship between Resiliency and Burnout in Iranian Nurses: A Systematic Review and Meta-Analysis. Open access Macedonian Journal of Medical Sciences, 6(11), 2250–2256. https://doi.org/10.3889/oamjms.

2018.428

›Klein, A., Taieb, O., Xavier, S., Baubet, T., & Reyre, A. (2020). The benefits of mindfulness-based interventions on burnout among health professionals: A systematic review. Explore, 16(1), 35-43. https://doi.org/10.1016/j.explore.2019.09.002

›Rudman, A., Arborelius, L., Dahlgren, A., Finnes, A., & Gustavsson, P. (2020). Consequences of early career nurse burnout: A prospective long-term follow-up on cognitive functions, depressive symptoms, and insomnia. EClinicalMedicine, 27, 100565. https://doi.org/10.1016/j.eclinm.2020.100565

›Yu, F., Raphael, D., Mackay, L., Smith, M., & King, A. (2019). Personal and work-related factors associated with nurse resilience: A systematic review. International Journal of Nursing Studies, 93, 129-140. https://doi.org/10.1016/j.ijnurstu.2019.02.014

Solution- EBP Part 1: Identifying Research Methodologies for Personality Disorders

The philosophy of practice that is premised on using only interventions proven by research to be efficacious is referred to as evidence-based practice or EBP. But the body of EBP knowledge is not static but dynamic as it keeps changing daily as new evidence of efficacy emerges. This new knowledge for EBP is generated by a process known as clinical inquiry which is undertaken by using the PICOT model.

This model requires the identification of the clinical issue of interest or problem

(P) requiring evidence-based interventions. Alternatively, the patient population

(P) this issue affects is identified as well as the problem itself.

This is followed by the intervention to be investigated (I),

the comparison or current intervention (C),

the expected outcome (O),

and the timeframe for the application of the intervention (T) (Melnyk & Fineout-Overholt, 2019).

In this EBP project, the clinical issue of interest chosen is the treatment of personality disorders. For this, the PICOT statement or question is “In adult patients diagnosed with a personality disorder (P),

does the use of psychotherapy combined with pharmacotherapy (I),

compared to pharmacotherapy alone (C),

result in better symptom remission (O) within a span of six months (T)?” The purpose of this paper is therefore to analyze four peer-reviewed articles from research databases CINAHL, PubMed, Cochrane, and ProQuest that provide evidence for the best intervention to manage personality disorders.

Full citation of selected article
Article #1
Article #2
Article #3
Article #4

Choi-Kain, L.W., Albert, E.B., & Gunderson, J.G. (2016). Evidence-based treatments for borderline personality disorder. Harvard Review of Psychiatry, 24(5), 342–356. https://doi.org/10.1097/hrp.0000000000000113
Ellison, W.D. (2020). Psychotherapy for borderline personality disorder: Does the type of treatment make a difference? Current Treatment Options in Psychiatry, 7, 416-428. https://doi.org/10.1007/s40501-020-00224-w  
Pearce, S., Scott, L., Attwood, G., Saunders, K., Dean, M., De Ridder, R., Galea, D., Konstantinidou, H., & Crawford, M. (2018). Democratic therapeutic community treatment for personality disorder: Randomised controlled trial. The British Journal of Psychiatry, 210(2), 149-156. https:/doi.org/10.1192/bjp.bp.116.184366
Timäus, C., Meiser, M., Bandelow, B., Engel, K.R., Paschke, A.M., Wiltfang, J., & Wedekind, D. (2019). Pharmacotherapy of borderline personality disorder: What has changed over two decades? A retrospective evaluation of clinical practice. BMC Psychiatry, 19(393), 1-11. https://doi.org/10.1186/s12888-019-2377-z

Why you chose this article and/or how it relates to the clinical issue of interest (include a brief explanation of the ethics of research related to your clinical issue of interest)
This article was chosen as it relates to the clinical issue of interest in that it investigates evidence-based treatments for borderline personality disorder. BPD is one of the personality disorders as classified by the DSM-5 (Sadock et al., 2015). The ethics of research have been avoided in this research as it is a review of previous trials on therapies for PDs.
This article was chosen because it relates to the clinical issue of interest. It is about reviewing the current evidence-based psychotherapeutic treatments that are available for BPD as one of the PDs. The issue of ethics did not arise as the research was not a primary study but a filtered one.
This article was chosen because it is about investigating the efficacy of democratic therapeutic community (DTC) treatment for personality disorders. This is how it relates to the clinical issue of interest. On ethics, the subjects were allowed to give informed consent (autonomy) and they were not harmed in any way during the study (nonmaleficence). Lastly but not least, they were assured that the study would benefit them, respecting beneficence (Haswell, 2019).
The choice of this article was informed by the fact that it addresses the issue of pharmacotherapy in the management of BPD. Being retrospective, the confidentiality of the patient information in the charts used was maintained to avoid causing psychological harm by breaching privacy in a violation of the principle of nonmaleficence (Haswell, 2019).

Brief description of the aims of the research of each peer-reviewed article
The aim of this review was to evaluate four major available peer-reviewed therapies for BPD.
The aims were (i) to provide a summary of available evidence-based psychotherapeutic treatments for BPD, and (ii) to evaluate their effectiveness and the evidence supporting that.
The aim of te study was to assess whether DTC could reduce in-patient admission and improve the mental health of personality disorder patients.
The aim was to assess the quality of the available drug treatment for BPD in inpatients.

Brief description of the research methodology used Be sure to identify if the methodology used was qualitative, quantitative, or a mixed-methods approach. Be specific.
The methodology was a systematic quantitative review of existing literature. Each of these modalities was assessed individually and their merits and demerits and compared against the others.  
The methodology is a qualitative systematic review of the available scholarly evidence.
This was a quantitative study in the form of a randomized controlled study/ trial or RCT.
The methodology was a quantitative retrospective evaluation of practice.

A brief description of the strengths of each of the research methodologies used, including reliability and validity of how the methodology was applied in each of the peer-reviewed articles you selected.
The strength of this paper is in its being a review of several primary research articles on the subject. It is therefore a summary of sorts which is better than a single study focussing on one therapy. Its reliability and validity depends on the collective reliability and validity of the four articles reviewed. Being a review, its validity and reliability are sound.
The major strength of this methodology is that filtered research provides the best and highest evidence in the pyramid of evidence at level 1. As a sum of the primary studies reviewed, the validity and reliability or generalizability of this study is beyond reproach (good).
The main strength of this study design is that it is experimental in nature and is therefore the best way to establish causality.
The strength of this study is that it is a primary study that generated new knowledge to enrich existing EBP. The sample size was n = 87 and this was enough to guarantee validity and generalizability of the results.

General Notes/Comments
The findings of this study are instrumental in generating new knowledge for enriching EB clinical practice.
This study adds to the body of knowledge available for EBP.
Being an experimental primary research study, this work is invaluable in generating entirely new knowledge about causality for EBP.
The study provides required evidence for pharmacotherapeutic interventions against BPD which is a PD.

Conclusion

This identification of research methodologies has been conducted systematically according to the tenets of clinical inquiry. A clear issue of clinical interest has been identified and a PICOT statement generated with it to facilitate the search for evidence from published peer-reviewed literature.

Reputable research databases have been used to search for evidence and finally four of the several articles retrieved have been reviewed in the matrix above. They show clearly that psychotherapy is the best intervention for personality disorders, but that prudent clinical practice requires that a combination of psychotherapy and pharmacotherapy be used for the best patient outcomes.

References

Choi-Kain, L.W., Albert, E.B., & Gunderson, J.G. (2016). Evidence-based treatments for borderline personality disorder. Harvard Review of Psychiatry, 24(5), 342–356. https://doi.org/10.1097/hrp.0000000000000113

Ellison, W.D. (2020). Psychotherapy for borderline personality disorder: Does the type of treatment make a difference? Current Treatment Options in Psychiatry, 7, 416-428. https://doi.org/10.1007/s40501-020-00224-w  

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4th ed. Wolters Kluwer.

Pearce, S., Scott, L., Attwood, G., Saunders, K., Dean, M., De Ridder, R., Galea, D., Konstantinidou, H., & Crawford, M. (2018). Democratic therapeutic community treatment for personality disorder: Randomised controlled trial. The British Journal of Psychiatry, 210(2), 149-156. https:/doi.org/10.1192/bjp.bp.116.184366

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Timäus, C., Meiser, M., Bandelow, B., Engel, K.R., Paschke, A.M., Wiltfang, J., & Wedekind, D. (2019). Pharmacotherapy of borderline personality disorder: What has changed over two decades? A retrospective evaluation of clinical practice. BMC Psychiatry, 19(393), 1-11. https://doi.org/10.1186/s12888-019-2377-z.

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