Evidence-based practice dictates that nursing interventions must be based on research findings supporting its effectiveness. Nurses must be adept in appraising research so that decisions to adopt interventions are informed by the quality and applicability of the findings. The PICO question approach was used to ascertain whether residents diagnosed with mental health conditions after they enter assisted living receive better care than residents who have pre-existing mental health conditions and received care outside assisted living. A search was made on PubMed to locate an article that would elucidate this topic. The purpose of this paper is to appraise and summarize the selected study and make a judgment on whether the evidence generated is strong enough to warrant adoption.
Research Question
McDonald et al. (2011) conducted a pilot clinical trial to investigate the effects of acceptance training as a nursing intervention on selected outcomes in older adults in retirement communities. The authors explicitly aimed to answer 3 questions pertaining to the immediate, short-term, and long-term effects of acceptance training on the following: 1. older adult acceptance of their chronic illnesses, 2. depression and anxiety, and 3. self-reported health and functional status.
Research Design
The study employed the longitudinal research design. Six retirement communities in northeastern Ohio were randomly selected thereby providing an element of randomness that strengthened the sample which was recruited via convenience sampling (Houser, 2015). However, there was no description of how random selection occurred. Comparisons were made with baseline measurements. Although conducted in multiple sites, the study is observational. As such, it lacks the typical elements of an experimental research, namely a control or comparison group, random allocation, and blinding, which render a study able to detect cause-and-effect relationships that establish effectiveness (Houser, 2015).
The goal of the acceptance training intervention was to assist older adult residents in accepting the chronicity of their conditions and consisted of 2-hour small group sessions conducted over a 6-week period (McDonald et al., 2011). Each group had between 7 and 11 members and was facilitated by a nurse clinician trained in the intervention. The sessions promoted socialization by allotting time for and providing refreshments. The first hour of each session is devoted to group counseling and the second hour to relaxation, music, and guided imagery. Counseling was based on the rational emotive behavioral therapy wherein residents become aware of their beliefs regarding their chronic health problems and the impact of such beliefs on emotions and behavior (McDonald et al., 2011). Older adult participants learned to recognize that these beliefs were in fact irrational and must be given up in place of a more rational, positive outlook.
The relaxation and music were used to prepare the patients for guided imagery using a previously developed CD. Guided imagery was meant to help participants associate the mental image of a special, quiet place chosen by the individual with that of a symbolic image of the illness (McDonald et al., 2011). As such, the intervention reinforced the group counseling sessions. Intervention fidelity was guaranteed by training the facilitators and is important because deviations make it difficult to attribute the outcomes to the original design of the intervention (Lawton et al., 2011).
Sampling
The sample size is important in a quantitative study. It should be large enough so that the statistical analysis can detect a difference in the outcomes being compared when there is truly a difference (Button et al., 2013). In short, a sample size that is too small could lead to a false negative finding. A small sample size also lowers the likelihood that when a statistically significant difference is in fact found, that this represents a true difference (Button et al., 2013). As such, a false positive finding may also occur. Power analysis is a mathematical computation used to determine which sample size is adequate enough to prevent false negatives and false positives (Houser, 2015). The sample size was inadequate as the authors performed a power analysis supporting this fact and was compounded by the high attrition.
Data Collection
Interviews were performed to collect data on the selected outcomes. The data collectors received training and this standardized the process thereby minimizing bias which can reduce data accuracy. Five instruments were used for the collection of data and were adequately described. Their validity and reliability was supported by the prior studies cited. Depression and anxiety were measured using the Center for Epidemiological Studies – Depression Scale and the State Anxiety Inventory, respectively (McDonald et al., 2011). The instruments enabled the collection of self-report data which can be prone to response bias and inaccuracy such as when the participant gives answers that he thinks are acceptable to the interviewer instead of truthful answers (Houser, 2015).
Limitations of the Study
Limitations include the lack of randomized participant recruitment and the absence of a control group. The authors could have allocated part of the sample to African Americans and to Whites and then randomly selected the participants for each race. Although baseline measurements were done, comparison to a group that did not receive the intervention would strengthen conclusions on effectiveness (Houser, 2015). The study also had low power with the small sample size. The study was a longitudinal pilot and replication through adequately powered experimental research is warranted to confirm the findings. Further, the authors collected self-report data. Patient ideas about chronic health conditions and self-rated health cannot be validated by more objective data and so the responses using the chosen tools would suffice. However, anxiety, depression, and disability can be verified using patient health records and clinical assessments.
Findings
All the research questions were answered. Outcomes were measured at baseline and at 3 time points during and after the intervention (McDonald et al., 2011). Acceptance training was associated with a progressive increase in self-reported acceptance of chronic illness from baseline. Reported functional status also improved consistently and significantly starting at the second time point. On the contrary, self-rated health was significantly lower at the last time point compared to baseline. Anxiety scores increased at the final time point compared to baseline while depression scores had a consistently downward trend. However, these differences were not statistically significant. Possible explanations were given for the contradictory and non-significant findings.
Summary
The study was a pilot of a nurse-led theory-based intervention to improve the psychological and health outcomes of chronic disease in older adults in retirement communities. The framework used was they biopsychosocial model and the rational emotive behavior theory. Residents were recruited and underwent group-based acceptance training sessions which aimed to improve chronic disease acceptance, depression and anxiety symptoms, and health and functional status. The intervention was associated with enhanced acceptance and self-reported functional status, reduced self-reported health, and no changes in depression and anxiety scores.
The evidence in the study is not strong enough to suggest practice change because it was designed as a pilot to test the feasibility of acceptance training in the chosen setting and research problem. The study had several limitations. A larger experimental study better designed to measure cause-and-effect relationship needs to be conducted to generate more reliable conclusions. However, the study underscores nurses’ ability to design, implement, and evaluate theory-based and holistic mental health interventions to address older adult needs in the residential setting which may be more effective than the standard biomedical approach.
References
Button, K.S., Ioannidis, J.P.A., Mokrysz, C., Nosek, B.A., Flint, J., Munafo, M.R. (2013). Power failure: Why small sample size undermines the reliability of neuroscience. Nature Reviews of Neuroscience, 14, 365-376. doi:10.1038/nrn3475
Houser, J. (2015). Nursing research: Reading, using, and creating evidence (3rd ed.). Sudbury, MA: Jones & Bartlett.
Lawton, J., Jenkins, N., Darbyshire, J. L., Holman, R. R., Farmer , A. J., & Hallowell, N. (2011). Challenges of maintaining research protocol fidelity in a clinical care setting: A qualitative study of the experiences and views of patients and staff participating in a randomized controlled trial. Trials, 12(108), 1-10. http://doi.org/10.1186/1745-6215- 12-108
McDonald, P.E., Zauszniewski, J.A., Bekhet, A.B., DeHelian, L., & Morris, D.L. (2011). The effect of acceptance training on psychological and physical health outcomes in elders with chronic conditions. Journal of the National Black Nurses Association, 22(2), 11- 19. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476051/pdf/nihms380530.pdf
