Idea of Evidence-Based Care - Essay Example

Introduction Evidence-based practice has its roots in the medical field, where multiple cases of meticulous research studies have been carried out. Dr. David Sackett, a pioneer in evidence based practice considered evidence-based medicine as the contemporary use of present best evidence in informing decisions regarding patient care (Sadock & Sadock, 2007.p.246). The entire idea of evidence based care is integrating individual clinical expertise with the best accessible external clinical evidence from systematic research. Evidence-based practice has readily been accepted in disciplines such as psychology and education, in these disciplines the approach is considered a means of building quality and accountability. In this regard, APA defines evidence-based practice as the integration of the present research with clinical expertise in the context of patient characteristics, culture and preferences (APA, 2001). Besides these two definitions, there has been others forwarded by credible medical and professional bodies. Though different in wording, all these definitions have underlined the importance of quality research, comparison of various researches to determine same outcome and adequate professional expertise. These three conditions form the bases of evidence-based practice. In this study, the concern is implementation of evidence-based practice in actual practice. The study reviews an actual situation entailing an elaborate interview with a patient in an acute ward/setting. The information gathered in this interview will help in the development of a vulnerability chart and inform incorporation of evidence-based practice. The entire idea of this inquiry is a successful imploration on that best approach to be used in developing an implementable solution for the patient. In achieving this objective, consent will be sought from the patient and the corresponding caregivers. Additionally, adequate discretion on the information supplied by the patient will be exercised. These will be safeguards to ensure that the patient’s rights are not upset in the course of this study. More so, these preliminary guarantees will be considered adequate in ensuring patient participation without fear of misuse of the information availed. The patient The patient was a 30 year old single Latin lady self-referred to an acute ward in a moderately busy urban hospital for feelings of hopelessness and anxiety resulting from these feelings. The lady reported to feeling stressed and was continually crying. The lady had recently lost her job and had since been spending the better part of her days in bed watching television. She hardly took walks or visited friends with her only activity being getting food from the grocery and using the restroom. As a result, she reported having gained 12 pounds in the past 4 weeks. Since losing her job, she had minimal social interactions but often talked to friends, and a number of her relatives over the phone, besides she always attended church on Sundays. In her own evaluation, the lady considered loosing the job, her errant 10 year old son, constant arguments with the boyfriend over financial issues and lack of sleep as the main contributions to her stress and depression. Her sleep patterns had been disrupted by constant worries and thoughts on the highlighted issues. Asked how she copes with these stressing situation, the lady noted that she had been brought up as an independent thinker and always tended to keep things to herself and look for a means of figuring them out. As a habit, she treats these stressing or overbearing thoughts by smoking and taking wine. Through her own confession, she was aware that these habits were not therapeutic. Assessment of a patient’s problem-stress vulnerability Individuals with low vulnerability require exposure to a great deal of stress before they get depressed. On the other hand, individuals with high vulnerability only require a minimal exposure to stress to become depressed. Individual’s personality as dictated by their genetic make-up and character determines how well they cope with stressing situations. Additionally, their interactions also determine their capacity to handle depression. The stress vulnerability model looks at four factors, which fall within the two elements, personality and social interactions, and how these have affected an individual’s coping or how they have informed an individual’s vulnerability. In this case, these factors are analyzed in reference to the information supplied by the patient being interviewed. Genetics In summary, the model observes that an individual’s vulnerability is related to their genetic constitution. In reference to the patient, she cited that her family has no history of mental illnesses. The only prevalent condition in the family was alcoholism this affected her paternal grandfather. There had also been cases of diabetes type 2 and hypertension, which had affected both the maternal and paternal families. Looking at this information, there lacked any genetic link between her present feelings and the history of her family. This meant that her vulnerability was in no way linked to her genetic constitution. Coping styles Individuals apply variant coping styles while dealing with certain situations. These coping styles can either be classified as effective or non effective. Individuals who use effective coping styles are much better placed to counter stressful situations. This is not the case with individuals who employ ineffective coping skills. In reference to the patient, the interview revealed that she took to smoking and taking wine when faced with stressing thoughts. Additionally, she largely kept things to herself having been brought up as an independent thinker, she was brought up to “just figure it out”. More so, she had resulted to isolation with her only activities being watching television and eating. In this regard, her coping skills can be classified as ineffective. This is because they would not help in addressing her “stressing thoughts” and bouts of feeling hopeless. In any case, her coping skills may have worsened her mental condition as they kept her away from care centers. Thinking style The way people think about themselves and others around them have a major effect on their level of vulnerability to stress. Positive thinkers, also referred to as optimists are less vulnerable as they hold hope that a situation will improve or turn out good. This cannot be the same for pessimists who continually grapple with their situations and see no signs of a positive outcome. At times, the level of vulnerability to stress can be much more than either being an optimist or a pessimist. In regard to our patient, she seemed so preoccupied with negative thoughts and situations. She often thought about her truant son, her quarrelsome boyfriend, and her dismissal. These thoughts preoccupied her mind to the extent that she could not think of a possible way to solve or improve her situation. The patient was simply not forward thinking and she seemed holed up in her sorry state. Though she may not qualify as a pessimist, her lack of drive was bound to worsen the situation. Probably she had not dealt with her dismissal. This situation increased her vulnerability. Environment How an individual tackles stress and the options available to them are all linked to their environment. Vulnerability to stress can be affected by something slight including relations at home state of one’s neighborhood and one’s activities. Looking at the patient, her environment was of no help. She was entirely holed up in bed and only watched television the two pivotal figures in her life, the son and the boyfriend were not supportive. In any case, the two were according to her contributors to her current mental state. The son was constantly reprimanded in school and hardly listened to the mother. The boyfriend constantly quarreled her complaining of her inability to help in meeting house expenses. These events in her environment were bound to worsen her situation and increase her vulnerability. Social skills Sound social skills are a great way of having people help out in stressful or challenging situations. Individuals who have large social circles and supportive individuals are much better placed during crisis. This cannot be said for people with a few friends or family and who are never there or supportive. The latter was the situation with the lady patient. Since losing her job, she had become anti-social and hardly went out to share her predicaments with supportive individuals. Even though, she talked to friends and family over the phone it was never about her problems. This was also the case in attending church she was not part of any groupings that would help her deal with her prevailing situation. This isolation only acted to increase her vulnerability. Theory underpinning this model and the evidence The stress vulnerability model is considered ideal in assessing a patient’s problem. This is largely because it incorporates a wide range of factors that help in exhaustively examining the factors informing a patient’s health situation. In a stress-vulnerability model, stress and vulnerability factors compete with coping and competence factors to determine psychotic relapse or remission, social function or dysfunction, and the overall quality of life (Witkiewitz & Marlatt, 2007.p. 124). An individual’s coping skills and ability to use these skills effectively can decrease the impact of stresses and vulnerability. The stress and vulnerability model was created by Zubin and Spring (1977) (Witkiewitz & Marlatt, 2007.p. 124). The model identified that every individual has distinctive biological, psychological and social elements. The basic idea included in this model is that individuals fall sick when the stress they are exposed to exceed their capacity. Additionally, individual’s ability to deal with stress, their vulnerability, is different therefore, situations that one can handle may be sufficient to make another individual depressed or psychotic. By determining an individual’s stress and vulnerability, it becomes much easier to determine factors around him/her that have informed their current situation. This is usually the first step in determining the best cause to take to help in the patient’s recovery. Following definition of evidence-based practice, it is possible to identify that this is a result of three main elements also identified in the first part of this study, professional expertise, best available research and individual characteristics (Hales, Yudofsky & Gabbard, 2008.P.747). Employing stress and vulnerability model helps in defining individual characteristics a fore step in employing evidence-based practice. Negotiated approach One major problem identified in the assessment process was the patient’s negative reaction to her job loss. Normally, a psychological reaction is expected on losing a job. However, such a reaction is countered by positive thoughts (optimism), a supportive environment and effective coping skills amongst other factors, which lower vulnerability. However, this is not often the case with all individuals, some live in challenging environments, lack effective coping skills, have poor social skills and are generally pessimistic. These factors affect one’s ability to cope with a stressful situation as they increase one’s vulnerability. Such was the situation with the lady she underwent a stressful event (job loss) and lacked a supportive environment (Goroll & Mulley, 2009.p.1441). The patient also lacked the mental capacity to handle the situation mainly due to other factors, which she noted as the reasons for her continuous feeling of hopelessness crying and bouts of depression. It should be noted that all these factors increased her vulnerability and heightened the chance of sliding into a depression, due to increased and unabated stress. In overall, she was at a risk of suffering from a mental condition, adjustment disorder. Adjustment disorder is a psychological response resulting from a particular stressor or life event that translates to momentous emotional or behavioral symptoms. These symptoms often lead to a slump in productivity for working or schooling individuals and a momentary change in social relationships (Hales, Yudofsky & Gabbard, 2008.P.747). At times, the life stressor could be a frequently occurring event such as changing business cycles, or an isolated event such as a job loss or diagnosis of a serious or draining medical condition. There are several types of adjustment disorders the specific one identified in this case is adjustment disorder with depressed mood. In this type of disorder, an individual not only demonstrates the stated psychological and social symptoms but also reports depressed mood, continuous or constant crying, and feelings of hopelessness (Goroll & Mulley, 2009.p.1441). These symptoms were present in the interviewed patient which left little doubt on her current mental condition. Intervention At the moment, the adjustment disorder with depressed mood has not been evident for a long period of time as the stressor event (job loss) had taken place 8 weeks ago. All the same, there is an immediate need to intervene to avoid further psychological reactions which may further affect the patient’s mental health. If adjustment disorder is not adequately handled it may lead to Major Depressive Disorder or Dysthymic Disorder. The preferred intervention would be aimed at prompting a change in the patient’s thinking style, social skills, environment and coping style (Goroll & Mulley, 2009.p.1441). Fortunately, the assessment clearly indicated that her vulnerability has not been affected by her genetic constitution. This was important as it would be impossible to affect genetic constitution through either of the intervention measures. In this regard, motivational interviewing would be the most appropriate intervention. Motivational interviewing is a client-based, directive technique for enhancing inherent enthusiasm to transform by imploring and resolving ambivalence. It is considered an ideal approach in helping out individuals with mental health disorders. This approach requires employment of four principles, empathy, discrepancy, self-efficacy and cordial response to resistance. Adjustment Disorder Adjustment disorders are common they affect about 2-8% of children in the community and up to 12% of individuals in a hospital setting. The disturbance starts within three months of a stressor and may at times take 6 months in the case of an acute stressor (APA 2012). If the stressor or the factors increasing vulnerability persist it may take a longer time to reach effective adaptation. In cases where the symptoms take longer than six months the stressor is considered chronic. The etiology of an adjustment disorder may be associated with more than one stressor, the more the stressors the greater the symptoms are expected to be (Mcmillan & Oski, 2006.p.628). Existent research on adjustment disorder indicates that the condition can be managed through counseling and psychotherapy. Counseling and psychotherapy can be availed by a psychiatrist. Counseling and psychotherapy focus on different aspects of a patient’s condition (Sadock & Sadock, 2007.p.245). Counseling entails providing advice that can help the patient in problem-solving. On the other hand, psychotherapy is concerned with investigating the psychosocial and dynamic issues affecting a patient and deciding on the best way of handling these issues (Strain et al 1998.p.145). Together, counseling and psychotherapy aids the patient in identifying the stressor and coming up with a specific way of allaying the resultant feelings or fears. They help the patient remain calm and achieve a sense of equilibrium when the event re-occurs or during other stressful events. The recommended approach in treating adjustment disorder is based on identifying a stressor (Mcmillan & Oski, 2006.p.629). Once this is identified, it is made known to the patient and a strategy to mitigate the effects arising from the stressor is formulated. The recovery time is determined by an ally of factors which include; the patient’s social support, the patient’s character, her level of performance prior to the condition and multiple other factors. Even with the variability of these factors, therapeutic support is often short-term (Strain et al 1998.p.148). Motivational Interviewing Having looked at the existent evidence on the handling of adjustment disorder, it is apparent that there is an immediate need to inform the patient of the stressor. In this case, there is the main stressor, which was the job loss and the other stressors are a truant son and a quarrelsome boyfriend. Therefore, motivational interviewing will enlist informing the patient of the condition and the stressor (Mcmillan & Oski, 2006.p.25). Subsequent engagement will be focused in determining the way forward and coming up with a solution to the condition. Notably, the solutions to the condition are as informed by the preceding research which identified counseling and psychotherapy as the main ways through which adjustment disorders can be addressed. Through psychotherapy, the patient will be informed of the effects the stressor/stressors have had on their life. In this case, the patient has kept away from friends a factor that has increased vulnerability and heightened the feelings of hopelessness and bouts of depression. Further, the stressors have forced her to adapt bad habits such as spending her entire day in bed, smoking and drinking. Smoking has separate effects not fully linked to the current disorder but which may manifest them later on in life leading to deteriorating health (Zubin & Spring, 1977). Spending her days in bed and eating from bed is likely to lead to further weight gain, at the moment she has already added 12 pounds, and this is bound to persist. Further, if she does not reconcile with the boyfriend and find proactive ways of dealing with her truant son, then the current condition may persist and may sooner or later translate to a major mental disorder. In addition to informing her of these probable effects, psychotherapy also involves helping the patient improve her coping skills. Right now, she has taken to drinking, smoking, sleeping and watching television. These, in no way inform her coping skills and are not in any way therapeutic. She needs to take to support groups, health habits such as taking walk, active job search and taking a more active role in helping her son (Mcmillan & Oski, 2006.p.25). These activities will transform the way she looks and thinks about herself and also provide her with a chance to talk to people and share problems or solutions. It is a nice thing that she still attends church, through motivational interviewing the patient can be informed of the need to take more roles in the church, now that she does not have a job or participate in church based groupings (Zubin & Spring, 1977). These activities help in opening up and churning bad habits such as smoking, spending time in bed and over eating. Most importantly, they help her in coping with the stressor which is fundamental in treatment. Lastly, by adopting motivational interviewing the patient is given a chance to express herself and give her views on the suggested coping skills. This provides a platform through which the patient and the doctor can evaluate other effective ways of ensuring the patient successfully deals with the stressors. Throughout the interview, the doctor/counselor is expected to exercise empathy, accommodate and roll with resistance from the patient, exercise discrepancy and always settle for the most efficient approaches in addressing the patient’s situation. Goals The overall goal is to develop adequate coping skills that will reduce the patient’s vulnerability and inform her full recovery within a month. Specifically the evidence-based approach will seek to ensure that the patient adopts effective coping skills, stops feeling hopeless, drops her bad habits and stops frequent crying. These goals should be achieved within the first month of therapy. Reflection-Gibbs Model Description The event involved interviewing a patient in an acute ward setting and developing an assessment of her condition. This required keenness, assurances and confidence on my part and also demanded the patient’s cooperation and trust. This also required adequate support by the nursing staff and hospital administrators who approved my request to interview the patient. Feelings At first, I was not sure whether I had enough knowledge to proceed with the exercise. The fact that this was my first time engaging a patient with an actual condition made me feel sympathetic and overwhelmed. I also felt anxious as I did not know whether the nurses and the hospital administrators would allow me to talk to the patient. I also had reservations on whether the patient would agree to my interview request. The support accorded to me by the nurses at the hospital and the patient’s willingness to participate made me feel confident. Evaluation The entire engagement was worth it. The required approvals were made without any hiccups, and the interview went well, the patient was also glad to talk to me. Analysis The exercise basically involved three parts, seeking hospital approval, seeking patient consent, engagement and interviewing the patient, carrying out research to inform evidence-based practice and making conclusions by deciding the best course of action. All these parts went well, but I felt I would have been more efficient in researching as this took most of my time. Conclusion Given my role and engagement I was convinced that evidence based practice is a practical yet effective way of addressing patients concerns. Additionally, the success of evidence based practice is hinged in the level of patient’s cooperation and the support of those around the patient. This accords objectivity and informs both efficiency and effectiveness in developing viable solutions to the patient’s conditions. Conclusion In conclusion, evidence based practice is a practical way of handling different mental health conditions. This is especially the case with adjustment disorder, which was the condition affecting the patient interviewed in this study. Through evidence-based practice, the study was able to identify sound approaches that would be employed to improve the patient’s situations. Notably, by relying on meticulous medical research on adjustment disorder this study was able to adopt psychotherapy and counseling to help the patient deal with the stressor and adopt effective coping skills. Most importantly, the adopted approaches would reduce the patient’s vulnerability and this will not only help in recuperation but also improve her capacity to deal with stress in future events. Bibliography American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Vol. IV. Washington, D.C.: American Psychiatric Association; 2012. Goroll, A. H., & Mulley, A. G. (2009). Primary care medicine: office evaluation and management of the adult patient. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. Hales, R. E., Yudofsky, S. C., & Gabbard, G. O. (2008). The American Psychiatric Publishing textbook of psychiatry. Washington, DC, American Psychiatric Pub. Mcmillan, J. A., & Oski, F. A. (2006). Oskis pediatrics: principles & practice. Philadelphia, Lippincott Williams & Wilkins. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: helping people change. New York, NY, Guilford Press. Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadocks study guide and self-examination review in psychiatry. Philadelphia, Wolters Kluwer Health / Lippincott Williams & Wilkins. Strain S.J., Smith G.C., Hammer, S.J. (1998). Adjustment disorder: a multi-site study of its utilization and interventions in the consultation-liaison psychiatry setting. General Hospital Psychiatry. 5(20):139-149. Witkiewitz, K., & Marlatt, G. A. (2007). Therapists guide to evidence-based relapse prevention. Amsterdam, Elsevier Academic Press. Zubin, J. & Spring, B. (1977). Vulnerability: A New View on Schizophrenia. Journal of Abnormal Psychology 86, 103-126. Appendices Appendix 1 Decisional Balance Worksheet Name: Miss XXX Date: March 2, 2013 Continuing Behavior PROS (Benefits) CONS (Costs) False feeling of wellness Weight gain Solitude Emotional turmoil Bouts of depression Anxiety and lack of sleep Continuous crying Stopping Behavior CONS (Costs) PROS (Benefits) Discomfort as one moves out of the comfort zone Greater chance of positively dealing with the stressors which include job loss, truant son and problematic boyfriend. Strange feeling as one adopts new behavior Proper management of physical and emotional health Physical strain as one adopts to greater physical activity Adopting healthy ways of dealing with the stressor Alteration of the patient’s current lifestyle Improving coping skills Reducing vulnerability Greater ability to deal with stressful events Appendix 2 Read More