Evidence-Based Practice in Psychiatric and Mental Health Nursing: Qualitative Meta-Synthesis

A guiding principle of evidence-based practice (EBP) is use of the highest level of evidence available (FineoutOverholt, Hofstetter, Shell, & Johnston, 2005; Melnyk & Fineout-Overholt, 2002). Within the quantitative– numerical perspective, randomized controlled trials (RCTs) are considered the highest level of research evidence (Cochrane, 1972; Melnyk & FineoutOverholt, 2005). The results of the RCTs are considered even more supportive of an intervention if there are enough studies to conduct a meta-analysis (Crowther & Cook, 2007; Guyatt, Mills, & Elbourne, 2008). Meta-analysis follows rigorous statistical procedures to determine the effect of an intervention (Mundy & Stein, 2008) and often rely on funnel (Einarson & Einarson, 2005; Song, Khan, Dinnes, & Sutton, 2002; Souza, Pileggi, & Cecatti, 2007) and harvest plots (Hofmann & Smits, 2008; Ogilvie et al., 2008). The usefulness of a meta-analysis of quantitative data is generally accepted within the hierarchy of EBP (Rice, 2008). Less frequently used are the findings from qualitative research (Sandelowski, Trimble, Woodard, & Barroso, 2006). Qualitative research findings are generally not included in levels of scientific evidence, such as those offered by the Oxford Center for Evidence-Based Medicine (Phillips et al., 2001) or those systems addressed in the Agency for Healthcare Research and Quality (2002). Reasons why qualitative data are not included in some of the levels of evidence rating systems involve philosophical debates and the valuing of different types of research (Walsh & Downe, 2005). This debate is largely one of philosophical perspective and will not be addressed here. The goal of EBP is to provide a scientific basis for patient care using the highest level of evidence possible. In psychiatric care, the topics of concern are often phenomenon related to the human experience, such as stigma and experiences that are not easily quantified. Thus, it seems only appropriate to include a discussion on the application of qualitative studies to EBP interventions as this methodology is capable of addressing subjective issues encountered in providing direct care to psychiatric patients. Qualitative findings are included in some of the more recent levels of EBP models. Evidence levels including studies on an experience or the meaning of a life event, such as grieving, rate qualitative studies at a higher level than those reporting similar phenomenon occurring during RCTs (Fineout-Overholt, Melnyk, & Schultz, 2005). Within these evidence grading systems, analysis of multiple studies on phenomenon are considered to be a higher level for EBP interventions. Equivalent to meta-analysis conducted with multiple quantitative studies are analyses of multiple qualitative studies conducted using meta-synthesis (Sandelowski et al., 2006). The metasynthesis is the highest level of evidence that can be attained for application of qualitative studies to EBP.