Use evidence-based research to combat negative distortions in nursing practice

By Michael C. LaFerney, APRN,BC

Cognitive therapy is an effective treatment for a variety of psychological disorders. These include mood, anxiety and personality disorders.¹ Cognitive therapy identifies several faulty thinking patterns (see Figure) that create our worries and concerns. It also is an effective tool for nurses to avoid burnout.

Nurses can familiarize themselves with these faulty thinking patterns and change the way they feel. According to David Burns, MD, "The minute you have a certain thought and believe it, you generate an emotional response." But, he points out, "feelings aren't facts," and a key component of cognitive therapy is to ask, "Where is the evidence?"¹

Evidence-based nursing practice can be an additional tool to dispute these irrational thoughts, improve your nursing practice and decrease burnout.

Scenario & Analysis I

Mary, a nurse on an inpatient psychiatric unit, spends a lot of time teaching Sally, newly diagnosed with bipolar disorder, about how lithium helps control the symptoms of mania. Sally has responded nicely to lithium since admission. Her mood is stable, her speech is normal and she is eager to learn about her newly diagnosed disease. She is being discharged today and can explain how lithium works, the need for frequent checks of her blood levels and for any side effects. Mary feels good about her teaching effort.

Three weeks later, Sally is brought back to the unit under an involuntary admission in full-blown mania. She has pressured speech, is delusional and hypersexual, and has a lithium level of 0.

Mary sees her and thinks to herself, "I spent a lot of time teaching her and she's already back?! I must really be a lousy teacher! I'm not going to spend that much time again with her. I feel like such a failure. She should have taken her lithium."

What are Mary's distortions and what evidence-based research exists to dispute them?

Mary's thought that she must be a lousy teacher is example of personalization. She is taking Sally's inability to comply with her lithium regimen as a personal failure. She is labeling herself a lousy teacher. She has emotional reasoning — she is equating her feeling as fact (I failed so I'm a failure) and creating an inability to work with Sally again by her "should" statement.

In cognitive therapy, we look for the "evidence." Where is the proof that Mary failed? Or that she is a lousy teacher? What is the evidence-based research to dispute this?

Research indicates that "bipolar disorder is virtually always recurrent (only a very small percentage of bipolar individuals will have only one episode in a lifetime)."² According to Gitlin, the percentage of patients in ongoing treatment suffering at least one relapse averaged 55 percent over 1 year and approximately 75 percent over 4-5 years.² A typical bipolar patient may experience 8-10 episodes in their lifetime.³ Patients with bipolar disorder have a relatively high rate of nonadherence to pharmacotherapy, estimated at 32-45 percent of treated patients.⁴ So Sally returning to the unit was certainly a possibility.

Gaebel notes that "patient noncompliance is as high as 50 percent under outpatient conditions; potential reasons may be either illness-related (e.g., lack of insight or idiosyncratic concepts of the illness or its treatment), drug-related (e.g., intolerable side effects) or related to inadequate treatment management (e.g., insufficient information or lack of environmental support)."⁵

This alone is evidence that many factors play a part in a bipolar patient's compliance.

Mary's distortion is in mistaking her level of influence as a nurse for control. She cannot control all the factors in Sally's life, and while it would have been preferable for Sally to take her lithium, patients will not always do what is recommended. This is true not only in bipolar disorder but also in many other illnesses where nurses spend time teaching patients.

Patient Noncompliance

According to Life Clinic, a Web site devoted to long-term health conditions, "approximately 125,000 deaths in the U.S. each year are attributed to noncompliance with a doctor's prescription, twice the number of people killed in automobile accidents." The most common types of noncompliance include:

• not having a prescription filled;

• taking an incorrect dose (too much or too little);

• taking the medication at the wrong time;

• forgetting to take one or more doses; and

• stopping the medication too soon.

According to the World Health Organization, the noncompliance rate for long-term therapies averages 50 percent. This includes treatment for hypertension, high cholesterol, diabetes and asthma.⁶

Changing Practice

After reviewing the research, Mary feels better about herself. She now realizes she cannot control all the variables involved in compliance, that it might take Sally several relapses to come to grips with her illness, and that expecting others to always do what we think they "should" do can only lead to disappointment and decreased self-esteem. Sally's relapse is not to be taken personally. Mary now knows this is a difficult disease that will require continued work and effort with Sally.

How can Mary use evidence-based research to improve her teaching? When reviewing the research, Mary recognized that while she spent a lot of time with Sally, she didn't provide teaching to Sally's mother, with whom Sally lives. She also noted that the stigma and the denial associated with this disease are difficult to overcome.

Mary now will provide education to Sally's mother to help her recognize Sally's symptoms and aid compliance with lithium. She also will refer Sally to a bipolar support group.

Mary is wise to continue her teaching efforts with Sally and her mother. The majority of psycho-educational interventions result in improved treatment adherence and numbers of hospitalizations and relapses. One study showed a 50 percent improvement in lithium compliance and a 60 percent decrease in hospitalization.⁴

Scenario & Analysis II

Bob, a medication nurse, is called into the nursing supervisor's office. She starts by telling him how he has done a nice job giving out the high amount of medications on the unit, but she needs to speak with him about a med error. Bob had self-reported his error, as is the policy. Bob thinks, "Oh, no. Here it comes! I made a big mistake. I hope I don't lose my license. She must really think I'm incompetent."

Looking at Bob, one can see several distorted thinking patterns. He thinks, "Here it comes (predicting the future); I made a big mistake (magnification). I hope I don't lose my license (jumping to conclusion, turning common events to a catastrophe). She must really think I'm incompetent" (mind-reading). And although she complimented him on doing a good job on the unit, he chooses to focus on the negative and discount the positive.

Is Bob thinking rationally at this point? What would the evidence-based practice say?

A University of Pennsylvania School of Nursing study reports that "during a 28-day period, 393 RNs kept a detailed journal of their errors and prevented errors, referred to as near-errors. Thirty percent of the nurses reported at least one error during the 28-day period, and 33 percent reported a near-error. Although the majority of errors and near-errors were medication-related, the nurses also reported a number of procedural, transcription and charting errors."⁷ So Bob is certainly not alone.

The study pointed out many reasons for this number of errors — many beyond the nurses' level of control. These include the high number of workplace distractions and, as in Bob's case, a high volume of meds. The study showed that "a nurse may be interrupted, on average, at least 19 times during a 3-hour period by at least 13 different types of sources." Moreover, according to the study's authors, approximately 33 percent of actual medication errors were because of late administration of drugs to patients, which in some cases was due to inadequate numbers of nurses on duty.⁷

As for Bob worrying about what his supervisor thinks, it is true that many nurses mistakenly think other nurses who make errors are incompetent. This is irrational group thinking, as only 5 percent or less of medication errors are estimated to be reported at all.8 In reality, Bob's supervisor views him as being very conscientious and appreciates the fact that his reporting of this error will aid in correcting it in the future. She is an advocate of blame-free reporting. What she is doing is an analysis of the error under JCAHO guidelines, which emphasizes eliminating future errors rather than judging Bob.⁹

Bob is overreacting. He is doing a good job and if evidence-based practice is correct, his reporting of the error is commendable. The nursing supervisor explains this to him and he is able to see that his thinking was not cognizant with the evidence.

Irrational Thought

Reviewing evidence-based research can aid nurses in disputing their own irrational thoughts. Nurses can learn to identify the irrational thought patterns in themselves, learn to change them and review the evidence to keep their own anxiety, depression and burnout to a minimum.

References

1. Burns, D. (1999). Feeling good: The new mood therapy. New York: William Morrow and Co. Inc.

2. Gitlin, M. (1995). Bipolar disorders: Clinical complexities, current challenges. The Journal of the California Alliance for the Mentally Ill, 6(2), 7-9. Retrieved June 19, 2005, from the World Wide Web: http://www.healthieryou.com/j62.html

3. Hirschfeld, R.M. (1995). Recent developments in clinical aspects of bipolar disorder. The Decade of the Brain: A Publication of the National Alliance for the Mentally Ill, 6, 2.

4. The Lundbeck Institute. Bipolar. Retrieved Sept. 13, 2005 from the World Wide Web: http://www.brainexplorer.org/bipolar_disorder/Bipolar_Disorder_treatment.shtml

5. Gaebel, W. (1997, Feb. 12). Towards the improvement of compliance: The significance of psycho-education and new antipsychotic drugs. International Journal of Clinical Psychopharmacology, 12(Suppl. 1), S34 ÐS42.

6. Commonwealth of Massachusetts Group Insurance Commission. (2005, Winter). Keeping up with medication dosage and frequency is vital to your health. For Your Benefit, pp. 3-4. Retrieved June 19, 2005 from the World Wide Web: http://www.mass.gov/gic/pdf/fybwinter2005.pdf

7. Medical News Today. (2004, Nov. 20). Nature and prevalence of errors in patient care. Retrieved June 19, 2005 from the World Wide Web: http://www.medicalnewstoday.com/medicalnews.php?newsid=16598

8. Cohen, H., Robinson, E., & Mandrack, M. (2003). Getting to the root of medication errors: Survey results, nursing. Retrieved June 19, 2005 from the World Wide Web: http://www.findarticles.com/p/articles/mi_qa3689/is_200309/ai_n9259722

9. Ashton, K., & Lyler, P. Improving the quality of health care: A mandate for nursing. Retrieved June 19, 2005 from the World Wide Web: http://www.medleague.com/Articles/medical_errors/ICN_Conference.htm

Michael C. LaFerney is employed by Arbour Senior Care, Rockland, MA.

Faulty Thinking Patterns

• All-or-nothing thinking

• Overgeneralization

• Mental filter

• Disqualifying the positive

• Jumping to conclusions

• Mind reading

• Fortune teller exercise

• Magnification and minimization

• Emotional reasoning

• Labeling and mislabeling

• Personalization