Evidence Based Practice in Mental Health Nursing Essay Example for Free

severalise Based Practice in Mental wellness treat EssayOne of the most putting green and disabling psycho lawful disorders encountered within cordial health and general medical settings is that of an anxiety disorder (Dattilio Kendall 2000). look has indicated that population with acquisition disabilities are more ordinary to psychological disorders than the general population (Hassiotis et al 2000) therefore it could be hypothesised that prevalence rates of anxiety disorders are similar if non greater within the instruction disabled population. Professional literature suggests that cognitive-behaviour therapy (CBT) has been an useful give-and-take against anxiety disorder (Beck 1995) however this literature has predominately toil some(prenominal) its focus to within the confines of psychogenic health and general medical settings (Dattilio Kendall 2000).The ability of people with reading disabilities to identify, evaluate and respond to their dysfunctional th oughts and beliefs, fundamentals of CBT (Beck 1995) have put into read/write head the very use of this interposition programme for this particular client group (Kroese et al 1997). From a professional and personal perspective and with the utilisation of the Seedhouse (1998) Ethical Grid responding to an anxiety disorder by way of CBT could be considered an ethically pleasing clinical intervention. Nationally and locally d wholeness government directives, Valuing concourse (Department of wellness 2001) and initiatives much(prenominal)(prenominal) as Health Action Plans (Department of Health 2002) function have treasure that they need to be more responsive to the mental health needs of people with learning disabilities. As a learning disability nurse deprivation to ascertain the durability of CBT as a practical intervention when presented with the dual-diagnosis of anxiety disorder and learning disability, is through the use of demonstration-based design.When deciding on the best possible clinical intervention for an set drill conundrum it seams logical to convert the issue into a single answerable question (Colyer Kamath 1999). Several authors have identify that the use of frameworks to inform the enlargement of the clinical question put up the practitioner with a regular attend of formulating an answerable question (Sackett et al 1997 Ridsdale1998). One such framework as telld by Sackett et al (1997) is a four- stage process, known by the acronym PICOPatient or PopulationIntervention or index chassisComparison or ControlOutcomeThe construction of an answerable question is the basis of licence-based coiffe and should function the practitioner to how to attend an answer (Ridsdale 1998). It is important that each variable under the PICO framework is clearly localized, universe as detailed and explicit as possible in order to extend clarification to the question. operative through PICO methodically the practitioner would instigate the process by defining the Patient or Population. Characteristics such age, gender and diagnosis would need to be deliberated and whilst the aforementioned were easily treasure in the practice sweep as adult male, identifying appropriate nomenclature for diagnosis can prove problematic. The term Learning hinderance is oft used interchangeably in literature with terms such as, Mental Retardation and cerebral Disabilities. Learning Disability is a term with contemporary usage within the United Kingdom to describe a client group with significant development delays (Gates 1996). Whilst the idiom Learning Disability is the preferred voice communication for the question due to its contemporary usage it must be accepted that its a term not internationally recognised nor is it a term used for long in the United Kingdom (Gates 1996). concern disorder comes in m either facets and can be described as severe psychological disorders in which abnormal or chronic anxiety interferes with dail y living (Adams Bromley 1998). The client in the practice field of operations had described psychological and physiological symptoms that were diagnosed as a social anxiety disorder through order scales and self-report measures. It is crucial that the practitioner is aware that the term identified for the question as social anxiety is often recognised by the synonyms, social phobia or panic disorder (Dattilio Kendall 2000). The recognition of this inconsistent terminology will enable an evaluation totake place betwixt the relationships of the chosen term to symptoms displayed by the client.The designation of existing clinical interventions is a valuable part of the process of developing endorsed-based interventions (Meijel 2003). Literature suggests that CBT is an effective treatment for a itemise of psychological disorders (Embling 2002 Hatton 2002). Central to the model of CBT is that distorted or dysfunctional thinking is prevalent in all psychological disorders (Beck 199 5). Analysis of accumulated experience of existing interventions and the aforementioned depict of its hardness led to the application of CBT as the question intervention.It is not imperative for the question to have a analogy intervention and this was the situation in the clinical problem described, therefore the conclusive element utilising the PICO framework was way out. The outcome should be measurable (Sackett et al 1997) and after initially trivialising with the term used it became evident that this would not develop into something that could be measured. Discussing whether or not an intervention is effective however would stand the question with a measurable outcome. Revision of the terminology identified through the PICO framework would accordingly rede the question as Is cognitive-behaviour therapy an effective intervention for adult males with learning disabilities diagnosed as suffering from social anxiety?A well-formulated appear scheme is an essential component in gathering appropriate severalize (Hewitt-Taylor 2002). Ridsdale (1998) discusses a four-stage attend strategy that helps to translate the question into a meaningful face a) Identify the subject elements of the questionb) Define the relationship between the subject elementsc) Convert the subject elements into search themesd) Decide on the scope of the searchAssistance to define the subject elements can be strand within the PICO framework Patient Learning Disability, companionable frettingIntervention CBTOutcome EffectivenessOnce identified an effective means of linking the subject elements of a question for the search process is through the use of operators. Operators such as And Or Not, form a logical link between the elements of the question and can be used collectively or individually in any electronic database search (Ridsdale 1998). All of the subject elements of the question were required in order provide a conclusive answer therefore the operator required for th e search strategy could be identified as And. The subject elements then require conversion into terms by which references can be retrieved (Ridsdale 1998). A keyword search would apply the terms identified as the subject elements, however making a inclination of the known synonyms of the subject elements such as Intellectual Disability and Mental Retardation, for inclusion, would substantially develop the search process.Finally the scope of the search decides what is wanted from the search. In order to identify the most appropriate emblem of testify that is required for the practice problem the type of question asked must be identified (Sackett et al 1997). The question developed through the PICO framework can be readily identified as questioning, the force of a therapy. Sackett et al (1997) proposes that the best available recount to answer this type of question is comparative / future studies and ideally random controlled trials (RCTs) which in refer determine the choice o f database (Ridsdale 1998).Sackett et al (1997) provides a comprehensive sort out of information resources such as databases, journals and web sites along with descriptionsof the type of evidence that can be found within these resources. It was established previously that the best type of evidence for the question would be RCTs and comparative / likely studies. From the descriptions supplied by Sackett et al (1997) it could be identified that the Cochrane Library supplies the user with expert text imperious reviews of set up of health- do interventions along with bibliographies of controlled trials.Further electronic databases identified through Salford University library information services were PsycINFO that contains citations and summaries of journal articles and books in the field of psychology chosen for its congruity with the clinical intervention. Swetswise an electronic journal aggregator that provides access to full text publications from several major health care rel ated academic publishers and IngentaConnect which offers full text availableness for all core Blackwell science and medical journals were chosen due to acquainted(predicate)ity of use and extensive subject matter. different databases considered were CINAHL, EMBASE and AMED however all were discounted due to their general nursing bias.Despite the recognition of Ridsdales (1998) four-stage search strategy and its systematic approach the initial search were completed exploiting familiar strategies through the IngentaConnect database. Preconceptions from previous endeavours searching for rele vanguardt evidence furnished the belief that a similar strategy would provide sufficient evidence to answer the question. A number of the subject elements were used through keyword searches whilst the operator And was used to link each in turn (See Appendix). This easy to use search strategy produced a number of hits however none matched the criteria identified as being the most appropriate type of evidence to answer the question. The search revealed that almost all of the evidence found belonged in either mental health (Heimberg 2002) or general medical settings (Scholing Emmelkamp 1999).Whenever the term learning disability or mental retardation was utilised they invariable appeared indiscriminately amidst the title or countermand of the article providing no ad hoc relevance to the question. The frustration born out of this strategy led to advance searches of electronic databases firstly through another familiar database, Swetswise. Ridsdale (1998) identifies that to a fault many hits will be regain if the subject element is to generaland this was evident in the first keyword search. The term learning disabilities produced 548 hits (See Appendix) far too many to feasibly scan. The subsequent four searches failed to produce a single hit a possibility in any case recognised by Ridsdale (1998) who suggests alternative synonyms are utilised in this circumstance.Due to the inability to find any relevant material of value towards answering the question Ridsdales (1998) four-stage strategy was then conscientiously adopted in conjunction with the knowledge acquired through lectures received at Salford University. A further search of Swetswise database was completed (See Appendix) which revealed significantly less hits than previously achieved but produced a literature review (Hatton 2002) specifically aimed at the use of CBT and people with learning disabilities. Whilst this evidence did not fulfil previous identified criteria it established that pursuing Ridsdales (1998) strategy could provide some success. A similar approach was undertaken while searching the Cochrane Library database which allows the user to restrict the search to the acquisition of systematic reviews and controlled trials whilst using a simple keyword option. Again the subject elements were utilised along with the recognised operator and despite new found confidence and knowledg e the search strategy revealed no evidence of systematic reviews or RCTs with regards to the question (See Appendix). All systematic reviews or RCTs retrieved belonged within general and mental health settings.The final electronic database to be utilised was PsycINFO (via Ovid) where again Ridsdales (1998) four-stage strategy was conscientiously adopted. PsycINFO requires the user to have some prior knowledge of how to use electronic databases and their search strategies, which initially can prove bewildering to the novice. Once familiar with the database and its ability to combine search strategies either through keyword, journal or author the user should find it a practical resource (See Appendix). No systematic reviews or RCTs were found within the results however a further literature review (Feldman Rivas-Vazquez 2003) aimed at psychosocial interventions and people with intellectual disabilities was unearthed along with evidence from child and adolescence services (Dadds Spenc e 1997) and psychiatric services (Carmin Albano 2003).Hatton (2002) suggests that research evidence on the effects of psychosocial interventionsfor people with learning disabilities is sparse, whilst Kroese (1998) adds that therapists are indisposed(p) to engage into therapy with this client group due to their dislike of having to relate to them. In an attempt to discover any type of evidence relating to people with learning disabilities and CBT the Salford University library catalogue was searched (See Appendix). A simple keyword search revealed one book (Kroese et al 1997) attaining the subject elements however again it did not produce the type of evidence recognised as the most appropriate to answer the question.Sackett et al (1997 p.2) defines evidence based practice asthe conscientious, explicit, and able use of current best evidence in making decisions about the care of individual patients.With this comment in mind it should be established as to what constitutes current be st evidence and its implications for the practitioner deficiency to implement evidence based practice. Belsey Snell (2001 p.2) states that, evidence is presented in many forms and the value of evidence can be ranked according to the following classification in descending order of credibilityI. Strong evidence from at least one systematic review of multiple well-designed randomised controlled trialsII. Strong evidence from at least one properly designed randomised controlled trial of appropriate sizeIII. Evidence from well-designed trials such as non-randomised trials, cohort studies, time series or matched case-controlled studiesIV. Evidence from well-designed non-experimental studies from more than one centre or research groupV. Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committeesIn accepting this hierarchy of evidence practitioners should concede that the systematic review of multiple well-designed RCTs constitutes be st available evidence (Colyer Kamath 1999). Sullivan (1998) adds weight to this argument when he states that RCTs constitute the strongest source of evidence and that the scientific community prefer the duodecimal research technique that makes use of empirical data following a systematic process.Whilst a number of RCTs were found (Dadds Spence 1997 Scholing Emmelkamp 1999) whilst undertaking the search strategy none belonged within learning disability settings. The only evidence found specific to the original question were literature reviews and a specialist book (Kroese et al 1997) aimed at CBT and learning disabilities. The literature reviews (Hatton 2002 Kroese 1998) revealed that a number of case studies and a case series had demonstrated the voltage feasibility of CBT reducing anxiety amongst people with learning disabilities. Whilst the specialist book (Kroese et al 1997) discussed conceptual and contextual issues of CBT and people with learning disabilities suffering anx iety disorders. This type of evidence appears in the lower reaches of the hierarchy of evidence and as such its subjectivity, reliability and validity can be disputed (Sullivan 1998).Whilst acknowledging the hierarchy of evidence and the device that comparative / prospective studies and ideally RCTs were the best forms of evidence to answer this type of question (Sackett et al 1997) it appears that in their absence the evidence revealed is the best available. RCTs are widely acknowledged as the gold standard of evidence-based practice (Rowland Goss 2000) however it is suggested that they bear little resemblance to day-to-day reality (McInnes et al 2001). RCTs can be hardheaded or explanatory the former is concerned with the overall effectiveness of an intervention whilst the latter examines the impact of specific treatment elements on outcome (Parry 2000) however neither considers the perspectives and uniqueness of the respondents.The evidence recovered for the question (Hatton 2 002 Kroese 1998) albeit in the lower reaches of the hierarchy acknowledges the feelings of the respondents due to its qualitative nature (patient centred, holistic and humanistic) therefore making it extremely satisfactory for the study of nursing phenomena (Parahoo1997) along with its relevance as regards answering a therapy question (Parry 2000).Kroese (1997) offers a number of reasons why there is this lack of quantitative research evidence surrounding the subject elements in the question. He suggests that people with a learning disability are a devalued population, it is impossible to ensure that changes are due to clinical manipulations if individuals (learning disabled) do not have stable cognitions. Finally there is a think that anxiety in people with learning disabilities is the same as in the general population consequently there is no need for specifically focused research. It emerges that learning disability services continue to lodge research evidence from general and mental health settings (Finlay Lyons 2001) a similar approach with the RCTs recovered from the search strategy could make them a valued resource however it would take a skilled clinician to make this a feasible option.Reflection is a necessary component of Continuing Professional Development and is a legitimate method for questioning personal effectiveness and responsibility in all aspects of health care (Driscoll Teh 2001). Through the process of reflection the practitioner recognised his own limitations in identifying appropriate evidence for his clinical problems, along with the often inconclusive, time consuming and frustrating strategies undertaken in the search of evidence in set up of his clinical practice.The structured frameworks utilised throughout the process described earlier gave the practitioner a systematic approach to formulating a question, developing a search strategy and identifying appropriate evidence to answer his practice problem. The ability to systematic ally approach future clinical problems will enable the practitioner to offer his clients a holistic, client centred practice from the best external evidence available.Adams, B. Bromley, B. (1998) psychology for Health Care Key foothold and Concepts, London, Macmillan PressBeck, J.S. (1995) Cognitive Therapy Basics and Beyond, London, GuildfordPress.Belsey, J. Snell, T. (2001) What is Evidence-Based Medicine? Internet Available from www.jr2.ox.uk/bandolier (Accessed 7th December 2004)Carmin, C.N. Albano, A.M. (2003) Clinical circumspection of Anxiety Disorder in Psychiatric Settings Psychologys Impact on Evidence-Based Treatment of Children and Adults, Professional Psychology interrogation and Practice, Vol. 34, No. 2 pp 170-176.Colyer, H. Kamath, P. (1999) Evidence-based practice A philosophical and political analysis some matters for consideration by professional practitioners, journal of Advanced Nursing, Vol. 29, No. 1, pp 188-193Dadds, M.R. Spence, S.H. (1997) Prevention and Early Intervention for Anxiety Disorders A Controlled Trial, Journal of Consulting and Clinical Psychology Vol. 65, No. 4, pp 627-635.Dattilio, F.M. Kendall, P.C. (2000) Panic Disorder In Dattilio, F.M. Freeman, A. Cognitive Behavioural Strategies in Crisis Interventions second Edition, London, The Guildford Press.Driscoll, J. Teh, B. (2001) The potential of reflective practice to develop individual orthopaedic nurse practitioners and their practice, Journal of Orthopaedic Nursing, Vol. 5, pp 95-103Embling, S. (2002) The effectiveness of cognitive behaviour therapy in depression, Nursing Standard, Vol. 17, Nos. 14-15, pp 33-41Feldman, L.B. Rivas-Vazquez, R.A. (2003) Assessment and Treatment of Social Anxiety Disorder, Professional Psychology Research and Practice Vol. 34, No. 4, pp 396-405.Gates, B. (1996) Learning Disability In Kenworthy, N. Snowley, G. Gilling, C. (Eds) Common Foundations Studies in Nursing morsel Edition, London,Churchill Livingston.Hassiotis, A. Barron, P. OHa ra, J. (2000) Mental Health Services for People with Learning Disabilities, British Medical Journal, Vol. 321, Issue 7261, pp 583-584Hatton, C. (2002) Psychosocial interventions for adults with intellectual disabilities and mental health problems A review, Journal of Mental Health, Vol. 11, No. 4, pp 357-373.Hewitt-Taylor, J. (2002) Evidence-based practice, Nursing Standard, Vol. 17, Nos. 14-15, pp 47-52.Department of Health (2001) Valuing People A New Strategy for Learning Disability for the 21st Century, A White Paper, London, HMSO.Department of Health (2002) Health Action Plans and Health Facilitation Good Practice Guidance for Learning Disability Partnership Boards, London, Department of Health.Heimberg, R.G. (2002) Cognitive-Behavioural Therapy for Social Anxiety Disorder Current Status and Future Directions, Society of Biomedical Psychiatry, Vol. 51, pp 101-108.Kroese, B.S. Dagnan, D. Loumidis, K. (1997) (Eds) Cognitive-Behaviour Therapy for People with Learning Disabilities, London, Brunner-Routledge.Kroese, B.S. (1998) Cognitive-Behavioural Therapy for People with Learning Disabilities, Behavioural and Cognitive Psychotherapy, Vol. 26, pp 315-322.McInnes, E. Harvey, G. Fennessy, G. Clark, E. (2001) Implementing evidence-based practice in clinical situations, Nursing Standard, Vol. 15, No. 41, pp 40-44.Meijel, van B. Game, C. Swieten-Duijfjes, van B. Grypdonck, M.H.F. (2003) Thedevelopment of evidence-based nursing interventions methodological considerations, Journal of Advance Nursing, Vol. 48, No. 1, pp 84-92.Parry, G. (2000) Evidence-based psychotherapy In Rowland N. Goss S. (Eds) Evidence-Based Counselling and mental Therapies Research and Applications, London, Routledge.Ridsdale, L (1998) (Ed) Evidence-based Practice in Primary Care, London,Churchill Livingston.Rowland, N. Goss, S. (2000) (Eds) Evidence-Based Counselling and Psychological Therapies Research and Applications, London, Routledge.Sackett, D.L. Richardson, W.S. Rosenberg, W. Hayes, R.B . (1997) Evidence-based medicine how to practice and teach EBM, London, Churchill Livingston.Scholing, A. Emmelkamp, P.M.G. (1999) Prediction of treatment outcomes in social phobia a cross-validation, Behaviour Research and Therapy, Vol. 37, pp 659-670Seedhouse, D. (1998) ethical motive The Heart of Health Care 2nd Edition, Chichester,Wiley.Sullivan, P. (1998) Developing evidence-based care in mental health nursing, Nursing Standard, Vol. 12, No. 31, pp 35-38