Evidence Based Practice in Mental Health Nursing Essay

nonpareil of the near common and alter psychological illnesss encountered inwardly kind health and habitual medical settings is that of an anxiousness dis clubho go for (Dattilio & Kend tout ensemble 2000). Re bet has indicated that mint with cultivation disabilities are more usual to psychological disorders than the general population (Hassiotis et al 2000) accordingly it could be hypothesised that prevalence rates of care disorders are similar if non greater inwardly the information disabled population. paid literature suggests that cognitive-behaviour therapy (CBT) has been an effective treatment over against anxiety disorder (Beck 1995) further this literature has predominately concentrated its focus to within the bound of mental health and general medical settings (Dattilio & Kend whole 2000).The ability of people with acquirement disabilities to identify, evaluate and respond to their dysfunctional thoughts and beliefs, fundamentals of CBT (Beck 1995) ha ve put into school principal the very use of this treatment programme for this particular client assemblage (Kroese et al 1997). From a professional and personal perspective and d oneness the physical exercise of the Seedhouse (1998) Ethical Grid responding to an anxiety disorder by way of CBT could be considered an ethically acceptable clinical interposition. Nationally and locally by means of governing directives, Valuing People ( division of wellness 2001) and initiatives such(prenominal) as Health Action Plans (Department of Health 2002) work have recognised that they need to be more reactive to the mental health needs of people with acquire disabilities. As a erudition disability nurse lack to ascertain the specialty of CBT as a practical intervention when presented with the dual-diagnosis of anxiety disorder and learning disability, is through the use of shew-based make out.When deciding on the best possible clinical intervention for an place use problem it se ams logical to convert the sheer into a angiotensin converting enzyme answerable distrust (Colyer & Kamath 1999). Several authors have identified that the use of cloths to inform the go againstment of the clinical doubt earmark the practician with a organized process of formulating an answerable question (Sackett et al 1997 Ridsdale1998). One such framework as described by Sackett et al (1997) is a four- stage process, known by the acronym PICOPatient or universe hindrance or IndicatorComparison or Control gistThe twisting of an answerable question is the basis of demo-based work out and should guide the practitioner to how to discern an answer (Ridsdale 1998). It is important that each variable under the PICO framework is clearly defined, being as detailed and explicit as possible in order to extend clarification to the question.Working through PICO methodically the practitioner would instigate the process by defining the Patient or Population. Characteristics such ag e, gender and diagnosis would need to be deliberated and whilst the aforementioned were good recognised in the practice area as adult male, identifying curb callinology for diagnosis go off prove problematic. The term larn hinderance is very much used interchangeably in literature with terms such as, psychical Retardation and Intellectual Disabilities. learnedness balk is a term with contemporary usage within the join Kingdom to describe a client group with significant development delays (Gates 1996). Whilst the idiom Learning Disability is the preferred terminology for the question due(p) to its contemporary usage it essential be accepted that its a term not internationally recognised nor is it a term used for long in the United Kingdom (Gates 1996).Anxiety disorder comes in m either facets and can be described as severe psychological disorders in which abnormal or chronic anxiety interferes with daily living (Adams & Bromley 1998). The client in the practice area had described psychological and physiological symptoms that were diagnosed as a neighborly anxiety disorder through rating scales and self-report measures. It is crucial that the practitioner is cognizant 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 to fall upon place between the relationships of the chosen term to symptoms displayed by the client.The identification of animate clinical interventions is a valuable part of the process of developing take the standd-based interventions (Meijel 2003). belles-lettres suggests that CBT is an effective treatment for a subdue of psychological disorders (Embling 2002 Hatton 2002). Central to the position of CBT is that distorted or dysfunctional thinking is prevalent in all psychological disorders (Beck 1995). Analysis of accumulated experience of existing i nterventions and the aforementioned demo of its validity led to the application of CBT as the question intervention.It is not imperative for the question to have a comparison intervention and this was the plaza in the clinical problem described, hence the conclusive part utilising the PICO framework was outcome. The outcome should be measurable (Sackett et al 1997) and after ab initio 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 provide the question with a measurable outcome. Revision of the terminology identified through the PICO framework would consequently translate 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 expect dodge is an essential component in gathering prehend induction (Hewitt-Taylor 2002). Ri dsdale (1998) discusses a four-stage see schema that helps to translate the question into a meaningful appear a) Identify the resign elements of the questionb) Define the relationship between the battleground elementsc) Convert the casing elements into search themesd) Decide on the scope of the searchAssistance to define the subject elements can be found within the PICO framework Patient Learning Disability, affectionate AnxietyIntervention CBTOutcome EffectivenessOnce identified an effective means of linking the subject elements of a question for the search process is through the use of agents. 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 undeniable in order provide a conclusive answer thitherfore the operator required for the search dodge could be identified as And. The subject eleme nts 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 make a list 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 character of evidence 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 quick identified as questioning, the effectiveness of a therapy. Sackett et al (1997) proposes that the best obtainable evidence to answer this type of question is relative / prospective studies and ideally random controlled trials (RCTs) which in turn determine the choice of database (Ridsdale 1998).Sackett et al (1997) provides a com prehensive catalogue of information elections such as databases, daybooks and web sites along with descriptionsof the type of evidence that can be found within these resources. It was formal previously that the best type of evidence for the question would be RCTs and comparative / prospective studies. From the descriptions supplied by Sackett et al (1997) it could be identified that the Cochrane program library supplies the exploiter with full text systematic critical reviews of effects of health-care 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 clauses 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 related academic publishers and IngentaCo nnect which offers full text availability for all core Blackwell science and medical journals were chosen due to long-familiarity of use and capacious subject matter. Other databases considered were CINAHL, EMBASE and AMED however all were discounted due to their general treat bias.Despite the recognition of Ridsdales (1998) four-stage search scheme and its systematic surface the initial search were completed exploiting familiar strategies through the IngentaConnect database. Preconceptions from previous endeavours inquiring for relevant evidence furnished the belief that a similar strategy would provide sufficient evidence to answer the question. A event 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 th at 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 meanwhile was utilised they invariable appeared indiscriminately amidst the title or abstract of the article providing no specific relevance to the question. The frustration born out of this strategy led to further searches of electronic databases firstly through another familiar database, Swetswise. Ridsdale (1998) identifies that too many an(prenominal) hits will be recovered if the subject element is to generaland this was evident in the first keyword search. The term learning disabilities produced 548 hits (See Appendix) removed too many to feasibly scan. The subsequent four searches failed to produce a single hit a possibility also recognised by Ridsdale (1998) who suggests election synonyms are utilised in this circumstance.Due to the inability to find any relevant material of value towa rds 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 satisfy previous identified criteria it established that pursuing Ridsdales (1998) strategy could provide some success. A similar onset was undertaken while searching the Cochrane Library database which allows the exploiter to restrict the search to the acquisition of systematic reviews and controlled trials whilst using a unbiased keyword option. Again the subject elements were utilised along with the recognised operator and despite new found confidence and knowledge the search strategy revealed no evidence of s ystematic 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 faith 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 & Spence 1997) and psychiatric services (Carmin & Alb ano 2003).Hatton (2002) suggests that explore evidence on the effects of psychosocial interventionsfor people with learning disabilities is sparse, whilst Kroese (1998) adds that therapists are reluctant 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 judicious use of current best evidence in making decisions about the care of individual patients.With this definition in mind it should be established as to what constitutes current best evidence and its implications for the pra ctitioner wishing 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 succeeding(a) classification in descending order of credibilityI. Strong evidence from at least one systematic review of multiple well-designed disarrange 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 pecking order of evidence practitioners should concede that the systematic review of multiple well-designed RCTs constitutes best on hand(predicate) evidence (Co lyer & 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 quantitative 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 potential 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 anxiety disorders. This type of evidence appears in the cut back reaches of the power structure of evidence and as such its subjectivity, reliability and validity can be disputed (Sullivan 1998).Whilst acknowledging the hierarchy of evidence and the proposal 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 admit as the gold standard of evidence-based practice (Rowland & Goss 2000) however it is suggested that they bear subatomic resemblance to day-to-day reality (McInnes et al 2001). RCTs can be pragmatic 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 2002 Kroese 19 98) 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 suitable 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 over 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 adapt research evidence from general and mental health settings (Finlay & Lyons 2001) a similar show up 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 debt instrument in all aspects of health care (Driscoll & Teh 2001). Through the process of formulation 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 support of his clinical practice.The structured frameworks utilised end-to-end 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 systematically 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 linchpin Terms 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? 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