One of the most common and disabling psychological disorders encountered within mental health and general medical settings is that of an anxiety disorder (Dattilio & Kendall 2000). Research has indicated that people with learning disabilities are more prevalent to psychological disorders than the general population (Hassiotis et al 2000) consequently it could be hypothesised that prevalence rates of anxiety disorders are similar if not greater within the learning disabled population. Professional literature suggests that cognitive-behaviour therapy (CBT) has been an effective treatment against anxiety disorder (Beck 1995) however; this literature has predominately concentrated its focus to within the confines of mental health and general medical settings (Dattilio & Kendall 2000).
The ability of people with learning disabilities to identify, evaluate and respond to their dysfunctional thoughts and beliefs, fundamentals of CBT (Beck 1995) have put into question the very use of this treatment programme for this particular client group (Kroese et al 1997). From a professional and personal perspective and through the utilisation of the Seedhouse (1998) ‘Ethical Grid’ responding to an anxiety disorder by way of CBT could be considered an ethically acceptable clinical intervention. Nationally and locally through government directives, ‘Valuing People’ (Department of Health 2001) and initiatives such as Health Action Plans (Department of Health 2002) services have recognised that they need to be more responsive to the mental health needs of people with learning disabilities. As a learning disability nurse wishing to ascertain the effectiveness of CBT as a practical intervention when presented with the dual-diagnosis of anxiety disorder and learning disability, is through the use of ‘evidence-based practice’.
When deciding on the best possible clinical intervention for an identified practice problem it seams logical to convert the issue into a single answerable question (Colyer & Kamath 1999). Several authors have identified that the use of frameworks to inform the development of the clinical question provide the practitioner with a systematic 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 PICO:
Patient or Population
Intervention or Indicator
Comparison or Control
The construction of an answerable question is the basis of evidence-based practice and should guide the practitioner to how to find 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 age, gender and diagnosis would need to be deliberated and whilst the aforementioned were easily recognised in the practice area as adult male, identifying appropriate terminology for diagnosis can prove problematic. The term ‘Learning Disability’ is often used interchangeably in literature with terms such as, Mental Retardation and Intellectual 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 terminology for the question due to its contemporary usage it must be accepted that it’s a term not internationally recognised nor is it a term used for long in the United Kingdom (Gates 1996).
Anxiety disorder comes in many 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 social anxiety disorder through rating 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 to take place between the relationships of the chosen term to symptoms displayed by the client.
The identification of existing clinical interventions is a valuable part of the process of developing evidenced-based interventions (Meijel 2003). Literature suggests that CBT is an effective treatment for a number 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 1995). Analysis of accumulated experience of existing interventions and the aforementioned evidence 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 situation in the clinical problem described, therefore the conclusive element utilising the PICO framework was ‘outcome’. 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 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 search strategy is an essential component in gathering appropriate evidence (Hewitt-Taylor 2002). Ridsdale (1998) discusses a four-stage search strategy that helps to translate the question into a meaningful search –
a) Identify the subject elements of the question
b) Define the relationship between the subject elements
c) Convert the subject elements into search themes
d) Decide on the scope of the search
Assistance to define the subject elements can be found within the PICO framework –
Patient – Learning Disability, Social Anxiety
Intervention – CBT
Outcome – Effectiveness
Once 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 the 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 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 type 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 readily identified as questioning, ‘the effectiveness of a therapy’. Sackett et al (1997) proposes that the best available evidence to answer this type of question is comparative / prospective studies and ideally random controlled trials (RCTs) which in turn determine the choice of database (Ridsdale 1998).
Sackett et al (1997) provides a comprehensive catalogue of information resources such as databases, journals and web sites along with descriptions of 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 / prospective studies. From the descriptions supplied by Sackett et al (1997) it could be identified that the Cochrane Library supplies the user with full text systematic 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 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 related academic publishers and ‘IngentaConnect’ which offers full text availability for all core Blackwell science and medical journals were chosen due to familiarity of use and extensive subject matter. Other databases considered were CINAHL, EMBASE and AMED however all were discounted due to their general nursing bias.
Despite the recognition of Ridsdale’s (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 relevant 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 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 hits will be recovered if the subject element is to general and 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 also 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 Ridsdale’s (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 Ridsdale’s (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 knowledge 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 Ridsdale’s (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 & Spence 1997) and psychiatric services (Carmin & Albano 2003).
Hatton (2002) suggests that research evidence on the effects of psychosocial interventions for 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 as:
“…the 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 practitioner 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 following classification in descending order of credibility”:
I. Strong evidence from at least one systematic review of multiple well-designed randomised controlled trials
II. Strong evidence from at least one properly designed randomised controlled trial of appropriate size
III. Evidence from well-designed trials such as non-randomised trials, cohort studies, time series or matched case-controlled studies
IV. Evidence from well-designed non-experimental studies from more than one centre or research group
V. Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees
In accepting this hierarchy of evidence practitioners should concede that the systematic review of multiple well-designed RCTs constitutes ‘best 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 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 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 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 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 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 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 suitable for the study of nursing phenomena (Parahoo 1997) 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 conjecture 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 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 support 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 systematically approach future clinical problems will enable the practitioner to offer his clients a holistic, client centred practice from the best external evidence available.
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