Informing and Evaluating Professional Practice , Critical review

University Degree Subjects allied to Medicine

Sheffield Hallam University

Faculty of Health and Wellbeing

Advanced Diploma in Adult Nursing.

Summative Assessment Submission.

Informing and Evaluating Professional Practice – January ’08 Intake

Date of Submission: 27th April 2009

Assignment Title: Critical Review

Research Question: ‘What are the attitudes of general nurses towards people with learning disabilities?’

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Word Count: 2195

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Evidence-based practice is an approach that enables the medical professional to provide the highest quality of care in meeting the complex needs of their patients and families (Melnyk and Fineout-Overholt 2004). In nursing science and research, relevant studies and investigations must be carried out, fulfilling certain criteria’s (Kim and Kollak 2006). Evidence-based practice has become a core requirement of contemporary nursing practice. The Nursing and Midwifery council (NMC, 2008) demand that nurses base their practice on the best available evidence.

This assignment will critically review articles around a chosen area. The subject question will be as follows: ‘What are the attitudes of general nurses towards people with learning disabilities?’

My previous profession involved caring for people who had profound and multiple learning disabilities. Over the years I accompanied many of them to hospital for treatments, also to general practitioners for appointments. I recognised on many of these occasions that health professionals seemed to lack awareness around the needs of people with learning disabilities. By looking at these articles I hope it will enhance my professional practice in a holistic manner.

It has only been twelve years since a report showed that General Practitioners were refusing to accept people with learning disabilities (Singh 1997), furthermore a survey for general nurses found that the majority were in favour of segregating people with learning disabilities from other patients in hospital (Slevin and Sines 1996).

The Valuing People White Paper in England (DOH 2001) states that people with learning disabilities are becoming more integrated into the community; as a result, they will be using the National Health Services more frequently. You only have to look at recent stories about the inequity that people with learning disabilities have to challenge. The Mencap (2007) ‘Death by Indifference’ report outlines major failings within the National Health Service and makes strong recommendations for change, to give people with learning disabilities equal health care.

Various sources are available to gain information from and it is imperative to use a variety in order to gather a range of information that is reliable and trustworthy (Hart 2000). The information was sought by utilising diverse approaches to relevant literature, these included books, journals, websites, newspapers, magazines and information search databases. To maximise the results of relevant and recent article a decision-making process will be utilised in the form of inclusion/exclusion and key words, tables of these can be found in Appendix 1.

Herbert et al (2005) states that a systematic review that specifies clear inclusion and exclusion criteria’s provide stronger evidence for their field of search than them that do not. Keyword searching is the most popular information discovery method because the user does not need to know either a query language or the underlying structure to the data (Bernstein 2002).

Whilst searching the question, it was found that a great deal of research, studies and articles had already been completed. This gave the reader more insight to the attitudes, fears and reactions of general nurses and other professionals towards learning disabilities. A Qualitative approach was sought to gain an insight the emotions of professionals, people with learning disabilities, families and carers. Siviter (2008) defines qualitative research as gaining insight into thoughts, feelings and experiences. Whereas Quantitative research is more reliable kind and is used for research that needs to be measurable.

The articles chosen for this research were analysed before they were critiqued. From the analysis, two articles were found to be directly relevant to the research question. These are:

SOWNEY, Margaret and OWEN, G. Barr (2005). Caring for Adults with Intellectual Disabilities: Perceived Challenge for Nurses in Accident and Emergency Units. Journal of Advanced Nursing 55(1) 36-45
FOX, David and WILSON, David (1999) Parents’ experiences of General Hospital Admissions for Adults with Learning Disabilities. Journal of Clinical Nursing. 8(5) 610-614

(A summary of these articles can be found in Appendix 2)

This is a preview of the whole essay

SOWNEY, Margaret and OWEN, G. Barr (2005). Caring for Adults with Intellectual Disabilities: Perceived Challenge for Nurses in Accident and Emergency Units. Journal of Advanced Nursing 55(1) 36-45
FOX, David and WILSON, David (1999) Parents’ experiences of General Hospital Admissions for Adults with Learning Disabilities. Journal of Clinical Nursing. 8(5) 610-614

(A summary of these articles can be found in Appendix 2)

Several different tools were created to critically appraise qualitative and quantitative articles, after looking through them, the Critical Appraisal Skills Program (CASP) was chosen. The reasoning for this was because it appeared uncomplicated and offered a structure that was comprehensible. The tool presents the user with a series of questions to deal with the characteristics of the study, also broad issues that need to be considered, for example: - Rigour, Methods, Credibility and relevance

CASP’s aim is to help health service professionals develop skills in the critical appraisal of evidence and promote the delivery of evidence-based health care. (Public Health Resource Unit 2006).

Both articles are similar as they are surveying different participants, health professionals and parents. They consider the attitudes of nurses and other professionals are different towards people with learning disabilities than the general population. Article 2 highlights issues that were apparent before the government implemented the White Paper (DOH 2001) “Valuing People: A New Strategy for Learning Disability” which sets out an ambitious and challenging program of action for improving services. Whereas article 1 highlighted fears, barriers and lack of knowledge that nurses have about people with learning disabilities.

Article 1 provided an outline of aims that would improve the health of learning disabilities in general hospital settings. Mencap (1998) stated that estimations had shown that 26% of people with learning disabilities were admitted to hospital every year compared to 14% of the general population.

The aims of the articles were to explore the experiences of nurses in accident and emergency departments, moreover, identifying that ‘their lack of understanding weakened opportunities in reducing barriers and providing unbiased care for people with learning disabilities’. Therefore, to discover the nurse’s fears and experiences the research will be qualitative. Article 2 is also qualitative in design as it consists of interviews with parents about their experiences of general hospital and inpatient care for their son/daughter with learning disabilities. The article looks at how nursing staff provide basic care for people with learning disabilities and their dependence on carers and family members.

Qualitative methods were used for both articles and this was stated within the literature. Article 1 focused on the nurse’s perspectives of caring for people with learning disabilities whereas article 2 paid attention to the relatives and carer’s, gaining insight from another viewpoint. Both articles focus on discovering the attitudes of general nurses towards people with learning disabilities. This was an appropriate design as the qualitative method explored holistic issues that people with learning disabilities have when they are in hospital. Such research aims to capture lived experiences, provide a person focused approach and give insight into the potentially disabling environment across the continuum of health services (Priestley, 2000).

In qualitative research the fundamental process of sampling is dependent on the selection of information rich cases (Patton, 2002); individuals that can act as so called ‘expert witnesses’ (Polit & Hungler, 1995). Within the studies, data was gathered from participants who had either, cared for somebody with a learning disability or came into contact, professionally, with some body that had a learning disability. Both article sizes were small, however, in article 1’s defense Porter and Hunt (2008) acknowledged that too many people in a focus group could make the group harder to control and have a huge impact on the group dynamics. It was apparent that some of the participants in article 2 might be bias to the care that their relatives received whilst in hospital as they may devote their day tending to their son/daughters needs when at home, therefore, expect others to do the same.

King and Wincup (2008) suggest that validity and reliability are important factors within qualitative research design. In accordance with both journal guidelines, articles are subject to peer review. This means that experts advise the journal on the feasibility of the publication. This helps to maintain standards in publishing and gives credibility and value to the published article. By gaining expert opinions the reliability (truthfulness) and validity (strength) of the articles are achieved.

Article 2 used pilot interviews to gain an insight into parent’s experiences of hospital treatment for their son/daughter who had a learning disability. The basic principle of interviewing is to provide a framework within which respondents can express their own understandings in their own terms (Patton, 2002). However, Issel (2008) expresses that interviewers tone, pace, facial expressions, verbal and non-verbal cues can alter the response of the interviewee. Therefore article 2 could be questioned as to whether this was the right method, it could be suggested that parents would say negative things and the interviews could be bias. Article 1 used combined methods of questionnaires followed by focus groups that were audiotape recorded. Methods can be successfully combined when appropriate; questionnaires are efficient when needing a large number of participants whereas focus groups are useful when detailed descriptions and explanations are required (Kaufman, Guerra, and Platt 2005).

Article 1 carried out questionnaires on 27 nurses this was designed to collect relevant demographic data about age, professional qualification, grade, gender and how many years experience they had, this was then followed by five focus groups that explored the experiences of accident and emergency nurses when caring for people with learning disabilities. It was noted that whilst the focus group was a valuable method, there was no opportunity to hone in on and seek deeper understanding on key emotive responses from individuals.

Qualitative analysis involves systematic, rigorous consideration of the data in order to identify themes and concepts that will contribute to our understanding of social life Gilbert (2001). On the other hand Flick (2006) identifies issues within qualitative analysis one of these being the transcription of oral conversations into written text.

The strength from both these studies is that the outcome can be applied to practice as a lens to interpret people's experience or to direct actions and interventions (Munhall 2006). The articles both thematically analyse their data, for common concepts (i.e., open code). These concepts, or codes, and the direct quotes they represent, were explored for similarities and differences within the participants reflective accounts. Finally, themes were identified that defined the relationships that existed within the data that was collected.

Basic ethical principles regarding methods of data collection is that participants should suffer no harm from their involvement throughout the evaluation process. (Dunkley 2000). Ethical considerations in research are paramount and the lack of a national ethical committee to review research in this area is an issue for concern. However, article 1 sought approval from the Research Ethics Committee and full details of their study was given to participants outlining their rights to anonymity, confidentiality and the right to withdraw from the study without prejudice. Written consent was also gained.

Both articles outcomes established that there were negative attitudes with health professionals towards people with learning disabilities. Article 1 found six interrelated themes, of these the first four; respect for individuals, communication difficulties, difficulties in gaining consent and lack of knowledge. In addition, previous authors had reported dependence on carers. Article 2 found that some of the reported experiences were alarming and that the consequences could have been more serious had the family member or carer not been present to advocate on the patients behalf. As acknowledged earlier, only article 1 emphasised on the ethical considerations whereas article 2 merely mentioned this, only that the interviewees were asked if they would agree to be interviewed. Article 1 recognised possible sources of bias and both article acknowledged limitations; these were discussed earlier in the sampling section. Both articles gave detailed descriptions of their findings and the need for further research to be conducted, also the necessity of training and collaborative approaches to re-address the deficits in nurses knowledge and competences to care appropriately for people with learning disabilities.

It appears that all research is governed by the ethical considerations. The Research Governance Framework (DOH 2005) outlines principles of good governance that apply to all research; it also invests in research that will save lives. Management of Social Transformations (MOST 2003) states that the research should be carried out in full compliance with, and awareness of, local customs, standards, laws and regulations moreover, the research should be conducted in a competent fashion, as an objective scientific project and without bias.

These articles appear to be reliable and valid as they are both published in peer review journals. Their discussion sections both highlight concerns about potential consequences due to general nurse’s attitudes, fears and lack of understanding towards people with learning disabilities. The research subject was relevant to local areas and Multi-disciplinary teams. Results from these reviews should change the policies and practices by introducing compulsory training for nurses in the field of learning disabilities as part of their initial training.

The use of the CASP tool facilitated my understanding. Being able to break the articles into sections offered me the opportunity to examine them closer, thus enabling the reader to absorb the literature that otherwise could have been missed.

Both articles were published in appropriate journals, which aimed the issues at professionals who require awareness, therefore benefiting the future care for people with learning disabilities.

Key issues highlighted included collaborative approaches and the need for professional development. The reviews enabled nurses to reflect on their experiences or question themselves as to whether they are competent enough to care for somebody who has a learning disability.

References

BERNSTEIN, Philip (2002). Proceedings 2002 VLDB Conference: 28th International Conference on Very Large Databases. China. Morgan Kaufmann

DOH (2005). Research Governance Framework, for Health and Social Care. London. HMSO

DOH (2001) Valuing People: A new strategy for learning disability for the 21st century. London. HMSO.

DUNKLEY, Jacqueline (2000). Health Promotion in Midwifery: A Resource for Health Professionals. London. Elsevier Health Sciences

FLICK Uwe (2006). An introduction to qualitative research. (3rd ed) London. SAGE

GILBERT Nigel (2003). Researching Social Life. (2nd ed) London. Sage Publications Ltd

HART C, (2000) Doing a literature Review. London. Sage Publications Ltd.

HERBERT et al (2005). Practical Evidence-Based Physiotherapy. London. Elsevier Health Sciences

ISSEL Michele (2008) Health Program Planning and Evaluation. Boston. Jones & Bartlett Publishers

KAUFMAN Roger, GUERRA Ingrid and PLATT, William (2005) Practical Evaluation for Educators. California. Corwin Press

KIM, Hesook Suzie and KOLLAK, Ingrid (2006). Nursing Theories. New York. Springer Publishing Company

KING Roy and WINCUP Emma (2008) Doing Research on Crime and Justice. Oxford.

MELNYK Bernadette and FINEOUT-OVERHOLT Ellen (2004). Evidence-based Practice in Nursing & Healthcare. London. Lippincott Williams & Wilkins.

MENCAP (1998). The NHS- Health For All? People with Learning Disabilities and Healthcare. Royal Society for Mentally Handicapped Children and adults. London. Mencap

MENCAP (2007). Death by Indifference. London. Mencap

MOST (2003) Ethical Guidelines for International Comparative Social Science Research in the framework of MOST. [online] last accessed 5th march 2009 at:

MUNHALL, Patricia (2006). Nursing research: a qualitative perspective. (4th ed) London. Jones & Bartlett Publishers

NMC (2008) The Code: Standards of conduct, performance, and ethics for nurses and midwives. London: NMC

PATTON, Q.M. (2002). Qualitative Research and Evaluation Methods. (3rd ed) Thousand Oaks: Sage Publications.

POLIT, D and HUNGLER, B (1999) Nursing Research. Principles and Methods. Lippencott Philadelphia.

POTER Stuart and HUNT Rosie (2008) First Steps in Research. Edinburgh. Churchill Livingstone

PRIESTLY, M. (2000), Dropping E: the missing link in quality assurance for disabled people. In: C. Davies, L. Finlay and A. Bulklman (eds). Changing practice in health and social care. Cornwall, UK: Open University. Chpt 18, 181-197.

Public Health Resources Unit (2006). Ten questions to help you make sense of qualitative research. [Online] last accessed 4th march 2009 at:

SINGH P (1997). Prescription for Change. London, Mencap.

SIVITER, Bethann (2008). The Newly Qualified Nurse's Handbook. London. Elsevier Health Sciences

SLEVIN, Eamonn and SINES, David (1996). Attitudes of nurses in a general hospital towards people with learning disabilities: influences of contact, and graduate-non-graduate status, a comparative study. Journal of Advanced Nursing. 24(6):1116-1126,

Appendix 1

Table 1: Inclusion/ exclusion criteria:

Table 2: Search carried out and articles found within different databases:

Appendix 2.