Stroke: Evidence-Based Practice - Essay Example

Evidence Based Practice Stroke is a leading cause of death and adult disability all around the world. Recovery from stroke increases the mortality of the patient but depression highly decreases the rate of morbidity of the strokes patient. Several studies have focused on the impact of stroke on the social recognition and quality of life of the patients. Therefore, it can be said that cognitive behavioral therapy may play a major role in decreasing the rate of prevalence of PSD focusing on the cognitive and psychological treatment of patients. Therefore, the study is aimed to focus on cognitive behavioral therapy for PSD patients as compared with the pharmacological therapy. Research revealed that the effectiveness of pharmacological therapy in treating PSD patients in evident. However, augmented and tailored cognitive behavior therapy can play a vital role in improving treatment outcomes of PSD patients Evidence Based Practice Problem Post Stroke Depression increases the risk of mortality and morbidity. Recovery from stroke decreases the rate of mortality of the patients but depression highly increases the rate of morbidity of the strokes patient. It also impairs the functional capacity of the patients and hinder with the social cognition attitude of the patients with stroke. The PICOT question to address the problem is: In stroke, survivors (P) does Cognitive Behavioral Therapy (I) as compared to anti-depressants (C) will increase the treatment outcomes of Post-Stroke Disorder (O) after treatment of stroke (T)? Significance Stroke is a leading cause of death and adult disability in the UK. Around 1,30,000 people met the stroke every year. The National Health Service has given an estimate of around £2.8 billion expenditure by hospitals and around £2.4 billion cost spent on informal care by the caregivers to the PSD patients (Broomfield, Laidlaw, Hickabottom, Murray, & Gillespie, 2011). Several studies have focused on the impact of stroke on the social recognition and quality of life of the patients. Therefore, it can be said that cognitive behavioral therapy may play a major role in decreasing the rate of prevalence of PSD focusing on the cognitive and psychological treatment of patients. Background The psychological impairment also appears in the patients of Post-Stroke Depression showing the signs of depression, anxiety, sadness, loneliness, isolation, alienation, etc. The cost and expenditure served on the treatment of PSD patients is also very high. Mostly the geriatrics and adults have been found as the victim of PSD however in some studies young adults also report the symptoms of PSD. Therefore, the study is aimed to focus on cognitive behavioral therapy for PSD patients as compared with the pharmacological therapy. Gaps While searching for the literature to address the PICOT question, it was found that few researches have been conducted on the evaluation of cognitive behaviors therapy for Post-Stroke Depression. Most of the research was found on the pharmacological treatment of PSD. Secondly, no study was found in which comparative analysis of cognitive-behavioral therapy with psychotropic medicinal treatment was conducted. Literature Review Study 1: Post-Stroke Depression: The Case for Augmented, Individually Tailored Cognitive Behavioral Therapy Introduction: 1. The purpose of the study was clearly mentioned that is to evaluate how Cognitive Behavioral Therapy can be used as a treatment approach for the therapy of post stroke depression. 2. The significance of the study has been discussed as it will be useful to identify the approaches and therapeutic models that can be tailored and augmented to make it effective for the PSD therapy. 3. The authors have clearly formulated the study by explaining the background and purpose followed by the research outcomes and the conclusion. Problem Statement 1. The problem statement was cognitive behavior therapy is not being used effectively as a treatment approach for PSD. It was not separately mentioned. However, the significance section demonstrated the problem to be addressed. 2. Key research questions have been mentioned separately the variable of the study mentioned was BID score of the patients. 3. The study has the potential to present a solution to the stated problem because of clear and well drafted arguments and precise conclusion. Literature Review 1. The literature review followed a logical sequence to compare various studies about CBT and discuss the limitations of the work. 2. The relationship of the study to previous research was clearly mentioned. The researcher related their objective with the prior research work to present arguments. 3. Knowledge gaps in previous researches were mentioned clearly in the study. Theoretical Framework 1. The rationale for the study was stated briefly in the introduction. 2. The theoretical basis for testing the problem statement was given. However, the hypothesis statement was not separately stated. 3. The researcher presented his outcomes based on the hypothesis and analysis of previous work. Methodology 1. The relevant variable was mentioned and discussed in relevance to the study outcomes. 2. The research design was met analysis and literature review that was perfectly used to address the research question. 3. The data collection method was not mentioned in the study. 4. i) Limitations of the study were limited researchers were included as a part of a meta-analysis. ii) No methodology for inclusion and exclusion criteria for studies was given. Sample 1. Subjects of the study were patients, and sampling method was not specified. 2. The sample size (34, 41 and 36) was not sufficient for the variables and study design. 3. No legitimate data was available indicating that rights of human subjects were protected. Instrument 1. The instruments used for data collection were databases that were appropriate for the study design. 2. The meta-analysis approach for studying the intervention approaches for PDS was adequately reliable and valid. Data Analysis No statistical approach was implied to test the results. Results 1. The results for each study were clearly defined and presented. Overall result was not separately discussed. 2. Figures were used for better representation of theoretical concepts. 3. The results were described in the light of theoretical background and research work. Conclusion 1. The conclusion was based on the results of studies included in the research and was related to the hypothesis. 2. Study limitations were not defined, but the observation suggested small sample size and absence of statistical evaluation as study limitations. 3. Generalizations of results were based on a comparison of data and studies from various sources. 4. Implications of the findings were not discussed in the study. 5. Recommendations for further studies were given in the study. Study 2: Cognitions and post-stroke depression Introduction 1. The objective of the study was to assess the negative and less positive cognitions in patients suffering from PDS than the non-depressed stroke patients in order to conclude the efficacy of cognitive behavioral therapy in treating PDS patients. 2. The significance of the study has been discussed. 3. Investigators provided the sense of research strategy clearly. Problem statement 1. The problem statement was that contradictory results have been found from studies revealing efficiency of cognitive behavioral therapy in case of PDS. 2. Research questions and variables were clearly mentioned. 3. The study has the potential to help in a clinical setting by providing a rationale for using CBT for PDS. Literature Review 1. The literature review was critical as well as logical to emphasize of the research question. 2. The study relationship with prior research was clear and descriptive. 3. The necessity of the research was given, however gaps were not mentioned. Theoretical Framework 1. The investigators built the rationale for the theoretical framework of a given study. 2. Theoretical evidences for hypothesis formulation were mentioned. 3. The hypothesis could be tested to obtain results. Methodology 1. Defined variables were gender and age. 2. Research design was quantitative questionnaire based study. 3. Data collection method ‘survey and observation’ was clearly defined. 4. Threats to research validity were not identified. Sample 1. The sample size was (50), and the Cognition Scale Method was elaborated. 2. The sample size was sufficient to compare the results form subjects. 3. Adequate assurance of the rights of human subjects was not mentioned. Instruments 1. Instrument used for data collection was questionnaire. 2. The internal reliability and construct validity of the measurement scale were adequate. Data analysis 1. The statistical evaluation was done by using Mann-Whitney test and Kruskal-Wallis test. 2. The statistical approaches used in the study were appropriate for the design. Results 3. The results were clearly presented showing no difference in cognition between normal depression and post stroke depression patients. 4. The data clearly demonstrated the results using tables and figures. 5. The results were presented based on the factual data obtained from the study. Conclusions 1. Conclusion was based on results and was related to the hypothesis. 2. Study limitations were not clearly defined in the study. 3. The results were generalized based on construct validity of the research and also supportive arguments from previous research work on the subject. 4. Implications of findings were discussed properly in the conclusion. 5. Recommendations for further studies were not stated in the study. Study 3: Post Stroke Depression: Treatments and Complications in a Young Adult. Introduction 1. The purpose of the study was to address the post stroke depression syndromes in relevance to a particular case and study the treatment methods. 2. The significance of the study was discussed focusing on the development of PDS in patients with no prior history of depression and high prevalence rate (80%) in western countries in the introduction. 3. The authors clearly formulated the study by explaining the background and purpose of the research followed by the research outcomes and the conclusion thus they give a perfect sense and understanding to the study. Problem Statement 1. The problem statement was clear that is the evidence based practice for the treatment of Post Depression Syndrome is very low. 2. The key research question was to analyze the impact of psychotropic medicines in recovery of young individuals from PDS. 3. . The identified variables were patients’ demographics, age, race and medical problem leading to stroke. 4. The study design has the potential to present a solution for the stated problem because of its data analysis method. Literature Review 1. The literature review followed a logical sequence to compare the study outcomes with the evidences obtained from previous researches. 2. The relationship of the study to previous research was clearly mentioned. 3. The investigators have mentioned the necessity of the study as a knowledge gap was found in studying the treatment of PDS in young individuals. Literature gaps were not identified in the study. Theoretical Framework 1. The rationale for the study was stated briefly in the introduction. 2. The theoretical basis for testing the problem statement was given. However, the hypothesis statement was not separately stated. 3. The hypothesis was not stated specifically, but the research question was tested as a hypothesis in the study. Methodology 1. Relevant variables of the study include age, patient demographics, race, and sex. 2. The study design used was the case study evaluation and meta-analysis. 3. The design was appropriate for the research question analysis. 4. Data collection method was not elaborated in the study. 5. The study did not indicate any threats to internal or external validity. Sample 1. The subject was a young patient, and sampling method was not described. 2. The sample size was (1) which was not sufficient to draw conclusion, therefore, meta-analysis of available research was conducted. 3. Rights of the human subject assurance were not mentioned in the study. Instrument 1. The data collection tools were observation and interview which were used appropriately for the evaluation of the case study. 2. The reliability and validity of the measurement instruments were adequate. Data Analysis No statistical tests were used to formulate results. Results 1. Results were clearly presented. 2. No tables or figures were used to demonstrate the results. 3. The results were presented based on the observation from the subject’ case. Conclusions 1. The conclusion was based on results and was related to the research objective. 2. The study limitations were not clearly defined in the study. 3. The results were generalized based on the case study evaluation results and the outcomes of research studies via meta-analysis. 4. Implications of the findings were not discussed in the study. 5. Recommendations for further studies were clearly stated in the study. Study 4: The effectiveness of an augmented cognitive behavioral intervention for post-stroke depression with or without anxiety (PSDA): the Restore4Stroke-PSDA trial. Introduction 1. The purpose of the study was to investigate augmented, activation based and tailored Cognitive Behavioral Treatment on reducing the symptoms of PSD in the patients of PSD. 2. The significance of the study was to assess the role of cognitive behavioral therapy in treating the depression symptoms in strokes patients and develop a treatment approach. 3. Investigators provided complete sense to the study by conducting a clinical trial to prove the results. Problem Statement 1. The problem statement was that Post Stroke Depression is having negative impact on the social recognition and quality of life of the patients. 2. The key research question was how cognitive behavioral therapy help in improving treatment outcomes for PSD. 3. Study outcomes reveal augmented tailored approach for CBT, and it can be significantly applied in clinical settings. Literature Review 1. The literature review was logical and critically analyzed prior researches. 2. The study relationship with previous studies was clear and coherent. 3. The necessity of the present study was identified by the investigators. Theoretical Framework 1. The theoretical framework for the study design was mentioned. 2. Theoretical basis of hypothesis formulation was clearly given. 3. The hypothesis was that patients treated with augmented CBT, tailored to their needs, will display major reduction in HADS scores than the patients receiving computerized cognitive training. Methodology 1. The study variables were not defined clearly in the study. 2. The study design was multi-center, assessor-blind, randomized controlled trial. 3. The design was appropriate for the research question. 4. Data collection methods using Hospital Anxiety and Depression Scale (HADS), Caregiver Strain Index (CSI) and Involvement Evaluation Questionnaire (IEQ) for care givers were sufficiently described. 5. Threats to research validity were not identified. Sample 1. The sample size was (106), and subjects defined were hospitalized Post Stroke Depression and Anxiety patients. 2. The sample size was sufficient according to the scope of the study. 3. Protection for the rights of the human subject agreement was not mentioned in the study. Instrument 1. The instruments used were HADS depression scale and questionnaire. 2. The instruments were appropriate as per study design. 3. The data collection instrument was reliable and valid. Data Analysis 1. The statistical method used were PASW 18 Baseline characteristics. Statistical tests include chi-square and t-tests. General linear model (GLM) will be applied for data analysis. 2. The research methods were appropriate to address the hypothesis. Results 1. The results were clearly presented in the study. 2. The study clearly demonstrated the results. 3. The results were presented based on the statistical evaluation of the results obtained by using the three data analysis approaches. Conclusion 1. The conclusion was based on results and was related to the hypothesis. 2. Study limitations were not clearly defined. 3. The results were generalized based on the statistical analysis of the data. 4. Implications of the findings were discussed in the discussion section. 5. Recommendations for further studies were stated in the discussion section. Study 5: Detection and treatment of post-stroke depression: results from the registry of the Canadian stroke network (Herrmann et al., 2011) Introduction 1. The purpose of the study was to compare the rate of diagnosis and treatment between strokes patients suffering from PSD admitted in specialized stroke units than the patients in standard units. 2. The significance of the study focused on the increasing prevalence of PSD and limited research availability on the treatment of PSD in clinical practice. 3. The investigators gave the sense of conducting research with evidences and literature support. Problem Statement 1. The problem statement was clearly mentioned focusing on high rate of depression in strokes patients it stated that one-third of the stroke patients develop depression within three months. 2. The key research question was ‘do the treatment rates vary between stroke patients in specialized units and those in standard units?’ 3. The study was capable of addressing the problem faced in clinical practice. Literature Review 1. The literature review was very comprehensive and followed a logical sequence to support the study. 2. The relationship of the study with previous researches was lucid and clear. 3. The necessity of the study was elaborated in the background. Theoretical Framework 1. The rationale for the theoretical framework was given. 2. The theoretical ground of the hypothesis was clearly mentioned. 3. The hypothesis was precisely given stating that the prevalence rates of PSD are low in the current study. Methodology 1. Variables were clearly defined in the study that are the length of stay in hospital and place of discharge. 2. The study design was prospective cohort study which was appropriate for the study. 3. Data collection methods were observations using Standardized Data Collection Forms containing information about type of stroke type, severity, disability, comorbid medical conditions, treatment, and outcomes. 4. Potential threats to research validity were not identified. Sample 1. Subjects were consecutive stroke patients greater than 66 years of age, and the sample size was 7643. The data was collected from 13 stroke centers in Ohio, Canada. 2. The sample size was sufficient to study the research hypothesis. 3. Assurance of human rights was not given in the study. Instrument 1. Appropriate instrument used for data collection were Standardized Data Collection Forms containing information about type of stroke type, severity, disability, comorbid medical conditions, treatment, and outcomes. 2. The reliability and validity of the measurement instruments were adequate when compared with previous studies using the same instrument. Data Analysis 1. The statistical tests used for continuous variables were means using one-way ANOVA and medians with the Kruskal–Wallis test. Binary and categorical variables were compared using X2 test. 2. Appropriate statistics was used for data interpretation. Results 1. Results were clearly mentioned in the study. 2. Tables and graphs clearly presented results. 3. The results were presented in relevance with the literature support, and the observations obtained using data collection instrument. Conclusion 1. The conclusion was drawn based on the statistical evaluation of obtained results. 2. Study limitations included absence of accurate prevalence rate of PDS, limited definition of PSD and small sample size (13) for data collection. 3. Results could not be generalized because to lack of external validity as only 13 stroke centers from Canada only were approached for conducting the research. 4. Implications of findings in nursing practice were discussed. 5. Recommendations for future research were presented. Synthesis Table (Melnyk & Fineout-Overholt, 2011, p. 131) Study Author Year Number of Participants Sample Characteristics Study Design Interventions Major Findings (Broomfield, Laidlaw, Hickabottom, Murray, & Gillespie, 2011) 2011 34 (single therapy) 41 (multiple) 36 (control) Patients with PSD Meta- analysis Use of Cognitive Behavior Therapy Increase ↑ (Herrmann, et al., 2011) 2011 7643 N=13 Patients with PSD age above 60. Prospective Cohort Study Use of Pharmacological Therapy Decrease ↓ (Nichol, Lincoln, Muncaster, & Thomas, 2002) 2002 50 Patients with PSD Quantitative questionnaire based study Use of Cognitive Behavior Therapy Increase ↑ (Vincent & Wynn, 2010) 2010 1 Patients with PSD (young adults) Case Study Evaluation and Meta- Analysis Use of Pharmacological Therapy Decrease ↓ (Kootker, Fasotti, Rasquin, Heugten, & Geurts, 2012) 2012 106 Patients with PSD Multi-center, assessor-blind, randomized controlled trial Augmented, activation based and tailored Cognitive Behavioral Treatment Increase ↑ References List Broomfield, N., Laidlaw, K., Hickabottom, E., Murray, M. W., & Gillespie, D. (2011). Post-Stroke Depression:The Case for Augmented,Individually Tailored Cognitive Behavioural Therapy. Clinical Psychology and Psychotherapy, 18(1), 202-217. Herrmann, N., Seitz, D., Fischer, H., Saposnik, G., Calzavara, A., Anderson, G., et al. (2011). Detection and treatment of post stroke depression: results from the registry of the Canadian stroke network. International Journal of, 26(11), 1195-1200. Kootker, J., Fasotti, L., Rasquin, S., Heugten, C., & Geurts, A. (2012). The effectiveness of an augmented cognitive behavioural intervention for post-stroke depression with or without anxiety (PSDA) the Restore4Stroke-PSDA trial. BMC Neurology, 12(51), 1-8. Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice. New York: Lippincott Williams & Wilkins. Nichol, C., Lincoln, N., Muncaster, K., & Thomas, S. (2002). Cognitions and post-stroke depression. British Journal of Clinical Psychology, 41(1), 221-231. Vincent, C., & Wynn, G. (2010). Post Stroke Depression: Treatments and Complications. Psychiatry Quarterly, 81(1), 73-79. Read More