Challenging Behaviours in People with Learning Disabilities - Literature review Example

Literature review on challenging behaviours in people with learning disabilities Literature review on challenging behaviours in people with learning disabilities Introduction A key challenge faced by nursing staff in health care professions is dealing with challenging behaviors exhibited by people with learning disabilities (Walsh and Wigens, 2003, p. 12). Staff concerned with taking care of people with learning disabilities is particularly vulnerable to verbal and physical aggression that can lead to emotional and physical strain of nursing staff. Due to this aggression, staffing issues such as nurse turnover neglect of care to clients, stress and nurse burnout may occur (Walsh and Wigens, 2003, p. 13). This paper will, therefore, focus on practice based care issue, reflection and research or evidence based practice among nurses handling challenging behaviors in people with learning disability. 1.2 Identification and rationale for selected practice based care issue including a rationale about the importance of research/evidence based practice From the early development of the nursing research profession, nurses have been interested in research methods successfully affect the care of groups and individuals (Ellis, 2010, p. 66). Despite numerous reasons for conducting research, none is greater for a nurse than the difference that might be made in the lives of people for the improvement of health. Emphasis on research utilization has been expanded with the increasing emphasis on evidence-based research. Although research and evidence-based research are believed to be related, research is often described as a subset of evidence based research (Ellis, 2010, p. 67). Research has been described as the systematic and pragmatic inquiry and study of materials in order to establish facts (Ellis, 2010, p. 68). The results of a research process establish a basis on which practice decisions and behaviors are made. Evidence based practice comprises several types of evidence including research findings and review, evidence based theory and the combination of that evidence with clinical expertise and patient values and preferences. EBP is described as the process of methodically collecting, assessing, and using research findings to make decisions about patient care (Ellis, 2010, p. 68). Using EBP in a clinical setting is not the same as carrying out a research. The key reason for using evidence-based practice is to pick the latest evidence from research and guide nurses to achieve the best probable outcome for patients (Barker, 2010, p. 76). One of the benefits of using evidence based practice by health professionals is that EBP results in higher quality care that leads to improved patient outcome since it incorporates the latest research evidence that are available to health professionals. The present use of confirmation in medical would yield increased patient outcome since evidence based research includes health care recommendations that help nurses in addressing questions that provide best patient care(Barker, 2010, p. 76). 1.3 Reflective model Gerrish and Lacey (2006, p. 78) defined reflection as an active process of watching one’s own experience in order to look at it more closely, sometimes to briefly direct attention to it, but often to study it at greater depth. The purpose of reflection is to learn how to take perspective on one’s own experiences. By increasing the power to investigate individual actions and experiences, we open up the possibility of purposeful learning-neither derived from experts or books but from our lives (Gerrish and Lacey, 2006, p. 78). Reflection is viewed as a component of the art of nursing that requires originality and conscious self-assessment over a period. Reflection involves empirical, esthetic, ethical, and personal guidance (Gerrish and Lacey, 2006, p. 78). Empirical guideline includes the source of knowledge/information, aesthetic entails finding out the issues that need attention, personal involves finding the factors that influenced a person’s feelings, and ethical guidelines dictates how a person will respond in respect to their ethical values (Johns, 2004, p.18). Reflection is important in nursing because it enables the nurses to think and reflect about difficult medical situations with the aim of improving them (Rose and Cleary, 2007, p.77). The process of reflection is observed as a technique of encouraging the expansion of self-directed, qualified and independent specialists. Taking part in the reflective process is connected to the enhancement of the improved of care, motivating personal and specialized development and barring the opening between concept and real practice (Rose and Cleary, 2007, p.77). Because of rapid technological developments, nurses will benefit from reflective process especially through interaction within the medical settings (Johns, 2004, p.18). The process mainly focuses on reflection-on-action but with regular use, it can be used to focus on reflection in and before an action. It has three phases; the descriptive phase, the reflective phase, and the emancipator phase (Jasper, 2003, p. 55). The descriptive phase involves the description of practice events, the examination of descriptions for comprehensiveness and descriptive accounts. The second phase involves reflection analysis against supporting theories, reflective analysis of the situations and intentions, obtaining knowledge about practice processes and self-awareness. The third phase includes critique of practice regarding conflicts and inconsistencies, engaging in the change process, and self-critique (Jasper, 2003, p. 56). Reflection is important in nursing because it enables the nurses to learn from their own experience and reflect of the effects of their conducts. The use of reflection in the health care setting increases the nurses’ confidence, improve their skill, adaptability, critical thinking, and decision making since they constantly evaluate different research that would be beneficial to the practice (Barker, 2010, p. 77). Reflections not only develop the nurse’s clinical performance, but also increase their job satisfaction and promote better group cohesion, which in turn promotes job retention in health care practice. Using reflections also reduces the cost in health care compared with traditional and outdated based practices (Bettany-Saltikov, 2012). Implementation of reflections manages available resources since it is used efficiently instead of being wasted in the process of finding ways competent patient care (Barker, 2010, p. 78). According to Davies (2012, p. 8-11), the reflective model has several limitations and benefits. As a benefit, it increases learning from an encounter with the situation. It promotes of comprehensive learning. Through it, one is in a position identify professional strengths and areas that need improvement. Nurses are in a position to use reflective model to improve their education process. The main weakness for the model is that one may not be comfortable it as it is tasking to assess their individual practice. Finally, it is time consuming and may turn out to be very difficult when trying to reflect different situations. Medical specialists also find it difficult to solve medical challenges they encounter from time to time, and not all practitioners understand the entire process of reflection (Jasper, 2011). 1.4 Studies conducted among patients with learning disabilities Decker (2007, p. 78) conducted a study in the UK with a population of 340000adults. Estimated 4000 adults with learning disabilities are in contact with health care services. This included about 700 adults with challenging behaviors who are in hospitals waiting to be settled. The study’s aim was to identify the overall workload of the nurses, the overall staff burnout in relation to caseload, the prevalence of the population of people with learning disabilities who exhibit challenging behavior and what contact demands these individuals require. Another aim was to discover courses that help these nurses fulfill their role. A postal survey was conducted of the total population of nurses for people with learning disabilities in the area. Data was collected using self-completion questionnaires (Decker, 2007, p. 79). The sampling technique for the study consisted of qualified and under-qualified staff who are in a direct care role in hospitals and residential homes for people with learning disabilities. Only staff who had been working at their present place of employment for more than three months was included in the study in order to ensure that the staff knew the clients they were dealing with well enough to be able to fill the questionnaire (Decker, 2007, p. 79). Eighty nurses selected from different organizations took part in the research. The questionnaires took about 30 minutes to be completed. The participants either posted the questionnaires back to the researchers using the pre-paid envelop that was supplied or the researchers collected them directly from the participants. Two hundred questionnaires were distributed but only 62 returned, giving a response rate of 27% (Decker, 2007, p. 79). The demographic questionnaire completed by staff about themselves included information on gender, age, job title, the length of time working in the current employment, qualifications and training (Decker, 2007, p. 79). The examination of information was conducted using the statistical package (SPSS). The data was examined for normal distribution using quantitative tests. Most variables were not normally distributed and the analysis was, therefore, computed using Spearman’s correlation for non-parametric data. Where there was a significant correlation between a measure of challenging behavior, stress level and cognitive behavior, regression analysis was conducted on the three variables to examine the presence of a mediating relationship (Decker, 2007, p. 79). The result of the analysis specified that there is a relationship between nurse burnout and severity of the learning disability. The outcome shows that the higher the severity of the challenging behavior, the higher the burn out level. The results also revealed that chronic challenging behaviors were correlated with potential fear of assault in the health care professionals as established by Rose and Cleary (2007, p. 77). The opposite was the case by the research conducted by Benner (2001, p. 89) who found that staff in the category exposed to more challenging behaviors exhibited less fear. The study, however, used Vignette method to measure fear among staff. The author found self-ability moderated the relationship between burn out and challenging behavior, and stated that the category experiencing chronic challenging behavior experienced less fear probably because of the effects of staff training (Benner, 2001, p. 89). The fear of assault measure revealed that the greater the fear, the greater the emotional exhaustion and depersonalization in the caregiver. The challenging behavior personal questionnaires showed that the more control the caregivers felt they had over the challenging behavior, the more personal accomplishment they felt (Benner, 2001, p. 89). The response rate for the research was low, although similar to that of Aveyard (2007, p. 78) who carried out a postal survey on challenging behaviors and emotional exhaustion among the nursing community in the same region. Purposes of poor rate of response may have been time pressures on the staff or the sensitivity of some of the questions, which required staff to give their views about clients and employment. These studies are always a possibility of the staff underreporting on items considered negative such as negative emotions because they do not feel at ease disclosing such information. As found by Hastings et al. (2004, p. 18), asking the respondent to report the challenging behavior of one patient is likely to yield an inaccurate measure of the total expose to challenging behavior. A study was conducted by McGill, Bradshaw and Hughes (2007, p. 67) to measure knowledge and emotional responses of students after a training course work aimed at improving intervention and assessment of challenging behaviors. The research discovered that there is an increase in knowledge, more accuracy in causal attributions, and a decline in negative emotions after the training course work. The sample will be of one hundred and fifty participants using survey design. It could, therefore, be argued that helping staff to understand and manage challenging behavior may result in less negative emotion and consequently less staff stress and better health care for clients. 1.5 Critique of the Rolfe model The Rolfe model was also adapted in this study. It is a simple cycle comprised of three questions that asks the consultant, What, So What, Now What (Rolfe et al., 2001, p.26-35). Through this investigation an explanation of the condition is specified which guides into the inspection of the position and the building of information obtained through individual experience (Rolfe et al., 2001, p.26-35). The main component of this model attempts to answer the question what, which means the setting; accomplishments, consequences, reactions, approaches, and difficulties. So what means what the practitioner has learnt acquiring about identity, relations, examples, attitudes, philosophies, actions, opinions, understanding, and enhancements. The last element attempts to recognize what should be performed so as to improve several outcomes, and create a learning opportunity (Rolfe et al., 2001, p.26-35). This model when used can motivate reflection from apprentice to higher levels. First, the medical practitioner reflects on the condition in order to explain it. The second stage inspires the medical practitioner to create individual theory and information about the condition in order to acquire information from the situation. At the final level, the medical consultant reflects on encounter and reflects ways of expanding the condition as well as reflects on the effects of their actions. This last stage makes a big contribution to the medical profession because of its nature of reflection. Using the Rolfe model, the researcher conducted a literature review on challenging behaviors in adults with learning disabilities on three main articles mentioned above. The most important limitation of these reports is that it is difficult to get foundation and consequence from this study method, which used correlation, and regression methods, which do not show evidence of causal relationships. Another weakness of the analysis is the latent overlap between the quantities measured. For instance, it can be stated that burnout constructs is similar to the constructs of fear in that they are all measuring negative emotion reactions. Although there are different limitations to the studies, strength in the articles indicated that staff giving a report on their real experiences with the clients they work with as opposed to vignettes in paper one. Methodology used may have increased the ecological validity of the research in paper two. The demographics of the selected sample were strength because there were different organizations involved from both the independent sector and the community services, which improves the generalizability of the findings in paper three. Furthermore, the questionnaire on challenging behavior provided a reliable broad measure of the extent of behavior the frequency, the level of management difficulty and severity of the challenging behavior. Asking staff to report the challenging behavior of one client is strength because it captures an authentic experience that staff can relate to easily (Crookes and Davies, 2004, p. 78). The studies revealed that negative emotions about challenging behaviors play a big part in stress experience and therefore in accordance with what Parahoo (2006, p. 67) suggested, helping staff develop the appraisal about challenging behaviors through continuous professional development programs may have an effect on the stress levels they experience. This might include practical strategies for controlling the behavior as well as ways for the staff to manage their fear and stress levels. The review of these studies enabled the researcher to identify the knowledge gap of has been done. Data obtained in these articles was not appropriate for parametric analysis and therefore, the mediation analysis should be assessed with caution. The technique can also be expended with very small samples. Another limitation of the study is that it did not consider some clients characteristics such as their level of cognitive ability. Therefore, more studies should be conducted using different cognitive levels of medical specialist. More studies can be conducted using large samples using different research designs and data collection instruments so as to improve the study findings. Information obtained in the three articles will enable the researcher explain how nurses handle challenging behaviors among patients with learning disabilities. The researcher was also well placed to know different research strategies used to obtain information in the articles. It is through this data that the researcher will use information obtained to handle different patients with learning disabilities. In conclusion, the study showed that health care professionals have a large workload of people with challenging behaviors and experience different levels of the challenging behavior severity. The population of adults with learning disability accounts for over one-third of the clients they visit and require much more frequent contacts and attention than other clients. The combination of high numbers and the level of challenging disability may affect the way nurses perceive their role and how they perform their duties because of the emotional exhaustion and stress related to the job. To increase other medical professionals and implementing training and practices method that help staff cope and manage challenging behavior may minimize emotional exhaustion and improve care for clients. Sample questionnaire for challenging behavior that was used to collect data Client name Observer number Behavior exhibited Morning Midday Evening Difficulty level Comments Hitting Kicking Shouting Communication issues Verbal coldness Other References Aveyard, H., 2007. Doing a Literature Review In Health And Social Care: A Practical Guide. London: McGraw-Hill, Open University Press. Barker, J., 2010. Evidence-based practice for nurses. London: Sage. Benner, P., 2001. From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall. Bettany-Saltikov, J., 2012. How to do a Systematic Literature Review in Nursing. London: McGrawHill. Decker, S., 2007. Integrating guided reflection into simulated learning. In P. Jeffries (Ed.), Simulation in Nursing Education. New York, NY: National League for Nursing. Davies, S., 2012. Embracing reflective practice. Education for Primary Care 23: 9–12. Crookes, P.A. and Davies, S., 2004. Research into practice: Essential skills for reading and applying research in nursing and healthcare. London: Balliere Tindall. Gerrish, K. and Lacey, A., 2006. The research process in nursing. Oxford: Blackwell Publishing. Hastings, R. P., 2002. Do challenging behaviors affect staff psychological well-being? Issues of causality and mechanism. American Journal on Mental Retardation, 107(6):455-467. Hastings, R. P. Horne, S., and Mitchell, G., 2004. Burnout in direct care staff in intellectual disability services: A factor analytic study of the Maslach Burnout Inventory. Journal of Intellectual Disability Research, 48(3): 268-273. Jasper, M., 2003. Beginning reflective practice. Cheltenham: Nelson thorn. Jasper, M. 2011. Vital Notes for Nurses: Professional Development, Reflection and Decision Making. John Wiley and Sons. Johns, C., 2004. Becoming a reflective practitioner (2nd ed.). Malden, MA: Blackwell. McGill, P., Bradshaw, J., and Hughes, A., 2007. Impact of extended education/training in positive behaviour support on staff knowledge, causal attributions and emotional responses. Journal of Applied Research in Intellectual Disabilities, 20, 41-51. Parahoo, K., 2006. Nursing research: principles, process and issues London: Palgrave. Rolfe, G., Freshwater, D., and Jasper, M., 2001. Critical Reflection for Nursing and the Helping Professions. Basingstoke, U.K: Palgrave. Rose, J. L., and Cleary, A., 2007. Care staff perceptions of challenging behaviour and fear of assault. Journal of Intellectual and Developmental Disability, 32(2): 153-161. Walsh, M. and Wigens, L., 2003. Introduction to research. Cheltenham: Nelson Thornes. Appendix A Table 1 Inclusion and exclusion criteria Inclusion Included all the studies in relation to challenging behavior Exclusion Excluded all studies not related to challenging behavior Table 2 Identifying and selecting relevant articles Data base used Boolean Operators Advanced search keywords searched, hits ,and advance search Titles read Abstracts read Studies read CINAHL Plus And (Narrow your search) How nurses handle challenging behaviour Excellence and power in clinical nursing practice The study did not indicate the research design and the number of participants. The study used Vignette method to measure fear among staff Benner, P., 2001. From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall The CINAHL Database Or (Broaden your search) Challenging behavior among children with learning disability Do challenging behaviors affect staff psychological well-being? Issues of causality and mechanism Defined burnout as an extended response to severe emotional and interpersonal stressors on a job He discusses the difficulties in distinguishing the concept of stress from anxiety in nursing practice Conducted a study on people with learning disabilities are in contact with health care service. This researcher aimed at identifying the overall workload of the nurses, the overall staff burnout in relation to caseload, the prevalence of the population of people with learning disabilities who exhibit challenging behavior and what contact demands these individuals require. The study use survey design. Hastings, R. P., 2002. Do challenging behaviors affect staff psychological well-being? Issues of causality and mechanism. American Journal on Mental Retardation, 107(6):455-467. CINAHL Plus with Full Text Not (To exclude term(s)) Emotional response on patients with disabilities Impact of extended education/training in positive behavior support on staff knowledge, causal attributions and emotional responses The study aimed at measuring knowledge and emotional responses of students after a training course work aimed at improving intervention and assessment of challenging behaviors McGill, P., Bradshaw, J., and Hughes, A., 2007. Impact of extended education/training in positive behaviour support on staff knowledge, causal attributions and emotional responses. Journal of Applied Research in Intellectual Disabilities, 20, 41-51. Table 3 Research studies critically appraised Research studies Benner, P., 2001. From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall author number one Aims The study did not indicate the research design and the number of participants. The study used Vignette method to measure fear among staff Methodology The total population was 344 The study used a sample of 56 respondents Survey design was used To determine people’s opinion The study used both qualitative and quantitative design Findings Found that staff in the category exposed to more challenging behaviors exhibited less fear Hastings, R. P., 2002. Do challenging behaviors affect staff psychological well-being? Issues of causality and mechanism. American Journal on Mental Retardation, 107(6):455-467. Author number two Defined burnout as an extended response to severe emotional and interpersonal stressors on a job He discusses the difficulties in distinguishing the concept of stress from anxiety in nursing practice The total population was 100 The study used a descriptive survey with 86 respondents This was a qualitive study that was ment to obtain in-depth information He discovered that the fear and anger measured in the current study could be claimed to be related to the notion of stress and consequently to burnout Decker, S., 2007. Integrating guided reflection into simulated learning. In P. Jeffries (Ed.), Simulation in nursing education. New York, NY: National League for Nursing. Conducted a study on people with learning disabilities are in contact with health care service. This researcher aimed at identify the overall workload of the nurses, the overall staff burnout in relation to caseload, the prevalence of the population of people with learning disabilities who exhibit challenging behavior and what contact demands these individuals require. The study use survey design. The total population was 3000 Used a sample of 700 people with challenging behaviors who are in hospitals waiting to be settled. The study used qualitative design The results of the study indicated that there is a relationship between nurse burnout and severity of the learning disability. McGill, P., Bradshaw, J., and Hughes, A., 2007. Impact of extended education/training in positive behaviour support on staff knowledge, causal attributions and emotional responses. Journal of Applied Research in Intellectual Disabilities, 20, 41-51. Author number three The study aimed at measuring knowledge and emotional responses of students after a training course work aimed at improving intervention and assessment of challenging behaviors The total population was 200 and the study used 100 respondents The study used correlational design to determine the relationship between variables. The study was quantitative design The research discovered that there is an increase in knowledge, more accuracy in causal attributions, and a decline in negative emotions after the training course work. Read More