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Analyse evidence for an aspect of learning disability nursing practice considering clinical expertise, resource availability, research evidence and client preferences.

Appraise factors which promote and assist in the implementation of change in clinical practice.

Intellectual Skills

• Explore and apply concepts and theories pertaining to personalisation, health andwellbeing and effective communication in relation to practice advancement

  • Explore and apply concepts and theories pertaining to evidence based practice, audit, evaluation and research in the context of contemporary LD nursing practice
  • Evaluate the student’s future role as a practitioner in promoting evidence based practice.
  • Demonstrate a questioning and analytical approach to practice and identify an aspect of learning disability nursing where evidence for care needs to be considered.

Analyzing Evidence for Obesity Management

Introduction

Learning disability nurses are entailed to carry out professional practice with the aim of providing specialist healthcare and support to individuals with learning disability and their families, and guide them in a manner that is supportive of a better quality of life. Practice development in learning disability can be achieved through engagement in continual research and translation into practice after critical appraisal of the research available. Against the growing trends of obesity prevalence across the globe, the need of management of obesity among individuals with the learning disability has been acknowledged.  Individuals are likely to face co-morbid conditions as a result of obesity such as hypertension and type 2 diabetes which leads to increased burden on individuals as well as caregivers. The present essay aims to address the research question of how management of obesity can be done among individuals with learning disability. The paper discusses the evidence gathered around the topic and analyses their feasibility, appropriateness, meaningfulness and effectiveness. Based on the appraisal, the best practice for the issue is identified. Next, analysis of the factors is done that would inhibit or promote the implementation of the best practice. The following section uses a change management model for showing how the change can be implemented. Moving on, the involvement of service users and stakeholders in implementation of the change is highlighted. The conclusion summarizes the key points from the paper.

For answering the research question, it was appropriate to search for relevant research articles in electronic databases. Medline, Science Direct and CINHAL were some of the databases referred to. Peer-reviewed articles reflecting on the chosen topic were selected with publication year not beyond 2013. Five articles were selected for the paper that gave maximal information of the concerned practice area.

Discussion of evidences

Spanos, Melville and Hankey (2013) carried out research for evaluating the clinical effectiveness of weight management interventions in individuals with learning disabilities and obesity. The evaluation was done with the help of recommendations presented in updated clinical guidelines on first line management of obesity. A systematic literature review was carried out with papers published between the years 1982 and 2011 found in reputed databases. The evaluation was done, and 22 papers were included. The classifications of interventions were done as per the components of behaviour change alone, behaviour change plus physical activity, dietary advice or physical activity alone, dietary plus physical activity advice and multi-component. Eight studies focused on multi-component interventions, while no study included exercise programs. Three studies were successful in highlighting significant weight loss of individuals at six months after implementation of the intervention. The studies did not support any particular interventions on the basis of effectiveness. The study indicated that there is a need for examination of the usefulness of multi-component weight management interventions in this regard. The main focus on the study was therefore in multi-component interventions, whose feasibility is hindered by the fact that a combination of physical activity and diet with a behaviour change strategy for influencing lifestyle might be difficult to design. The intervention is nevertheless appropriate since the key factors related to obesity that is diet, physical activity and health behaviour are addressed through it. It is meaningful since individuals can relate to the intervention and gain a positive experience out of it. However, the effectiveness of the intervention is limited, as pointed out by the review.

Discussion of Evidences

Beeken et al. (2013) assessed a manualised weight management program (Shape Up-LD) addressing obese and overweight individuals with mild to moderate learning disabilities. The study was a pilot randomized controlled trial. The background to the study was that a rich pool of literature highlight that individuals with learning disabilities come across drastic consequences of obesity. The study focused on recruiting 60 obese and overweight individuals with mild-moderate learning disabilities as well as their caregivers. Shape Up-LD was proposed to be the intervention provided in addition to usual care. The manualised intervention involved 12 weekly sessions including messages on healthy eating messages, information on physical activity and applicability of behaviour change methods for helping people consider proper management of their weights. Feasibility outcomes included recruitment rates, compliance rates, completion rates, loss to follow-up, a collection of information for cost-effectiveness analysis and an estimation of the treatment effect on weight. Weight loss can be achieved through Shape Up-LD that leads to better quality of life. This marks the effectiveness of the intervention. The intervention is practical as educational sessions can be easily carried out in support of skilled healthcare workers. The intervention is meaningful since patients are likely to have a positive opinion about the intervention. Since the knowledge gap between the individuals would be addressed through the intervention, the beliefs and thoughts related to it would be appreciated.

Willems et al. (2016) carried out a systematic review of utilization of behavior change techniques integrated into lifestyle change interventions for individuals with learning disabilities. The review considered examining how behavioural change techniques can increase physical activity and enhance nutrition. It is noteworthy to be mentioned in this regard that obesity can be managed through dietary changes and increased physical activity. 45 studies were included in the systematic review, and for assessment of the quality of interventions, the researchers considered use of Physiotherapy Evidence Database. The results indicated that behavior change techniques were directed at providing information about behavior changes. The studies included were of low quality and had study limitations as there was an absence of theoretical framework. The intervention based on behaviors change techniques is therefore not feasible. Appropriateness is not limited since the integration of a theoretical approach would make the intervention better. The intervention is meaningful since behavior change had been linked time and again with positive health outcomes. Lastly, the effectiveness of the intervention is to be improved through a positive and appropriate intervention designed particularly for individuals with learning disability.

Best Practice and Factors for Implementation

Doherty et al. (2017) mentioned that obesity is found to be at a higher rate among individuals with learning disabilities. The researchers carried out an integrative review with available literature. The strategy under assessment was multi-component weight management interventions (MCIs) that can be tailor-made for varied population groups.  Five articles were considered for the study in which MCIs had been specifically designed for people with learning disabilities. The review indicated a limitation in research studies that had the focus on the research question considered for the review. Nevertheless, it identified evidence on MCIs being made specifically for those with learning disabilities and is obese. The feasibility of the intervention is hampered by the fact that it is not always possible to make the multi-component intervention custom made due to varied needs of those with learning interventions. There is, however, appropriateness of the intervention since only a tailor-made approach can address the behavior change readiness in individuals.  The meaningfulness of the intervention cannot be justified as there was a lack of qualitative data highlighting the experiences of the individuals. The effectiveness of the intervention was limited as only two studies were successful in coming up with clinically significant results of weight loss.

Harris et al. (2018) pointed out that people with learning disabilities have more chances of experiencing obesity as compared to those not having the condition. The researchers aimed at examining the importance and applicability of existing randomized controlled trials considering the implementation of multi-component weight management interventions for those with learning disabilities and obesity. A systematic literature review was carried out, and risk of bias assessment was undertaken with the help of Cochrane Collaboration tool. The study design was meta-analysis, and six randomized controlled trials became a part of the study. The main outcomes of the study were that interventions assessed in the papers were not supportive fo the clinical recommendations put in place. The recommendations included energy deficit diet (EDD), behavior change technique, and physical activity. It was thus inferred that present multi-component weight management interventions could not bring in more benefits that no provision of treatment. The feasibility of the intervention is not limited since multi-component interventions can be designed practically. The appropriateness is also justified since a comprehensive approach is outlined through multi-component interventional approach. The effectiveness is however limited since there is no strong evidence of the benefits of the intervention. As compared to no intervention, the multi-component intervention does not bring in any added benefits.

Involving Service Users and Stakeholders

Best practice 

Individuals with learning disabilities are found to be facing varied challenges in relation to maintaining a healthy living. A nurse working in the domain of learning disability is responsible for bringing improvement in the person’s mental and physical health, and maintaining the same. Further, there is a need of reducing key challenges faced by individuals in living life in an independent and healthy manner (Brown et al. 2017). Supporting individuals with learning disabilities to prevent obesity requires nurses to work in hospital wards, mental health settings, community centers, residential centers and patient’s home. It is crucial that nursing practice in this domain is based on evidences gathered from existing pool of literature (Murphy et al. 2017). The best practice for addressing obesity management in individuals with learning disability is delivery of information on diet, physical activity and behavior change. Through this intervention nurses can help the individuals to lead a better quality of life through prevention of co-morbid conditions. Further, individuals can lead an independent life with sufficient knowledge gained on how to combat and manage obesity.

Analysis of the factor that would promote to inhibit implementation

The main resources that will help to bring the change towards proper implementation of the weight management program for overweight or obese individual with mild to moderate learning disability include a dietician who are specialised in learning disabilities (Beeken et al. 2013). This trained dietician will provide training to the professionals who will then assist on delivering comprehensive Shape Up program along with usual care interventions (Beeken et al. 2013). Shape Up program is to be placed over 1 day followed by another half day of observation program under the community settings via a trained dietician (Beeken et al. 2013). So a trained dietician is another resource that will be important for successful procurement of the intervention. The usual care will be procured by facilitator and these facilitators are also required to be trained in order to procure quality care to the individuals with earning disability (Ptomey and Wittenbrook 2015).

Barriers in delivering the best practice

Difficulty in establishing rapport with the individuals with the learning disability (LD) may create a barrier with the successful implementation of the best practice. This is because; lack of development of rapport will lead to non-comprehensive participation in the Shape Up program. So in order to increase the rapport with the individuals with learning disability prior to the initiation of the program, it is the duty of the care giver to indentify the emotions of the individual with LD (Fisher and Byrne 2012). Practising this will help to increase the emotional engagement of the care givers with the individuals of LD and thereby helping to increase the rapport and subsequent care procurement (Fisher and Byrne 2012). Another barrier towards successful implementation of the best practise include conveying of the each session message to the individuals with LD. This is because, individual with LD experiences difficulty in reading comprehension and this creates a barrier towards successful conveyance of messages (Cornoldi and Oakhill 2013). In order to overcome this barrier, proper pictorial illustrations must be used with along other info graphic messages written in simple sentences (Lewis, Wheeler and Carter 2017). This simple representation of the messages will help individuals with LD to easily understand the procured messages and then abide by it according or to follow the instructions (Lewis, Wheeler and Carter 2017).

Conclusion

Application of Change Management

Lewin’s Change Management Model

Kurt Lewin’s Change Management Model mainly entails creation of a perception that a change is required and then progressing towards the new or the desired domain of change and then finally sealing the new change as a current norm (Sarayreh, Khudair and Barakat 2013). This change management model is subdivided into three steps including unfreezing, changing and refreezing (Sarayreh, Khudair and Barakat 2013). Unfreezing step is the initial step of the change management which mainly deals with the process of generation of awareness regarding the importance of change. The way of conveying the message of importance of change is communication (Cummings, Bridgman and Brown 2016). After the importance of change or the requirement o change has been established, the nest step that will be followed is the changing step (Shirey 2013). This is the step where the main changes or revamp will be done. This step is also popularly known as “transitioning” or “moving” stage which is marked via the implementation of change. This is the hardest ad the difficult stage of the change management process as this step deals with uncertainty of the outcome or the fear of the unknown outcome. So in order to deal with the uncertainty, communication supports are critical and this support must be planned carefully and then executed (Burnes and Cooke 2013). Through this process, the participants of the change should be continuously remained about why the change is important for them and how they will get benefited (Burnes and Cooke 2013). Refreezing is the last step of the change management process and it symbolizes the act of reinforcing; solidifying and stabilizing the new state achieved after the change implementations (Jabri 2017). This step is especially important in order to ensure that the participants of the change management do not get revert back to the previous state. Efforts must be taken so that the change does not get lost (Jabri 2017).

Lewin’s change management in the context of the best practice

According to Ali et al. (2012) the individuals with LD are unaware of their health conditions and are devoid of awareness about the importance of maintaining god health. Cook, Li and Heinrich (2015) is of the opinion that the LD individuals who are overweight or obese, not only become more prone to social bullying but also become susceptible towards developing complex diseases like the cardiovascular disease, type 2 diabetes and these decrease their quality of life and life expectancy. The step of unfreezing will mainly deal with educating the individual with LD with the importance of maintaining a normal weight: height ratio and how with health-wellness is going to improve their quality of life. This education in the domain of importance of weight management should be done via the use of the power point presentation filled with pictorial representation and simple sentences (Baxter et al. 2012). The interactive yet attractive communication style will not only generate interest among the obese LD individuals but will also help them to understand that extra pounds of weight are creating a barrier towards healthy living (D'angelo et al. 2013). However, before making them understand the important of healthy weight, it will be the duty of the care giver to make rapport (emotional connect) with the individual as this will facilitate later stages of communication (Nind and Hewett 2012). Generation of awareness about the requirement of change will create an urge to change and that will be best step to implement the step (Viswanathan, Chen and Pompili 2012). The implementation of the change will be done via comprehensive application of the Shape up L-D program as discussed in the paper Beeken et al. (2013).

This implementation of the program will be done under the proper supervision of the professional dietician and trained facilitator who will help the individual with LD to indulge into mild to moderate physical activity (Taggart, Coates and Truesdale?Kennedy 2013). Throughout the entire change implementation stage, the participations will be encouraged and motivate regarding how a proper weight will help to attain a healthy social life free from the disease burden (Grondhuis and Aman 2014). Further support will also be requested from the family members as it is the family members over whom the individuals with LD rely upon and have faith. So motivation coming from the family members will help individuals with LD to stick with the change management program (Taggart et al. 2012). The freezing stage will most deal with evaluation of the outcome of the intervention (shape up LD). The positive outcome of Shape up LD (that is weight loss) will then be used motivate the individuals with LD to stick to this healthy lifestyle (proper diet and physical activity) during the later stages of their life. Moreover, the family of carers will also be trained so that they can assist this individuals with maintenance of healthy lifestyle via helping them to participate in daily physical activity and healthy diet (freezing the change) (Spanos, Melville and Hankey 2013).

Involvement of the service users and stake holders

The main service users are the individuals with LD. The involvements of the service users in the change management process will be done via establishment of the emotional connect. According to Ahmad et al. (2014), establishment of the emotional connects will help the service givers to understand the weight related inhibitions and associated complications from their (LD individual) personal perspectives. In doing this, personalised motivational plan for weight loss can be easily generated. Other stakeholders in this process will include the family members of the service users. Their involvement will mostly be achieved via education program which will be designed to generate the awareness about the physical complications associated with obesity and the main reason behind the weight gain among the individuals with LD. The educational program of the family of carers will also include their (family members) in the weight loss process and how they can serve as the strength of pillar for individuals with LD (Arnold, Heller and Kramer 2012).

 

 

Conclusion

Thus, from the above discussion it can be concluded that the best intervention for the control of obesity and weight gain among the individuals with LD is delivery of information on physical activity, diet and behaviour change methods . This best intervention can be procured under the guidance of professional dietician and trained care givers. However, in order to generate awareness among the individuals with LD, effective communication along pictorial representation of data is crucial. This will help the individuals with LD to quickly understand the consequence of obesity and thereby generating awareness to participate in the intervention process. Apart from awareness generation, further involvement in the intervention program can be generated via establishing emotional contact with the individuals with LD. The participation of associated stakeholders can be similarly done via education and awareness program. The entre change management of the best practise interventions will be done as per the steps of the Lewin’s change management model while taking into consideration of the associated barriers.

 

References

Ahmad, N., Ellins, J., Krelle, H. and Lawrie, M., 2014. Person-centred care: from ideas to action. Health Foundation.

Ali, A., Hassiotis, A., Strydom, A. and King, M., 2012. Self stigma in people with intellectual disabilities and courtesy stigma in family carers: A systematic review. Research in developmental disabilities33(6), pp.2122-2140.

Arnold, C.K., Heller, T. and Kramer, J., 2012. Support needs of siblings of people with developmental disabilities. Intellectual and Developmental Disabilities50(5), pp.373-382.

Baxter, S., Enderby, P., Evans, P. and Judge, S., 2012. Barriers and facilitators to the use of high?technology augmentative and alternative communication devices: A systematic review and qualitative synthesis. International Journal of Language & Communication Disorders47(2), pp.115-129.

Beeken, R.J., Spanos, D., Fovargue, S., Hunter, R., Omar, R., Hassiotis, A., King, M., Wardle, J. and Croker, H., 2013. Piloting a manualised weight management programme (Shape Up-LD) for overweight and obese persons with mild-moderate learning disabilities: study protocol for a pilot randomised controlled trial. Trials14(1), p.71.

Beeken, R.J., Spanos, D., Fovargue, S., Hunter, R., Omar, R., Hassiotis, A., King, M., Wardle, J. and Croker, H., 2013. Piloting a manualised weight management programme (Shape Up-LD) for overweight and obese persons with mild-moderate learning disabilities: study protocol for a pilot randomised controlled trial. Trials, 14(1), p.71.

Brown, M., Surfraz, M., Wroldsen, R., Popa, D. and Grung, R.M., 2017. Improving healthcare access for people with intellectual disabilities in four European countries. Learning Disability Practice, 20(6), pp.36-42.

Burnes, B. and Cooke, B., 2013. Kurt Lewin's Field Theory: A Review and Re?evaluation. International journal of management reviews15(4), pp.408-425.

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