This chapter presents findings from the articles that matched the inclusion criteria. It will introduce evidence found via literature search described on ‘Chapter 2: Methodology’. Therefore, this chapter presents the evidence on the health promotion interventions for obesity in adults with ID; and its effectiveness. It also includes some of the key limitations found by the researcher/s that carried out each of the discussed reviews. The documents reviewed had directly and indirectly the same point: to be designed aiming to reduce and tackle obesity in people with ID. Nine studies met the inclusion criteria. Furthermore a systematic and an integrative literature review were focused on obesity and people with ID.

One systematic review was focused on weight loss interventions for people with ID and was written by Hamilton et al. (2007). It includes programmes that focus on nutrition, physical activity or health promotion (education). From the research five studies will be presented in this chapter. The other documents reviewed could not be included in this piece of work as Hamilton et al. included the review of five outdated studies, in which three were undertaken in the 1980s. The approaches to the management of obesity for people with ID discussed in the systematic review included behavioural approaches, and surgical interventions including gastric bypass surgery and pharmacological treatment. However, relatively few researchers have examined the effectiveness of weight loss interventions for adults with ID.

One paper was an integrative literature review of interventions designed to reduce obesity in people who have ID was written by Jinks et al. (2010). The paper is a review of the effectiveness of non-surgical, non-pharmaceutical interventions designed to promote weight loss in people with ID. It also discusses how qualitative evidence on people’s experiences and motivations can help understanding of the quantitative research outcomes. An integrative review method was used and synthesis of the findings related to study design, participants, and types of interventions, outcome measures and participant perspectives. Twelve studies met the inclusion criteria, seven of these studies will be presented in this chapter as it met the inclusion criteria of this research. Interventions presented by Jinks et al. (2010) that included as participants people without ID and focused only in adolescents were excluded. The majority of the interventions discussed were focused on energy intake, energy expenditure or health promotion. Just a small number of studies incorporated behaviour modification approaches.

The nine studies to be discussed in this chapter were undertaken in different settings (supported and non-supported living, day centres, group and residential homes). The majority of the researches were undertaken with population from the United Kingdom (three studies) and United States (five studies) with the exception of one study from Taiwan. Sample sizes of the intervention studies varied in numbers of group of 6 to 201 participants. The preponderance of the studies used samples of people who are considerate to have mild to moderate ID. One study (Rimmer et al., 2004) focused only on people with Down syndrome. Most of the groups were of mixed gender, only Bradley (2003) that included only women in the study. The age of the participants that undertook the researches varied a lot. All participants were aged 16 years or older. None of the studies were focused only with elderly participants, although one study had participants of ‘ageing group’, meaning individuals older than 32 years of age. A summary of these findings are presented on the next page on Table 4.

Table 4. Study description, sample and findings.

Study

Description

Country and Settings

Sample

Findings

Aronow and Hahn (2005)

One year multi component intervention

US.

Non-institutional settings.

201 adults (mild to moderate ID – 59% overweight/obese)

Health risks = decreased

Health strength=

increased

Bradley (2005)

One year nutritional and physical program.

UK.

Supported living settings.

09 women (mild ID – 8 obese)

Weight loss

8 of 9 having breakfast regularly

Healthy diet=increased

Chapman et al. (2005)

One year multi-component intervention

UK.

Day centre.

Input group 38 adults (97% overweight/obese)

Nor input group 50 adults

(64% overweight/obese)

Input group=significant weight loss

Non input group=

Non significant weight loss

Mann et al. (2006)

9 week health promotion program.

US.

Independent and supported living settings.

192 adults (mild to moderate ID) all overweight/obese

Highly significant decrease in BMI

Marshall et al. (2003)

6 to 8 week health promotion intervention promoting weight loss. Modifies Active’ materials including information on exercise and healthy eating.

UK

Day centres.

25 adults with ID

(17 overweight/obese)

Weight reduced significant

Podgorski et al. (2004)

12 week physical activity intervention promoting weight loss. Follow-up of one year.

US.

Day Centre.

15 older adults (40 – 80+) (mild to severe ID) 10 overweight/obese

Physical fitness scores improved

Rimmer et al. (2004)

12 week physical activity intervention promoting weight loss. Fitness program of 3 sessions a week lasting 45 minutes.

US.

Supported living settings and Group homes.

52 adults with Down Syndrome (69% overweight/obese)

Small but not statistically significant weight reduction

Sailer et al. (2006)

10 week weight loss program

US.

Human services centre.

6 adults (mild to moderate ID – all obese).

Moderate weight reduction

Wu et al. (2010)

6 months physical activity intervention promoting weight loss. Fitness program of daily 45 minutes sessions.

Taiwan.

Disability Institution.

146 adults with ID

(47.9% overweight/obese).

Decreases in individual’s weight

The types of intervention of the studies varied from a range of categories. Some studies focused on nutrition (Sailer et al., 2006), physical activity (Rimmer et al., 2004; Chapman et al., 2005; Wu et al., 2010) and mainly health promotion intervention (Aronow and Hahn, 2005; Marshall et al., 2006). A study included the use of behavioural relapse prevention strategies (Mann et al. 2006). Another used mainly behavioural approaches and concentrated on teaching self-control techniques and self-monitoring of food intake (Sailer et al. 2006). The majority included educational programmes planned to increase understanding of the significance of having and keeping a healthy lifestyle. To obtain improved understanding, some of the studies involved activities that were intended to improve participants’ life skills. These studies included, for example, visits to supermarkets, food preparation and food-tasting sessions (Bradley, 2005), and health fairs and a ‘Shop, Cook and Eat’ initiative (Chapman et al., 2005).*

The types of interventions were a large combination and examples of different interventions tackling obesity. A variety of professionals apart from the researchers were involved in the process and delivery of the interventions.

The BMI was the most common outcome used in the studies to diagnose obesity and outcomes. Even though two researches (Podgorski et al.,2004; Sailer et al., 2006) used as measurement the total body weight. Waist measurement (Bradley,2005), cardiovascular

Results of studies with weight reducement:

Every nurse has the responsibility to safeguard their patients from harm and the NMC (2009a, p.14), states that “it is every adult’s right to live in safety and be free from fear and abuse”. There are a number of individuals who can be classed as a vulnerable person, these individuals can be either children or adults. A vulnerable adult is someone who is over 18 years old and meets any one of the following criteria: is receiving any form of healthcare or welfare service, needs assistance to carry out daily activities, unable to take care of him or herself and is unable to protect him or herself against harm. (DoH, 2009, Section 59)(DoH, 2000, p.8-9). Older people are generally regarded as vulnerable adults because of their general poor health and their high dependency on others to help with daily activities. In Peter’s case, he is not very young, is inclined to be forgetful and has mobility issues and therefore has the high probability of requiring help at home to help with his independence. All of these issues combined could have serious impacts on his health and safety which would mean that Peter could fit into each, if not all, of the mentioned categories and therefore he should be regarded as a vulnerable adult.

The Independent Safeguarding Authority (ISA) is responsible for the vetting and barring of any individuals who may come into contact with or work with vulnerable individuals (ISA, 2009, p.3). The ISA have an Independent Barring Board who are responsible for maintaining two separate lists, one for the protection of children and the other for the protection of vulnerable adults, which contain the names of any person who has been referred to them for the harming of any vulnerable person (ISA, 2009, p.3). The harming of a vulnerable person, whether it be physical, verbal, psychological, emotional, financial or neglect, is regarded as abuse. Vulnerable adults may be abused by a wide range of people, including family members and abuse can be in the form of a single or a recurring act. As Peter’s daughter wants him to have the surgery the nurse will have to establish whether there is an underlying reason for this. Assessment of this situation would be essential because intimidation or coercion, which are both forms of psychological abuse, may cause Peter to be incapable of making his own decisions (DoH, 2000, p.11). As such, if this was assessed to be abusive behaviour, it would be important to remove Peter away from his daughter as the nurse has a duty of care to ensure that her patient remains safe at all times (NMC code??).

Nurses have a professional responsibility to their patients, are accountable for their actions when the patient is in their care and have a duty of care to ensure that the patient receives good quality care at all times (NMC code 1.4???). Every nurse must always ensure that they work within their abilities and should raise any concerns, to a senior member of staff, if they have been asked to perform any duties which they are not competent in performing and therefore may potentially cause harm to the patient (NMC, 2009b). Reasonable care must be taken to avoid acts or omissions which are likely to cause reasonably foreseeable harm to whomever a duty of care is owed (Dimond, 2008, p.40). If the nurse does not provide sufficient care to the patient and causes harm as a result, she will be held liable in the tort of negligence (Tingle & crib, p.92??), which is a civil wrong for the breach of duty to take reasonable care not to injure or harm a person. In order to be held liable in the tort of negligence it must first be proven that the nurse owed a duty of care to that patient, next the claimant must prove that there was a breach in this duty of care and then it must be proven that the damage being claimed for was caused by this breach of duty (Tingle???). The Bolam Test is the test which is used to determine a breach of duty and is concerned with how negligence should be established (Legal aspects??). It does this by testing the standard of care which should be given from a professional and comparing it to the standard of care which was actually given in the cases of the alleged negligence (????).

Accountability means being “responsible for something or to someone” (NMC, 2002, p10). According to Dimond (2008, p.5), registered nurses are held accountable to the patient, the public, their employer and their profession, and these are known as the four arenas of accountability. Where the registered nurse is accountable to the patient and the public, she is accountable to the law and accountability to her employer means she is responsible for keeping to her contract of employment and failing to do so may result in a hearing in front of the employment tribunal. Professional accountability assumes that the nurse is a member of the profession and that she has accepted the rights, status and responsibilities of the profession (foundations, p.473????). The NMC (2002, p.3) suggests that professional accountability involves using knowledge, skills, experience and professional judgement in order to make decisions which are in the best interests of the patient and should be able to justify the reasons for her decisions. This implies that nurses, as professionals, are competent in their area of practice, which allows the patient to gain trust in the nurse and enables the nurse to be able to act in the patient’s best interest (foundations, p.473??). Therefore, nurses have a duty of care to those they care for and as such, this implies that there is a right and a duty attached to professional accountability.

Registered nurses must follow the guidelines within the Code of Professional Conduct and as such should be legally accountable for their work (NMC, 2009b) and will be brought in front of the Fitness to Practice Panel, and possibly removed from the register, for unprofessional behaviour that breaches the Code of Conduct (Brooker and Nicol, 2003, p.6). This is different for nursing students, as they are only accountable to their employer, in this case the university, and the law. It is not possible to hold students professionally accountable as their names have not yet been entered onto the professional register however the NMC states that students are still responsible for their actions (NMC, 2010, p.1). From this it must be said that it will be the registered nurse who is mentoring, or working with, the student that can be held accountable for the student’s actions or omissions as it is their responsibility to ensure that the student is working within their abilities (Brooker and Nicol, 2003, p.7).

Nurses are fundamentally responsible for the promotion and restoration of health, the prevention of illness and to ease suffering for their patients (Hendrick, p.76???), however nursing is not just about treating a patient’s illness; it’s about caring, teaching and supporting a patient at a time when they need it the most. This can be done if the nurse makes building a nurse-patient relationship with her patient a priority in the patients care. Communication is a necessary foundation for any nurse-patient relationship to be built appropriately and there are a number of ways in which people can communicate such as verbally, non-verbally, written or electronically. The nurse should always communicate with the patient at their level of understanding and should always avoid using medical jargon when speaking to the patient (NMC???). Effective communication is not just about talking, it involves active listening too and is an essential key in building a trusting relationship with the patient. Different communication techniques could be used between the nurse and the patient which include observing, listening, silence and open-ended questions (Brooker and Nicol, 2003, p.46). Without the appropriate use of these different communication techniques the relationship will not have a base to build on and if there is no relationship, the patient will not have the trust required for them to share their feelings, anxieties or wishes. In our scenario, Peter has opened up to the nurse by telling her how he is feeling and has put his trust in her to help him make the decision as to whether or not he should have the surgery. In this situation communication is the vital key as it is important that Peter is given open, honest, accurate and unbiased information about any procedures or assessments that will be carried out and the nurse must ensure that he fully understands the benefits, risks, side effects and consequences of these procedures (???). The patient should be consulted every step of the way which will enable them to remain autonomous.

All healthcare professionals should have a respect for their patient’s autonomy and should treat their patients as individuals, with rights, rather than objects of care (Hendrick, p.95??). Autonomy is the right of the person to make their own decisions and accepting their choices. One way in which a patient can exercise their autonomy is by giving consent and as such, autonomy is a requirement for consent (tingle & cribb, p.143??). Consent can be given in different forms such as expressed or implied. Expressed consent can be either written or verbal and this can be given by the means of a written and signed consent form or by word of mouth. Implied consent can be a simple gesture, such as holding their arm out for an injection or by arriving at the hospital for an operation. Each form of consent is as equally valid as the other however, consent is only legally valid if it is given voluntarily, based on clear and accurate information and if the patient is competent (tingle and mchale, p.100-105??). Gillan (Tingle and Cribb, 2007, p.140) defines consent as “a voluntary un-coerced decision made by a sufficiently autonomous person on the basis of adequate information to accept or reject some proposed course of action that will affect the patient”. This definition suggests that communication, autonomy and consent are intricately liked as effective communication is important because you must give adequate, open and honest information to the patient in order for the patient to fully understand and consider all the issues involved, which will enable the patient to be able to make an autonomous decision and ultimately be able to give consent. No other person is authorised to give consent, for any procedure or treatment, on behalf of another adult unless they are the legal power of attorney for the patient (legal aspects???).

Gillan’s definition of consent states that consent can only be given by a sufficiently autonomous person. The DoH states that healthcare professionals must not make any assumptions that a person is incapable of making their own decisions, therefore they should carry out an assessment which would assess whether the individual is mentally capable of making these decisions for themselves. Autonomous decision making is therefore based on the matter of ‘capacity or incapacity’ (foundations p.500??). The term capacity is used to define the individual’s ability to make their own decisions about a particular matter at a particular time (Legal aspects???) and, as autonomy is the basic foundation for consent, if incapacity is suspected the individual is therefore not allowed to give consent until they are deemed competent.

The Mental Capacity Act 2005 states that healthcare professionals are required to assume that every person has the capacity to make their own decisions and that the healthcare professional has to prove that the individual has a lack of capacity and must then be deemed incompetent (tingle and crib, p.143??). Deciding whether a person has the capacity to make informed decisions for themselves is determined using the assessment tools defined in the Mental Capacity Act and cannot be established or judged by an individual’s age or appearance (The Mental Health Act section 2 and 3??). There are two basic concepts that underpin the Act these are: the concept of capacity and the concept of best interests (Legal aspects???). Both of these concepts link together and as such, if the patient lacks mental capacity actions can be taken or decisions can be made on their behalf and these must be made or taken in the best interests of that person. The assessment used to determine whether a patient is capable of making a treatment decision is split into two stages: the first stage is to determine whether the patient has any issues which prevent them from making a decision, and the second is to establish if this issue which prevents the patient from making a decision causes the patient any problems in communicating their decisions or wishes (Legal aspects???).

A person is not able to make their own decisions for themselves if they are not able to understand any of the information given to them, remember the information, utilise that information as part of the decision making process and are not able to convey or share their decision (Legal aspects???). However, if the information is not given to the patient in a way that is appropriate to his circumstances such as using simple words or visual aids, they are not to be judged as unable to understand that information (legal aspects, p.139???). Additionally, if the patient has a short memory span and can only retain information for a short period, they must not be classed as unable to make their own decisions, as this issue may not prevent them from being able to make the decision relevant to the treatment (legal aspects, p.139???). In such instances this decision must be made whilst the information is still held within the patient’s memory. From this is must be said that every person should be encouraged and enabled to make their own decisions or to participate as fully as possible in the decision-making, by being given the help and support they need to make and express a choice (NMC, 2008a).

In this scenario it states that Peter has an inclination to be forgetful, because of this he must not automatically be deemed incompetent and it is vitally important that all the steps required to deem a person incompetent must be taken into account. One of the steps suggests that even though the Peter has a short memory span, it is vital to ensure that the information given is understood clearly and that the decision is made before the he forgets. This would enable Peter to give informed consent, however if he forgets this information and has not made an informed decision before his memory span lapses he must be deemed incompetent. From this we can establish that it is important to have the necessary mental capacity as it protects the individual’s right to make their own decisions (legal aspects??). If the individual is lacking in capacity then decisions need to be made on their behalf and these decisions that are made on behalf of someone else should be the decisions which limit the person’s basic rights and freedoms the least (legal aspects mc???).

The Human Rights Act 1998 ensures that individual’s rights are respected and that basic human rights such as the right to life, the right to not be discriminated against, the right to liberty, and the right to freedom from torture or degrading treatment and the right to respect for private and family life, home and correspondence are promoted (Human Rights Act 1998??). These rights can be promoted by providing high standard of care and treatment, respecting a patient’s privacy, dignity and confidentiality and by safeguarding the patients from harm. A person’s rights and freedoms are protected and promoted by the nurse when she acts as an advocate for them. Being an advocate for the patient is vitally important as it ensures that the patient’s choices and decisions are respected.

The nurse can act as an advocate in many different situations such as, offering an alternative explanation, or asking the other professionals to give the information again in basic terms, if the nurse feels that the patient has not been given clear, honest and adequate information. (NMC??). Another way for the nurse to act as an advocate is to try to adhere to the patient’s wishes if the patient was proved to be incompetent; if this is not possible then she must act in their best interests. As Peter has asked the nurse in this scenario to help him make the decision as to whether or not he should have the surgery, he is putting his trust in her and allowing her to become his advocate. However, until all the necessary steps have been taken to ensure whether Peter has understood what he has been told and once his mental capacity has been assessed, no other person can make this decision for him, unless he was deemed to be mentally incompetent. If he was deemed to be incompetent the decision as to whether he has the surgery or not will be made by the healthcare professionals, unless his daughter has lasting power of attorney, and will be based on his best interests. The decision that is likely to be made is that Peter will go ahead with the surgery, as this is in his best interests and will improve his quality of life. If Peter is deemed competent, then Peter should make the decision for himself and his decision will be final. If Peter decides not to go ahead with the surgery, then Peter’s home life would need to be assessed.

Inter-professional working is required in order to care for the patient holistically. Holistic care is primarily concerned with ensuring that the patient’s basic needs are met (NMC, 2009a, p.9) and making sure that any observations, medications and decisions are recorded accurately (NMC, 2008b, p.6). A nurse’s role also includes supporting and teaching the patient and their families about the illness or about improving their lifestyle to prevent the illness from re-occurring. It is extremely important that the nurse develops a close working relationship with these other multi-disciplinary professionals, as Peter will need support when he gets home whether or not he has had the surgery. The range of other professionals which may be involved in Peters care when he gets home include social workers, occupational therapists and physiotherapists. It may be possible that Peter’s daughter may be pushing for Peter to have the surgery as she may be his primary carer and might be feeling stressed or overworked and if this surgery can improve his mobility, this may offer her some form of relief. If this is the case, the nurse could arrange for a carer to help them within their home and that way Peter’s daughter may get some relief from the work involved in his care. In this case, the nurse can act as an advocate to ensure that the decisions are not being made for him or that he is under no undue pressure or being forced to make the decision.

Being an advocate for a patient implies that there should be a level of trust between the nurse and the patient and this level of trust can be built up through a therapeutic relationship. Therapeutic relationships are an intervention which is central to nursing and a nurse should have an essence of self-awareness and self-knowledge and have an awareness of the boundaries of the professional role in order to be able to establish a therapeutic relationship with their patient. Effective communication, trust, respect, genuineness, acceptance and empathy are key principles in establishing this relationship (Brooker and Nicol, 2003, p.45). When this relationship has been established the patient may feel at ease to share information and have a willingness to open up and share their feelings (Dossey and Keegan, 2008, p.370). Establishing and maintaining this nurse-patient relationship is vital to the holistic care of the patient and even though the nurse should develop a close relationship with the patient in order to open up communication barriers she must always keep and emotional distance from the patient and their families. It is the nurse’s responsibility to ensure that she never oversteps the professional boundaries throughout the care of the patient (NMC Code).

In conclusion it has been established that in order for a patient to be given high quality, safe care a nurse needs to have the appropriate skills and knowledge to be able to perform the even the simplest of tasks competently. This assignment has briefly looked at the importance of a therapeutic relationship with communication being one of the vital keys, as without using it effectively it will be difficult to bond and build a professional relationship with the patient. It has also been identified that every nurse has a duty to protect their patients, that they should safeguard their patients and promote their rights and autonomy. It is vitally important that the nurse has the confidence to speak up to other professionals if she feels that the information hasn’t been delivered to the patient honestly, accurately or clearly, otherwise she could be held accountable if something was to go wrong. The importance of the guidelines and codes issued by the NMC, have also been discussed, as they are in place to help protect, not only the patient, but also the professionals who are involved in the patient’s care. One of the guidelines which has been focused on, is for the nurse to make sure that the patient has given informed consent without any undue pressure and that the nurse, acting as the patient’s advocate, can help protect the patient. We have also looked at the importance of using assessment tools to assist in decision making process as this is used to identify whether the patient has the capacity to give consent or not. We have established that all health care professionals need to work together as a team and must communicate, not just with each other, but with the patient and his family to ensure patient’s needs are met and that every patient should be awarded the opportunity to live independently or be offered help and support from the necessary health care professionals to enable the patient to live as independently as possible.

NuRS21010 Understanding Evidence-Based Nursing Practice

Concept	Terms	Boolean Operator	Hits
Population: Childhood	Childhood, young people, children, child, youth.	(Childhood obesity or young people or children or child or your ) and health promotion or cognitive behavioural therapy	38
Intervention: health promotion	Health, promotion,	(Childhood obesity or young people or children or child or your ) and health promotion or cognitive behavioural therapy	21
Comparison: Cognitive Behavioural Therapy	CBT, behavioural, behavioural	(Childhood obesity or young people or children or child or your ) and health promotion or (cognitive behavioural therapy or CBT )	17
Outcome: obesity	Obese, weight gain.	(Childhood or young people or children or child or youth ) and ( obesity or obese or weight gain) and health promotion or (cognitive behavioural therapy or CBT )	11

Which is more effective in reducing childhood obesity health promotion or Cognitive behavioural therapy?

Concept	Terms	Truncate	Hits
Population: Childhood	Childhood, young people, children, child, youth.	Child* obesity health promotion or cognitive behavioural therapy	26
Intervention: Nurse led health promotion	Health, promotion,	Child* obesity and health promotion and cognitive behavioural therapy	15
Comparison: Cognitive Behavioural Therapy	CBT, behavioural, behavioural	Child* obesity health promotion or cognitive behaviour* tharap?	10

The first part of my essay will be based on the evaluation on my question this will include looking at the strengths, weaknesses and how I could improve it if I were to do it again.

I wanted to research the question: which is more effective in reducing childhood obesity, health promotion or Cognitive behavioural therapy? As I find the topic childhood obesity really fascinating especially with the current national epidemic of childhood obesity. This made me realise that it’s a concerning health issue so I wanted to explore the possible interventions which were available for those suffering from childhood obesity. To do this I compared one of the most common interventions (health promotion) to one of the emerging interventions being used to treat childhood obesity (cognitive behavioural therapy). I used the CINHAL database for my literature search as it provides indexing of the top nursing and allied health literature (CINHAL, 2013) and offers information relevant to my question.

When researching I used truncation I decided to truncate the terms in my research question as I wanted to collect the information which was relevant to my question rather than irrelevant data, as it did not correlate to my question. This worked as each time I truncated I was able to gather data which related to my research question so this was beneficial mechanism when gathering relevant data.

A research mechanism which I used was the Boolean operator to help me find appropriate literature. Boolean operators utilise the terms: “and”, “or” and “not” to restrict, increase, or narrow searches depending on Boolean logic, which describes how Boolean operators manipulates large sets of data (Barker et al 2011).Boolean operators link keywords and phrases this informs the search engine how to interpret the search, which helps identify the results the researcher is looking for (Barker et al 2011). By utilizing the Boolean operator it helped narrow my search and provided me with the literature which was relevant to my research question. Because at first when I researched I got a lot of hits but a majority if the literature was irrelevant and therefore not required, but by using the boolean operator it allowed me to access specific literature for my research question.

I think I could have improved my research question by making my research question more specific for instance instead of childhood obesity which is a very large age group I could have narrowed it down to teenagers. As this will give me a sense of direction when looking for supporting literature as it’s a specific age group this can be supported by Sackett (2000) who sates that by asking a precise question you can look for specific knowledge for chosen research topic.

Whereas with my current question I have a lot to cover as it looks at childhood obesity which is a broad age group, which makes it difficult gathering supporting literature. Another weakness is that although I gathered literature for my research question a majority of it was applicable to health promotion interventions in comparison to cognitive behavioural therapy in relation to childhood obesity. So to alter this I think I would have compared health promotional techniques to non-health promotion health techniques. This will ensure I get a balance of supporting literature between the comparisons, as there was little literature for cognitive behavioural therapy.

This part of the essay will critically appraise intervention for ineffective airway clearance in asthmatic children: a controlled and randomised clinical trial (Lima et al, 2013). The CASP tool (Guyatt et al 1993) will be used to achieve this.

1. Was the question clear?

The population that was studied was 42 asthmatic children age < 36 months. The applied treatments consisted of actions linked to change of positioning and stimulation of cough. The outcome of the research is the effectiveness of interventions for ineffective airway clearance (IAC) in asthmatic children (Lima et al, 2013). From this it is appropriate to say that the study asks a clearly focused question. It’s vital that research questions are clear. The question must emphasis the topic of interest and be presented in such a way that someone who is not an proficient in that field will recognise why the research was carried out (Blaikie, 2009).

2. Was this a randomised controlled trial?

The study used a randomised clinical trial (RCT). A RCT is where partakers are randomly allotted to one or more control groups this is determined by the number of interventions (Parahoo, 2006). Randomisation means allocating applicants to experimental or control groups at random so that partakers have an equal likelihood of being placed in either group (Lang, 1997). This eradicates selection bias and offers equilibrium amid recognised and unidentified confounding factors to make a control group similar to the treatment group (Akbong, 2005).

The method was apt for the question being researched as Machin & Fayers, (2010) states that RCT’s are the principal mode for defining the comparative efficacy and safety of substitute medical devices, interventions or treatments. This method is apt for the research as the question aimed to analyse the effectiveness of an intervention for the nursing diagnosis of ineffective airway clearance in asthmatic children. The study used this method to verify the effect of asthmatic of an intervention for asthmatic children. Lawrence et al (2010) RCTs are the finest for trials determining the impact of health interventions, they’re very robust and systematic for critiquing the efficiency of health interventions. Though there is a risk of bias when there are errors in the strategy and organisation of a trial (Akobeng, 2005).

3.Were participants allocated to intervention group and control groups?

The partakers were aptly allocated to intervention and control groups. As participants were allocated to groups via generating an algorithm of random numbers through the use of the R software (Lima et al, 2013). The inclusion criteria in the study were asthma identified by a doctor, based on assessment and physical existence defining features and linked factors termed in the NANDA international taxonomy age < 36 months. Participants with other illnesses were excluded (Lima et al, 2013). By using the NANDA international taxonomy indicates the study used stratification method to help allot the children into groups. The NANDA international taxonomy is a nursing board which offers paradigms for nursing diagnoses (NANDA, 2012). The intervention group had participants with a higher weight and age values in contrast to the control group. Randomisation can eradicate selection bias, but doesn’t promise that both the intervention and control group will be parallel in relation to key features of applicants (Chia, 2000).In research, vital prognostic factors are acknowledged prior to research. To ensure the intervention and control groups are alike a distinct block of randomisation lists for different mixtures of prognostic elements is made. This is stratified block sampling or stratification (Akobeng, 2005).

4. Were participants and staff blind to participants study group?

The team member who did the randomisation did not partake in the interventions or the outcome evaluation. This shows that the study used blinding which is vital as there is a threat in RCTs exploring the benefits of one intervention over an alternative as it can impact outcomes, causing influenced results. Blinding trials reduces bias, blinding refers to the exercise of stopping partakers, health professionals, and those gathering and examining data from knowing who is in the experimental group and who is in the control group, to avert them from being influenced by such knowledge (Day, 2000). Studies show that by blinding patients and health professionals avoids bias. Trials which didn’t blind bore more estimates of treatment effects than trials in which authors conveyed blinding (odds ratios overstated, by 17%) (Schulz &Grimes, 2002).

5. Were all participants accounted in conclusion?

All the participants in the study group were followed up for its conclusion. The participants in the control group did not get the option to be in the intervention group or vice versa.

6 .Were participants in all groups followed up and data collection in the same way?

All the participants were followed up in the study

.

The effect of the intervention was evaluated at a single moment, due to the obstruction of secretion as it reversed quickly and linked to working with other professionals (Lima et al, 2013).

7. Did the study have enough participants to minimise the chance of play?

The study used chi-squared test for power calculation. The test aims to test the hypothesis of no association between two or multiple groups, criteria and population (West, 2008). The chi test found P=0.061, statically significance was assumed at P < 0.05. (Lima et al, 2013). When looking for p-calculation the following should be considered: the size of the sample, the parameters of the substitute and null hypothesis i.e. how they differ, the significance or confidence level and the distribution of the parameter to be valued (Olbricht &Wong) .

8. What is the main result?

The study found an improvement in obstructive symptoms in those who took the intervention offered, with great alterations in the displays of choking and adventitious breath sounds. The generalisations may be limited as children in the intervention group show higher values for age and weight. The group also consisted of children under the age of 36 months thus likely to have asthma attacks (Lima et al, 2013). This may question the validity of the results found. The study also found there was little research in this topic making it challenging when trying to compare findings with other research (Lima et al, 2013). The study uses a small sample as there are only 42 participants in the study, so not really representative. Akobeng, (2005) argues that when a study uses a small sample of participants in it can be difficult identify the real variances of results found from both the intervention and control group. The study highlights the need for research on airway clearance techniques to assess the effectiveness of its use. The findings suggest studies to offer planned interventions during hospitalization to determine the link between the intervention and a decreased in the duration of hospital stay (Lima et al, 2013).

9. How precise are these results?

The study used Mann–Whitney test uses the findings of the t-test to identify variances amid two groups of habitually distributed population (Burns & Grove, 2005). The Mann Whitney test found that after the intervention, the intervention group showed greater improvement than the control group for the indicators of choking (16.83 vs. 26.17, P = 0.007) and adventitious breath sounds (16.4 vs. 26.6, P = 0.005). This illustrates that the detected variance between the groups is doubtful to have happened by chance hence the null hypothesises rejected due to no variance and the other hypothesis as there is an actual variance in the intervention group is taken into account (Akobeng, 2005).

10. Were all vital outcomes considered so the results can be applied?

The participants in the study are classified as asthmatic it doesn’t specify the type of asthma they have. Knowing they type of asthma they had i.e. chronic or acute asthma is beneficial as will illustrate if there is a different effect on a patient with certain type of asthma. For instance Schechter (2007) found that airway clearance therapy has little or no effect on acute asthma, so techniques used in this study may not be applicable for those with acute asthma. Airway clearance techniques requires training in order for patient or carers to carry it out correctly, this may be an issue for some as they may not have the funding or money for training.

In relation to parents and carers airway clearance techniques may be a barrier for them when implementing it to their child. As airway clearance techniques require equipment and considerable amount of time (Walsh et al, 2011) to carry out in order to ensure that it is carried out correctly and effectively on child. This can be an issue for parents and carers especially if they don’t have the time due to other issues such as work or taking care of other children.

According Pryor (2009) to policy makers and health care professionals in the UK, are less likely to utilise the intervention of airway clearance in asthma patients due to the uncertainty of the effectiveness of its usage in asthma patients this is also because of little research available on this topic. The study itself also mentions the lack of research available on airway clearance Walsh et al, (2011) techniques for asthma (Lima et al, 2013). Also found although airway clearance techniques have progressed over the years there is little research to illustrate the effectiveness of airway clearance techniques amid the child population who have asthma (Walsh et al, 2011).

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