Evidence based practice
Evidence based practice (EBP) is the knowledge base supporting an intervention. EBP consists of various pieces of research, studies and trials conducted to test the efficacy of an intervention. (Dawes et al 1999). An important role within nursing is the ability to access information in order to compile an evidence base to support practice or, identify any aspects of practice which could be improved to promote best practice. (Bowling 2002).
It is important that nurses are aware of the evidence and, actively seek to apply it to their own practice (Pearson 002), in the future it is hoped that more health care professionals will participate in and, conduct their own research, and be part of a research and evidence base led service. (DoH 2006). Beck (1998) (see appendix 2) recognized the need for an evidence base in the use of CBT in the management of anger control. He conducted a meta analysis of 50 study’s into CBT for anger management, and concluded that CBT is 76% more affective in the management of anger than no intervention.
This is supported by Ellman (2003) (see appendix 2) who conducted a randomised control trial on 69 male adulescents which he placed randomly in one of four groups. Three experimental groups and one control group. Each control group were to receive a one hour anger control session twice weekly for four weeks. The results which serve to strengthen the evidence base for Anger control concluded that the experimental groups showed a great deal of improvement compaired with the control group which showed no improvement.
Further support comes from Bradbury et al (2007) (Appendix 2) who found that participants who dropped out of Group CBT for anger control were at a higher risk of poor self-esteem and depression, as well as not benefiting from the improvements in anger control enjoyed by the remaining group. Galovski 2002 found that self-referal to anger management was more effective than referral by an external source. His study looked into the use of short term CBT to treat people with ‘road rage’the group was constructed of self-referrals and court-referrals of which the self-refferals made a greater improvement in general anger.
Novaco (1983) advocates the use of interventions in the control of anger and aggression. This model highlights the effect of external stressors and inappropriate coping mechanisms as a feature of dysfunctional anger. (Novaco 1983). Muir-Cochrane (2003) suggests some alternative oping mechanisms which can be suggested to the anger control group such as the physical exercise, keeping a diary (documenting the occurrence of angry feelings inc what time these occurred and what stressors were present which can help an individual to rationalize these feelings), relaxation methods and, seeking assistance when feelings persist.
This can be facilitated on a one to one basis or, as part of a therapeutic group. (Muir-Cochrane 2003). Analysis of the appropriate client group and setting for an Anger Control Group. Anger is a subjective emotional condition associated with physiological and cognitive arousal. A degree of anger is acceptable to an individual however, factors such as the frequency, length and intensity of the anger can cause it to become dysfunctional. (Novaco 1983).
The management of anger within the community is advocated in theory where possible as, hospital wards are unnatural environments(RCPRU 1998) and the rules and structure enforced within the ward environment can exacerbate feelings of anger and incidences of violence. (Sookoo 2004). A Cognitive Behavioural Therapy group (CBT) is ideal within this setting as members will achieve their goal/s by adopting more effective behaviour patterns which a counselor or facilitator can ssist with. (Johnson et al 2003).
This type of group is appropriate as members are there on a voluntary basis and have a shared goal which they can support each other in achieving alongside their individual goals. (Johnson 2003). The common goal within an anger control group is to address the frequency, duration and intensity of anger and aggression and, to reduce and sustain this at a functional level. An Anger Control group is an effective means of addressing and, overcoming incidences of dysfunctional anger and aggression however, members must appropriately placed in order for he intervention to be effective.
Criteria for an ideal anger control group member is someone who experiences one or more of the following:- *Explosive aggressive outbursts, *Overreaction of hostility towards insignificant others *Making swift, harsh judgements about people *Angry body language (clenched fists, glaring looks, refusal to make eye contact etc) *Passive aggressive behaviour (social withdrawal due to anger, complaining about authority figures behind their back, refusal to meet expected behavioural norms). *Verbally aggressive language. (Paleg 2005).
Anger control is not an appropriate intervention for a person who is violent or, currently abuses drugs or alcohol as these individuals have issues which need addressing before that of anger. (Paleg 2005). It is important that group members attend on a voluntary basis and are there having identified that they have a problem that they want to resolve and not solely at the request of others. (Galovski 2002). Ratigan (1998) identify 12 key questions for selection stressing the importance that the group is appropriate to each member and, the need for ground rules from the outset such as maintaining confidentiality.
Ratigan 1998). Anger Control is appropriate for use within community or outpatient based Mental Health services. The setting should be in a convenient location and time for group members. An adequate sized room is important with facilities (toilet, water etc) and should be warm enough and well furnished (enough chairs). It is important that the is not interrupted and, health and safety standards should be taken into account. (Hough 1998). Discussion and analysis of the theory underpinning stages of group development and group processes that needs to be considered prior to and during the facilitation of a group.
Humanistic Psychologist John Heron developed a six category intervention building on the work of Blake et al (1976) which outlined the skills a facilitator or leader could use when engaging with their clients. This framework has more recently been identified as an effective method of delivering clinical supervision and reflective practice. (Sloan 2001). The six categories of Heron’s framework are:- Prescriptive – Offering advice or guidance which may be influential or directive regarding a clients behaviour. Informative- Offering information which is relevant to the needs of the client. Offer information or instruction.
Confronting – to openly challenge a clients beliefs in order that they might see the full picture and make informed decisions. Cathartic – Guide the client through painful emotions that they are ready to deal with. Catalytic- Encouraging self exploration and problem solving. Supportive- Validation and conformation of the clients worth inc attitudes, beliefs, qualities etc. (Heron 2001). The use of these depends on the facilitators role and, they can be placed into two categories Authoritative (prescriptive, informative and confronting) and Facilitative(Cathartic, Catalytic and Supportive).
Heron 1989). Bion (Psychoanalysist and contempory of Klein) conducted much of his work in London during and following the second world, it was then that he developed a framework for understanding group dynamics which would be usefull for facilitators working within a group. (Hough 2006). Bion identified that as an individual may put up defences against reality so does the group. The term ‘basic assumptions’ was used to describe the use of defence and avoidence mechanisms within the group. (McLeod 2003). Tuckman (1965) developed one of the best known models for describing the group life process.
The model consists of five stages which the group will work through from their formation to the end of their adjouration. The stages are as follows:- 1)Forming. 2)Storming 3)Norming 4)Preforming 5)Ending (also known as mourning). Formation is the initial period where new relationships are formed. This is a time of caution for group members as their ego’s are concerned with forging relationships. A code of conduct within the group will start to develop as behaviour norms are tested and, the group will be dependent on it’s leading member. Storming occurs later as individuals form sub groups and, may be in conflict with the leader.
This will have a negative effect on the task achievement as morale declines. Norming follows the conflict stage that is storming. Conflicts will begin to subside and a feeling of order prevails. The groups common intrest of achieving their goal will increase. Preforming occurs as the group matures and forms a support system, focus is on the task in hand and, issues surrounding individual roles should have gone. Finally the ending stage will occur where the group have achieved what they set out to do. Members may reflect on past experiences and, may ‘mourn’ the ending of the group or, attempt to remain in contact with lliances.
Appraisal of the characteristics of my anger control group. The individuals within the anger control group knew each other prior to the intervention. This may have had some effect on the stages they went through as a group during the session. Group feedback suggests that the stage of forming (Tuckman 1965) was experienced by the group. Group feedback suggested that the introductions and icebreaker activity assisted with this. I did not observe this at the time and feel that the norming and preforming stages were more predominant throughout the session.
I had predicted that the group would be at the forming stage on comencement of the session and there for dependent on me as the leader, however this was not the case. This became apparent as I led the group into the icebreaker by taking the first turn to disclose information about myself. The group appeared at ease enough to disclose some personal facts and, had I took a step back may have followed this with a discussion which could have been beneficial. I observed the norming stage within the group fairly early on, during the discussion about symptoms of an anger control problem.
This in effect set a long term common goal for the group – that of reducing the frequency, duration and intensity of their anger. It was possible to observe this from the content of the groups discussions which were task orientated. An open extange of views and feelings ensued. Although there was no talk of ground rules I feel that the group adhered to some assumed rules. The group were supportive of each other and, listened to what each other had to say, there was little if any conflict. According to Aronson (1990) a good level of interaction between group members increases the attractiveness of the group to an individual.
This in turn results in a lower drop out rate. This supports the view that the group were at the Norming stage as those who are likely to drop out would probably have left by this stage. One group member asked me repeated questions in order to clarify the situation and move on. Hough 2006 suggests that this is a task role in that asking questions and direction fare task orientated. This is important within the group as stops the group from becoming stagnant as they may be in danger of at the preforming stage. This member was focused on the task and,
Reflection of my experiences facilitating an anger control group using Heron’s six category intervention as a reflective model. When facilitating the anger control group I feel that I took on an authoritative role according to Heron’s six category model (Heron 1989). This involved being more Prescriptive, Informative and Confronting rather that Cathartic, Catalytic and Supportive (facilitative). The planned session was highly informative in that it followed a rigid educational structure. The session began with introductions, followed with an ice breaker task as the facilitator nstructed the group to each disclose a fact about themselves.
This was referred during the group evaluation as being a positive intervention. It was commented that this made the group “feel welcome and, helped bring about the forming stage. ” This was an informative step as, the group were instructed to undertake this task. The session continued on an informative note as the facilitator went on to empower the group into symptoms of excessive anger. This was also intended to be confronting as it enabled individuals to fully acknowledge an uncomfortable truth which may apply to them as I felt that one r more of the symptoms listed would be experienced by most people during everyday life.
Group feedback highlighted that the use of an informative approach was good, however there was no mention of the use of confrontation. This leads me to feel that Confrontation was not affectively achieved in the therapeutic sense. This could highlight a lack of self awareness as my intentions were not percieved by the group. I can address any issues surrounding self awareness in the future utilizing a model such as the Johari window (Luft 1988). This is and ongoing process as it will enable me to continuously dentify weaknesses and seek to address them.
Following this there was some discussion where the group members were able to share their experiences regarding the symptoms listed. As the facilitator I disclosed my experience first as I hoped it would gain the trust of the group and, enable them to feel comfortable sharing their feelings. In hindsight however I feel that this was unnecessary, a more appropriate method could have been to suggest the topic, and allow a less structured discussion between group members where by I could observe and, intervine occasionaly to assist in the exploration of feelings.
One of the criticism’s the group made during feedback following the session was that I missed out on some opportunities to explore feelings. This would have been a Cathartic intervention which involves the exporation of painfull emotional feelings such as fear, grief or anger. This revelation made me question the session as, being an anger control session a facilitative role may have been more effective than the authoritative role I took on. The use of catharsis would have addressed the feeling of anger within the group and, may have been more relevant to the groups common goal.
Following the discussion I feel I intervined too soon by directing to the next activity I had planned. This could be as I felt nervous and keen to cover as much as possible, in the process neglecting the needs of the group. This was picked up on by the group as a negative factor “the facilitator appeared slightly nervouse on occasions. ” The activity that followed was a suggestion of alternative coping methods the group could use such as the use of a diary or journal to facilitate self-observation by documenting date, time, situation, emotional arousal level from 1-10.
The intention was that the group could use this data to eed back to the group each week and, hopefully the intensity frequency and duration of each instence of anger would be reduced. The intention was that this would lead to a Catalytic intervention in future sessions as self-exploration and problem solving occurred during discussion of the journals. The final activity I had developed for the group was a relaxation activity which the group could utilize in their own time as a means to de-escilate anger as early warning signs occurred.
This involved a breathing exercise with a cue word such as calm to focus on when inhailing and xhaling. The group responded well to this and, appeared more relaxed. Feedback suggests that the group enjoyed this exercise and, I made good use of voice and tone to assist relaxation. The over all feeling of the group was a positive one as people reported feeling more relaxed. Following this an open discussion occurred. One group member disclosed that she often felt guilt having lost her temper especialy with those closest to her. She asked me what could be done to avoid this.
Looking back I feel that this could have been an ideal opportunity to explore the eeling of guilt. I could have given her the means to solve this problem through self-exploration (Catalytic) or, assisted her to abreact the negative feeling (Cathartic) however I panicked and attempted to answer her question. This was inaffective and, I feel that I may have lost some of the groups trust as I may have appeared incompitent. In future if I find myself in this position I hope to admit that I don’t have all the answers and could use that opportunity to discuss with the group what they would do and go down the route of exploring feelings.
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