Aims: To highlight the vital contributions of mental health and learning disability nurses (LDNs) who render direct care services and support to those with complex needs, and to assess the impact of employed strategies, competence of workers, and usefulness of current research findings in health care.
Background: Mental health includes our psychological, emotional and social well-being which are determinant factors of how we think, feel or carry out our daily activities. This reflective essay focuses on mental health and learning disabilities; a critical examination of the assessment procedures; the impact of legal and ethical factors on the process; and contributions from the theory and practice of assessment techniques in the nursing profession.
Design: The study aims at identifying and presenting a quantitative report of the relevant issues encountered by healthcare professionals in satisfying the mental health needs of people with LD, including the basic skills and knowledge required by nurses as key stakeholders for coordinated assessment and effective care management.
Findings: The “less-scientific” nature of psychological treatments leaves researchers competing with neuroscience for the highly-sought-after government funding. Therefore, scholars in mental health need a boost through public donations, adequate remuneration and training of health professionals, and provision of conducive work environments for bright scientists to move in.
Conclusion: In partnership with other healthcare agencies, interprofessional teams and representatives of service users, LDNs make invaluable contributions toward helping affected individuals lead quality lives with as much independence as possible. However, it is worth noting that while the number of nurses has been decreasing, there’s a lot of work to be done through workforce planning if a successful balance of care is to be achieved in light of the unique individual needs.
Approximately 1.85 million people around the world were registered as users of Adult Mental Health and/or Learning Disability services, according to a 2015 report from the UK Health and Social Care Information Centre (HSCIC) (Willis., 2015), but the commonness of co-morbidities and complex nature of individual sufferer’s condition (RCN., 2016) are responsible for their emotional needs being downplayed or ignored (Lloyd., 2010).
Learning disabilities (LD) refer to a list of disorders which pose problems to an individual’s learning abilities and are often accompanied with physical challenges. These are mostly diagnosed by psychologists through a combination of intelligence testing, academic testing, social interaction, classroom performance and aptitude as well as perception, cognition, attention, memory and language abilities (Smith et all, 2010).
Records from the healthcare sector prove that people with learning disabilities have not been directly involved in studies (Stacey & Edwards., 2013). As a result, the applied research processes together with the available statistics and policies framed with some sketchy evidence have been questioned by scholars. These denunciations and factual academic discussions influenced a new approach in the study of people with learning disabilities (Durell., 2016) thanks to huge efforts from self-advocacy groups and teams of quality researchers who collaborate with them (Johnson., 2009).
Nurses supporting people with learning disability often use a challenging behaviour instead of a mental health conceptual framework in their efforts to understand problematic behaviours (Taylor et al., 2008) and this leaves a chance where the underlying mental health problems are overlooked or poorly treated. Categorically, the two ways of treating mental ill-health are: through medication and psychotherapy or cognitive behavioural therapy (also known as CBT). Although the effectiveness of these treatments depends on the individual and type of problem, for many patients, the talking therapy or a combination of both offers the best result. This study therefore provides an insight on the effectiveness of these inclusive researches aimed at giving people with learning disabilities the right of speech which resultantly enhances nursing practice (Rohan et al., 2015).
The challenges encountered by people with learning disabilities who also have mental health issues is a matter that requires urgent attention through special health services but in spite of the central role played by nurses, critics believe disability nursing has functioned with a comprehensible model of mental health (Prout & Browning., 2010). To improve or sustain physical and mental health of service users whose health needs are dependent on medical technology, there’s need for a common ground to be established between arguments on achievements recorded by psychiatric nursing and learning disability nursing in relation to patients’ wellbeing and social inclusion (McManus et al., 2009).
Disability Rights Commission in the UK suggested increased access to mainstream health services and timely provision of direct specialist support in both community and in-patient settings, including multi-professional teams and multi-agency settings, as some of the ways through which disability nurses can eliminate health inequalities of sufferers and support them to live a satisfying life (DH., 2007). The 2001 white paper Valuing People identified four principles: right, independence, choice and inclusion (Marriott et al., 2010). These imply that people with learning disabilities are entitled to the same rights and choices as everybody else; should be helped to live with minimal dependency; should be empowered to have choice in their care services and treatment; and should be included in society through access to services and with valued social roles (Acquah., 2012).
This discourse explores some factors stifling effective solutions to the mental health needs of those with learning disabilities and explain how an applied approach can provide scholars and professionals with a logical theory that identifies links between mental health nursing, normalization and developmental psychiatry. It also assessed applied behavioural theory as a dynamic and essential structure upon which further meaningful solutions can be deducted (May et al., 2009). In addition, recommendations are made on how LDNs, educators, commissioners and health/social care providers can offer more effective contributions in the future (Cordall., 2009).
2.1. Importance of the Study
This research examines the current theory and practice applied by LDNs in supporting people with LD and tending to their mental health needs. It evaluates the quality of contributions offered by learning disability and mental health nurses as well as other health professionals and identifies the major skills or knowledge they are required to possess for a high-level competence that addresses problems in modern-day nursing practice. In furtherance, it studies how effective assessment of needs can be conducted to provide needs-led assistance to those with autism and challenging or offending behaviours.
2.2. Study Objectives
This research provides useful information for nurses, HCAs and nursing students who render support services to both children and adults with learning disabilities. Its contents are also valuable for those in new professional roles such as mental health workers (DH., op cit.) The aims include:
- to give an insight on how LDNs can personalize their services and effectively handle mental health care plans for people with learning disabilities
- to offer clear explanations of the mental health needs of people with learning disabilities
- to highlight the need for a better understanding of their communication needs
- to enhance the ability of LDNs to properly use mental health assessments specially planned to address patients’ needs
- to expound government care policies for people with learning disabilities
- to promote collaborations and information-sharing between health professionals and services.
Using an inclusive or participatory methodology (Walmsley., 2004) which ensures that participate are actively involved in designing and researching as well as interpreting results, a total of eleven survey questions as shown in Figure 1 were developed to gauge four core areas of the treatment process: the relationship between a client’s perceived clinical needs and his/her program goals; the quality of staff and available services; respect for clients’ safety and privacy; and the available opportunity for active participation of clients.
This study made use of results from a 2018 survey conducted by Liberty Healthcare Corporation, an agency which provides healthcare management and staffing for profound behavioural health, mental ill-health, correctional mental health, dual diagnosis (intellectual/developmental incapacities) and primary care settings. Using the Liberty QualityCare Client Satisfaction Survey tool formulated by a group of professional clinicians and executive administrators, an analysis was conducted on the program performance problems between 2015 through 2017. The tool was beta tested for the period under study to allow more contributions from clinicians at the two different program sites involved in the alpha/beta assessment.
After the testing, Liberty QualityCare shared the survey tool to three programs across the UK where it has full responsibility of clinical results, and supervised proceedings for each year.
Figure 1: Client Satisfaction Survey
The survey helped researchers collate useful feedback on treatment goals and the accessibility of program services. It also presented a clear understanding of the clients’ ability to sustain general health through a proactive lifestyle. To gain insight into the satisfaction process, clients had chances of adding comments and questions for each yearly survey.
3.1 Ethical Considerations
The UK governments have different policies, interpretations and structures for implementing decisions on how needs of people with learning disabilities are catered for. Nonetheless, some common themes in all four nations (England, Wales, Scotland and Northern Ireland) include that:
- people with learning disabilities share the same rights with other citizens and should be seen as equal
- they have the right to be independent
- they should be supported to take charge of their lives and make personal choices
- they deserve same opportunities as others
- citizens should unanimously empower people with learning disabilities through social inclusion.
Although the policies tackle mental health needs in different ways, they are focused on same issues such as: ensuring that people with learning disabilities have unrestricted access to general mental health services wherever obtainable; fostering collaborative functioning between primary and secondary caregivers in mental health as well as specialist learning disability services; and providing minor, specialist inpatient services for individuals who are unable to gain support from mainstream services etc.
With respect to service users’ consent and confidentiality, all assessment procedures employed were in compliance with the UK guidelines on ethics (Booth and Booth., 2003; Aldridge., 2007).
3.2 Survey Design
This study employed a cross-sectional survey design utilizing the survey tool from Liberty QualityCare which proved beneficial in addressing client satisfaction. An assessment of clients in the key four areas listed above, provided direct inputs from end users of service and enabled successful management of the outcomes. Clients’ assimilation of program goals is pivotal for successful clinical results to be achieved (Heneage et al., 2010). Their participation is also required to maintain a respectful environment that promotes good health, safety and confidentiality (Deb S. et al, 2001; APA., 1994).
All eleven questions from the Liberty QualityCare Client Satisfaction were answered with the following, using a 5-point Likert scale: ‘agree,’ ‘strongly agree,’ ‘neither agree nor disagree,’ ‘disagree,’ and ‘strongly disagree.’
The survey had an introduction which read, “Your opinion is important to us. There are 11 statements below and for each, you are expected to check ONLY ONE (1) of the boxes that best represent your feelings: ‘Strongly Disagree,’ ‘Disagree,’ ‘Neither Agree nor Disagree,’ ‘Agree,’ OR ‘Strongly Agree.’ Your answers are strictly confidential and will be useful to your program leadership team for improvements on your service plan.”
The four open-ended questions are as follows:
- What appeals to you about the services?
- What changes would you suggest we make to the services?
- What are your questions for the next satisfaction survey?
- What are your comments for the leadership team?
The subjects in this study are clients above the age of 18 who voluntarily agreed to fill out the Liberty QualityCare Client Satisfaction Survey.
3.4 Selection Criteria
Once in a year, the leadership of Liberty QualityCare sent out printed copies of the client satisfaction survey to clinical leaders in charge of programs in all parts of the UK for onward distribution to clients, with written assurances of confidentiality. Deadlines for returning the completed questionnaires to the vice-president were also issued to the clinic leaders, including envelopes with return address to ensure smooth delivery of by mail, particularly for those clients who wish to send in their surveys individually.
For any client who wished to participate but was found to be functionally illiterate, the coordinator for continuous quality improvement used a mix of interview questions and special satisfaction recognition tools to collate answers through verbal response or facial recognition.
The vice-president who is in charge of quality performance/improvement was obligated to aggregate the survey results from respondents, record the data in a summary report, which is passed to the participating executive directors and other members of the management board. This procedure ensured that a client’s feedback would not jeopardize his/her treatment plan, services or progress.
3.5 Data Analyses
Liberty QualityCare used the improvement circle of Plan, Do, Check/Study, and Act from Shewart and Deming (Deming., 1986; Shewart., 1939) to sieve outcomes of each annual survey it conducted. Directors and clinical teams held yearly meetings to review the summary report and survey results as well as brainstorm on intervention strategies that can improve the program and enhance chances of attaining organizational goals (Chakraberti and Fombonne., 2001).
Despite the difficulty in finding comparison data for benchmarking this kind of survey, the leadership team deduced reports from the available quantitative data and used descriptive statistics to present trends and relationships. A review was also conducted on files from the Association of Support Professionals that gave a standard of 17 to 23% as customer satisfaction response rate whereas PeoplePulse (n.d.) gave a yardstick of 15 to 30%. Liberty QualityCare admitted its survey tool experienced fluctuations because its clients were not mandated to complete the survey, including the fact that the population varied in volume per year as shown in figures 2 and 3. Nonetheless, Liberty QualityCare considers its client’s satisfaction response rates were dependable for strategic decision-making.
Figure 2: Number of Respondents
Figure 3: Clients Response Rates
The Liberty QualityCare team decided between 2009 and 2014 that clinical time could be maximized by aggregating data according to the percentage of “Agree” and “Strongly Agree” responses to each question. As explained in figure 4, this idea enabled the management to focus on improving performance on all questions that attracted less than 70% “Agree” and “Strongly Agree” responses from clients.
Figure 4: Percentage of Positive Response
In the sixth year, Liberty QualityCare leadership agreed it would be productive to use the mean Likert score in addition to the percentage of no, neutral or negative responses to present a comprehensive picture that showcases clients’ neutrality, satisfaction and dissatisfaction responses on safety, care procedures and capacity to stay functional (Copper., 1997; Emerson., 1997) as shown in figure 5.
Figure 5: Results for 2017
England, Scotland, Northern Ireland and Wales have policies and institutional framework for decision-making, implementation and interpretation on behalf of citizens who are incapable of making informed decisions by themselves. The law on consent applies to every citizen and resident of the countries, including those with learning disabilities.
Laws on capacity to consent in the UK are available in the Mental Capacity Act (DCA., 2005) for England and Wales. Scotland has its guidelines in the Adults with Incapacity Act (Scottish Executive., 2000). While Northern Ireland has no existing statue on consent, legislation is under consideration as part of the general Review of Mental Health. Details are found on www.rmhldni.gov.uk but contemporary practice is based on case law from Reference Guide to Consent to Examination, Treatment and Care (DHSSPS., 2003).
Inclusive learning disability research has been significantly influenced by self-advocacy which, according to Walmsley and Johnson (2003), plays a priceless role in bringing people with learning disabilities under an umbrella and encouraging them to make contributions in research projects. The role of self-advocacy groups in helping researchers gain understanding of learning disability organizations in order to present accurate information to policymakers and offer meaningful representations for this vulnerable group cannot be overemphasized.
Some of the criticisms against self-advocates is that they are seen as tokenistic. Moreover, people with learning disabilities are allowed little or no control over the research plan. (Aspis., 2000). It is also argued that self-advocacy has made no significant impact in the lives of the group (Walmsley and Johnson., op cit). In their 1997 piece, Walmsley and Downer called on stakeholders in health and government circles to embrace an inclusive approach in researches concerning “severe” learning incapacities (Walmsley and Downer., 1997; Williams et al., 2008).
This literature review explored if and how mental health nurses are receiving appropriate trainings for care of people with learning disabilities who also have mental problems. To identify relevant literature for review on the topic, a systematic approach was adopted including an extensive search in five electronic databases – Medicine, CINAHL, ERIC, PubMed and Scopus.
Time frame of searches was limited between 2012–2017 and a total of 15 articles were identified as relevant to the topic area for review, inclusive of 3 main themes: (i) attitudes (ii) practice and (iii) education. Findings show that there is lack of research focused on directly addressing the issue of inclusiveness and improving quality of care received from nurses. The literature also suggests that there are considerable setbacks in the ability of mental health nurses to provide adequate and appropriate care for people with learning disabilities and mental ill-health.
Three areas of the study analysed attitudes exhibited by health care staff, qualified personnel and student nurses towards those with learning disabilities, and the impact of a negative attitude from health professionals has direct links to a variety of unfavourable results with regards to accessing care services, recovery, rehabilitation and maintaining self-esteem. On the other hand, increased positive attitude is reported where an individual has a friend or relative with a learning disability. In furtherance, records show that nursing students have more positive attitudes than their non-nursing peers.
Practice issues presented themes within four papers which stressed that a majority of LDNs lack the prerequisite skills needed to adequately cater for the mental health needs of individuals with learning disabilities. Poor coordination and role confusion and poor were highlighted as factors related to this trend.
Deductions from the study suggest this topic area needs advanced inquiries for an increased chance of improving knowledge on this subject at pre-registration and post qualifying levels to achieve transformative delivery of mental health nursing care to every member of this particular group.
Mental health problems are often confused with learning disability although the first refer to a broad-range emotional, psychological and psychiatric problems which include anxiety, depression and schizophrenia. Anyone can experience mental health issues at a point or the other and may gain successful treatments whereas this cannot be said of learning disability.
6.1 Learning Disability vs Mental Health Problem
Results of this study show that approximately 40% of adults with learning disability suffer mental health problems, and this number is higher than double the projected incidence of mental ill-health among the populace. In furtherance, children with learning disabilities are also vulnerable to mental health issues by 36% than those without a learning disability (McCarron et al., 2011; Cooper et al., 2007).
6.2 High Incidence of Negative Life Events
A long list of pieces from researchers found there’s an increased chance that people with learning disability will experience poverty, deprivation, negligence, violence and other adverse or potentially traumatic events earlier on in life. This includes unemployment (Hastings et al., 2004)
6.3 Mental Health vs Learning Disability Services
Access to mental health services are granted only when an individual with learning difficulty has been verified on a need-based criterion and, according to Taylor et al (2007), there are many reasons why mental health problems are not often diagnosed in people with learning disability.
Services rendered for mental health and learning disability are often separated and do not function simultaneously. In addition, mental health services are not always provided for people with learning incapacities, and this creates a gap in delivery as well as deny members of this group access to government-funded initiatives such as Improving Access to Psychological Therapies (IAPT) and memory clinics. Moreover, patients with mild mental ill-health and profound learning disabilities are most likely to receive learning disability services (Kroese B., Rose J., Heer K. and O’Brien A., 2013).
6.4 Physical Activities
Researches prove that people who work or are engaged in continuous physical activities have lower risks of suffering mental ill-health than those who are disabled, unemployed or sick. The overall ratio is higher for women, according to an updated 2010 survey from the University of Essex, England.
7. Main Methods of Conducting Research in Health and Social Care
Every significant action taken by registered nurses which forms the caregiver’s foundation for decision-making is referred to as “nursing process.” In mental health/learning disability, this process involves 5 main areas (ANA., 2007):
Assessment: While conducting initial assessment of patients with learning disability and in subsequent communications, the psychiatric-mental health registered nurse collates every available objective and subjective information as well as observations. The data include: status of the care user’s general physical, mental and emotional health; main complaint/problem; family/personal, social groups and/or community; daily activities; health habits; religious or non-religious beliefs, and any other factor which is capable of altering an individual’s response to treatment or ability to function independently.
Diagnosis: LDNs employ results from the assessment to pinpoint a patient’s actual and/or potential problems and, depending on the nurse’s competence, the information is transformed into an acceptable structure using the field’s common classification system(s) such as, for example, the North American Nursing Diagnosis Association’s (NANDA) Nursing Diagnosis Classification.
Planning: The nurse develops a unique care plan which clearly states the interventions to be used in achieving expected outcomes, with each diagnosis having at least one motive. In addition, the short and long-term objectives must be realistic, measurable, comprehensible and prioritized with and established time frame. Collaborations from clients, their families and other clinicians are required in the development of responsive and productive care plans.
Intervention: Nurses ensure that their care activities are properly identified and executed for clients’ needs to be achieved. Methods of intervention include self-care activities, milieu therapy, counselling, health education, medications, health promotion, psychotherapy and case management.
Evaluation: The nurses follow up on their interventions to know if all expected outcomes were met, and if unaccomplished, more effective changes in plan or intervention are employed after thorough reviews.
8. Implications for Evidence-based Practice
Evidence-based practice (EBP) in nursing refers to combining the best possible research to harmonize with clinical expertise and patient needs. It includes the explicit, conscientious and careful application of the best evidence gathered from systematic study and used in making decisions in individual patients’ care plan (Malloch and Porter O’Grady., 2006; Sackett et al., 1996).
For evidence-based practice to function effectively and provide the desired results in contemporary healthcare and mental health delivery structures, there is need for it to improve on the current practice setting by making use of practicing professionals who are directly involved in care delivery and possess applied clinical experiences. Since late 2000s, there has been an increasing interest in the use of evidence-based practice in medical, nursing and health care, particularly inspired by some unprecedented technological innovations which are now available to researchers (Breslin E. and Lucas V., 2003). However, the health care sector has minimally exploited chances presented by technologies in the practice setting, and particularly in care services. Moreover, healthcare professionals and nurses have been criticised for a perceived unwillingness to “try something new,” and are often distracted from employing new developments in the industry due to the following: organizational bottlenecks, quality of staff, and lack of support from colleagues, superiors or management. Most practitioners consider changes as “excessive stress,” and prefer function in the clinical setting without utilizing evidence-based practice which they say is just not practical (Dixon L. et al., 2001).
9. Limitations of Study
Well-documented barriers to research translation are replete in both academic and health care settings, with a mix of factors influencing the progression of evidence-based and/or inclusive researches into practice. Introducing and sustaining evidence and evidence-informed protocols within a framework of competing priorities in healthcare is an uphill task, and in spite of the available quality recommendations with capabilities of enhancing utilization of evidence-based practice, research findings show that implementation is inconsistent. Many factors from individuals and organizations impede acceptance and implementation. Other issues include: time limitations; unfavourable clinician behaviour; difficulties encountered while developing evidence-based guidelines; lack of continuing education; and an unsupportive organisational culture (Haynes and Haines., 1998; Wallis., 2012). According to McKenna (2004), mention must be made of the availability and dissemination of evidence as well as individual motivation and the culture of specific healthcare practices, as part of the factors suppressing effective use of informed research.
There is an urgent need for nursing researchers to explore and assess the effectiveness of psychiatric nursing interventions, including the different modalities for mental health treatment and conventional, alternative and complementary therapies. In furtherance, inquiries should be conducted on how to successfully integrate psychosocial, psychobiological and psychodynamic interventions with psychiatric-mental health nursing practice.
All research results that have been thoroughly sieved and are found usable in clinical practice should be clearly presented by nurse researchers, who should also team up with nurse administrators to create a conducive work environment and ensure there’s an organizational culture in support of quality research programs and implementation of results that revolve around nursing intervention.
11. Conflict of Interest
The author is grateful to Liberty QualityCare and all participants who voluntarily contributed in no little way to the success of this study.
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