A Critique of Mental Health and Learning Disabilities Nursing Practice
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 their family caregivers as well as collaborate with other health and social care workers for prompt and appropriate responses.
Background: Mental health and learning disabilities nursing practice, through an evidence-based perspective on care services, examines the hypothesis that about 40% of people with learning disabilities will suffer mental health disorders in their lifetime. The study also critiques testimonials that a large number of mental health and learning disability nurses, who relate with patients on daily basis, lack awareness of this group’s complex needs.
Design: This research provides us with a biopsychosocial framework through which we can easily understand people with severe learning problems together with their associated complex and emotional needs. It presents a list of relevant issues encountered by healthcare professionals in presenting and identifying mental health needs in this particular group, including the basic skills and knowledge required by nurses as key stakeholders for coordinated assessment and effective care management.
Findings: An approximated 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 by the UK Health and Social Care Information Centre (HSCIC). However, the commonness of co-morbidities and complex nature of individual sufferer’s condition are responsible for their emotional needs being downplayed or ignored. In pursuance of a balanced mental and physical health as an area that demands attention and urgent improvement, Willis (2015) confirmed that NHS England included it in the agency’s Shape of Caring review.
Records from the healthcare sector prove that people with learning disabilities have not been directly involved in studies and, as a result, the applied research processes as well as the available statistics and policies framed with the 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).
Some inclusive and extensive evaluations have explored learning disability, outlined its background and stimuli, identified its core characteristics, and underscored possible setbacks facing users of the findings. 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.
In partnership with other healthcare agencies, inter-professional teams and representatives of service users, the invaluable contributions from learning disability nurses directed at helping affected individuals lead quality lives with as much independence as possible cannot be overemphasized in this research. 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.
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. 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.
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).
This discourse will explore 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 will assess applied behavioural theory as a dynamic and essential structure upon which further meaningful solutions can be deducted. In addition, recommendations will be made on how LDNs, educators, commissioners and health/social care providers can offer more effective contributions in the future.
2.1. Importance of the Study
This research examines the current theory and practice applied by LDNs in supporting people with learning disabilities 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.
Through and inclusive approach (Walmsley., 2004), this study was conducted using questionnaires developed with population, exposure and outcome (PEO): Are mental health and learning disability nurses adequately equipped for their challenging roles in mainstream mental health settings?
Using a systematic approach, some relevant websites with reliable information on research, nursing and legal/administrative contexts were visited before an extensive search through major UK health databases and healthcare literature was conducted. The search criteria are as follows: available in English language; published after 2001; and inclusive of both adults and children.
3.1 Keywords used or generalized in the research
People with learning disabilities: Members of this diverse group are like every other person. They possess different personality traits, individual history, perspectives and principles. These vulnerable people have the same legal rights as other citizens although findings from past and recent trends prove they often suffer discrimination and exclusion.
Learning disability as a life-long condition is considered as one of UK’s prevalent forms of deformity affecting over 2% of the population. Its sufferers exhibit difficulty in learning, communicating or handling of daily tasks. They also vary widely in their abilities thus requiring special support plans (Deb S. et al, 2001).
The World Health Organization (1992) in its “The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines” and Diagnostic Statistical Manual -IV (APA., 1994) defines, through a higher-level medical and psychologically based yardstick, when an individual is eligible to use professional services provided to those with learning disability. To determine need-based qualifications rather than eligibility based on individual ability, the current evaluation methods aim at improving assessments through:
- level of intelligence handled by clinical psychologists in the health sector. An IQ (Intelligence Quotient) test score below 70% is considered as a proof of learning disability
- an individual’s budgeting/expenditure, social activities, personal hygiene and communication
- a check on the person’s history to know if disability was noticed before the age of 18 for conclusions to be made on their admissibility for the Department of Health’s last factors.
From a medical perspective, the degree of learning disability is often classified as mild, moderate and severe or profound.
Autism: About 25% of people with autism (a life-long, persistent developmental ailment) are prone to having learning disabilities. The disorder is referred to as a “spectrum condition” because the effects vary according to individuals although it has three core signs which are found in every individual patient’s life such as impairment of communication, withdrawal from social activities, and lack of imaginative skills (Chakraberti and Fombonne., 2001). People with autism are prone to suffering mental health problems, including anxiety disorders and depression (Copper., 1997), however, those autistic patients who do not show signs of learning difficulties are believed to have either Asperger’s syndrome or “high functioning autism.”
Challenging Behaviour: This term is relative to learning disabilities but marginally different to that used in services for people with mental health needs. According to Emerson (1997), challenging behaviour includes self-harm, aggressiveness and anti-social behaviours; it refers to some culturally unacceptable behaviours which present threats to people’s life, property, and may lead to restrictions from use of community facilities. These groups often use higher support services. Causes include communication needs, physical discomfort, poor environment or an underlying mental health issue.
To achieve lasting positive change in people who showcase challenging behaviour, a person-centred active support (PCAS) is necessary. The model encourages individuals in this group to participate in meaningful activities and forge relationships with others throughout the day, and immediately this is achieved, an all-encompassing functional assessment is conducted on their behaviours by health experts who apply the results to form and implement effective intervention strategies. These methods include: changing of environments where the behaviours occur; skills acquisition or positive programming; direct treatments to control profound behaviour; and application of spontaneous approaches that guarantee continuous and productive support whenever challenging behaviour is noticed.
Offending Behaviour: The criminal justice system categorises law breakers who are found to have learning difficulties, behavioural issues or mental health problems, under the same legislation as retard offenders. This group of people require assistance from professional mental health teams to protect their individual rights and well-being. Where necessary, these vulnerable people are identified at the police station and included in adult schemes managed by knowledgeable adults who offer legal representations to ensure fairness.
To assess and treat this group of people, efforts from professionals are required to avoid misinterpreting the threats and thereby compromising public safety or erroneously suppressing an individual’s liberty. Examples of the ways to observe differences in people’s intent are:
- acquiescence, which presents individuals with questions that are mostly answered in the affirmative and with less chances of protests. This may, however, permit examiners to them to seek praise/approval and withhold information on limitations
- diagnostic overshadowing, where assumptions are made on the person’s behaviour to describe it as an outcome of his/her learning disability and hence their normal characteristic
- suggestibility, when the respondents are more responsive and positive to suggestions. This is most likely to have negative outcomes if the individual is under formal interrogations
- Psychosocial masking, which limits expression of psychiatric symptoms due to restricted lifestyles and presents individuals with symptoms such as childish imaginations or unsophisticated acts which may conceal serious symptoms during questioning.
Vulnerable People: People with learning disabilities are considered as vulnerable members of the society because they have high chances of suffering neglect and abuse by the government agencies, individuals and private organizations. Abuse incidents are, however, unreported and thus unrecognized since members of this group are most likely to have communication problems which makes it difficult for proper recounting of ill-treatments. In some cases, they may not consider the cruel behaviours as abusive acts.
The Department of Health, in its No Secrets Guidance which is currently under review, calls for the local authority and other involved agencies to collaborate in their efforts to control, prevent and protect adults and children with learning disabilities. The parties are also encouraged to ensure that staff members are regularly enrolled for proper trainings on safeguarding this group.
3.2 Ethical Considerations
With emphasis on countries in 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 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.
Where guidelines on people with learning disabilities can be found in the UK:
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
- providing minor, specialist inpatient services for individuals who are unable to gain support from mainstream services etc.
3.3 Legal Considerations
Mental health nurses are required, as a matter of obligation, to be knowledgeable in existing mental health laws in their different countries notwithstanding that UK’s Mental Health Acts have been negligent of people with learning incapacities who also exhibit mental health problem.
The acts for the UK countries are as follows:
The Mental Health Act as found on www.dh.gov.uk (1983, revised 2007)
The Mental Health Order for Northern Ireland as found on www.opsi.gov.uk (Amendment 2004)
The Mental Health (Care and Treatment) Act for Scotland as found on www.scotland.gov.uk (2003)
England, Scotland, Northern Ireland and Wales have policies with provisions on 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).
3.4 Research Types, Procedures and Presentation of Audit Data
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 2000–2018 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 with an increased chance of improving knowledge on this subject at pre-registration and post qualifying levels and, consequentially, transform the 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.
4.1 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).
4.2 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)
4.3 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).
4.4 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.
Image 2: Assessment of Risks according to Gender and Employment
- 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.
- 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).
- 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.
For success to be recorded in the implementation of research evidence into clinical practice, the focus should be on changing human behaviour since no successful attempt at improving the quality of care for patients can be achieved if findings are not translated to incorporate a clear understanding of the associated barriers and facilitators change in human behaviour. Nurse researchers must understand these and apply them as guidelines in their development of practicable and sustainable implementation strategies.
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.
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