Appraise the nursing care of a person with a learning disability and give your suggestions as to the nursing interventions that may be necessary to maintain or enhance their development.
In compilation of this essay the author has taken every measure to preserve the confidentiality and identity of all service users that have been referenced to.
Throughout this essay the author will attempt to bring to the readers attention, through discussion, the variables which constitute a package of nursing care required to meet a learning disabled clients needs in order to maintain and enhance their development. He will discuss issues surrounding staff, including experience and turnover, the service model of care in situ, the environment in which the client resides and the services available including the delivery of primary health care. Also, the learning disability philosophy of the organisation supplying the care will be examined to ascertain the level of fulfilment to the individuals particular requirements. The basis of the discussions will encompass a particular client the writer has worked alongside during placement, endeavouring to protect his identity and integrity throughout the assignment.
For the purpose of this paper we will refer to the client as Steve (not his real name) to preserve his identity. He resided with his family prior to moving to a large institution owing to his ageing mother, with whom he still has regular contact, being unable to fulfil his necessary care requirements without it affecting her own health. A gentleman approaching middle age with a severe learning disability including multiple physical and sensory disabilities that are not uncommon within this group (Gates 1999). A mixture of health care professionals are presently attending to his nursing care ranging from D and E grade RNLD’s, health care support workers and an activity worker all employed in the community unit of four bungalows and a day unit funded by the local NHS Trust.
It could be disputed that a high proportion of the learning disability workforce is unqualified (DoH, 2001, Larson & Larkin 1999) and with it brings the possibilities of the health needs of clients being neglected (McKenzie et al 2002). A situation recognised by the NHS Trust supplying Steve’s care who offer statutory training in disability awareness, continence management and amongst others, epilepsy. Moreover, the opportunity to achieve NVQ level 2 and regular supervisions to discuss progress and individual training opportunities, which incorporate the endorsements of Mencap (2001) and the DoH (2001) white paper ‘Valuing People’. Collectively this should enhance and maintain his development but prior to applauding staff opportunities for knowledge base development we should examine staff retention.
The author observed during the first two months of his placement six changes of personnel and after discussion with the RNLD in charge discovered further changes had taken place six and ten months previous. Changes of this proportion have been discovered to have a detrimental affect of the nursing care delivered regardless of experience (Larson & Larkin 1999, Turner 2001). Several ‘bank staff’ were utilised during the author’s placement and although excellent in approach and delivery of direct care, few had knowledge of Steve’s ongoing care plans and strategies to manage his occasional difficult behaviours. Few incentives were in place to encourage longevity of contract and when asked to work extra hours permanent staff seldom received enhanced rates for doing so. However, we should contemplate Poissonnet & Veron (2000) when they say, "extended workdays should be avoided as much as possible to avoid deterioration in performance".
Steve’s requirements are recognised by the utilisation of a person-centred planning (PCP) framework and ‘named nurse’ co-ordinated role, involving multidisciplinary professionals and a ‘significant’ others coalition. An annual major PCP meeting and quarterly reviews agree targets and formally record progress enabling adjustment of care plans or the setting of new goals according to individual needs. It appears to be an empowering structure that is holistic and responsive to the individual and that allows support to be more flexible, furthermore it is an approach validated by the DoH (2001). It has been discovered that if PCP is implemented successfully it results in improved opportunities for people to make simple everyday choices that in the majority of incidents do not stretch resources (Parley 2001). Having choice burdens you with responsibility, which needs explaining, but that burden will enlighten and develop the individual (Draper 1999).
Evidence based practice is well recognised, endorsed (DoH 2001, Hogg & Lambe 2000) and advocated by Steve’s care team. Research articles from prominent and established nursing journals validate his individual care plans giving foundation for their implementation. Constituting the quality of these research and journal articles was difficult as none had supporting documentation to suggest they had been ‘systematically reviewed’, a process central to the drive for evidence based health care (Parahoo 1997). Furthermore some had become dated, an issue recognised by the staff team who were in the process of critiquing predominant literature in order to ameliorate the situation.
It was difficult to visualise how certain care plans of Steve’s were being evaluated even though the PCP approach was implemented. One particular care plan was evaluated via the nursing records; the author felt it implausible for the evaluator to search through three months of nursing records to find the relevant information. Care plans should incorporate measurable goals (Parley 2001, Gates 1999) therefore; recording charts or a space provided for documenting observations would enhance the process of evaluation resulting in increased accuracy and efficiency. The successful application of the model requires staff to develop their knowledge of the PCP approach (Parley 2001), but when questioned Steve’s staff had received no training or guidance something the author previously attained and discovered most beneficial.
"A clients living space will have an impact on how they cope with day-to-day activities" (Stanford & Shepherd 2001), and this applies directly to Steve due to his physical and visual disabilities. As a blind paraplegic, Steve’s environment has immense consequences on the quality of his daily living. Combine this with the unexplainable situation of having to share a bedroom with another client and living space with five other wheelchair users and we can speculate what a profound influence this may have on his existence. Remarkably Steve maintains a high level of mobility around the bungalow but on occasion disharmony occurs with staff and other clients due to his apparent lack of courteousness when clattering into them.
The bungalow is situated in low income, under-invested area of the city incorporating a high rate of juvenile crime (National Statistics 2002). Regardless of these facts the immediate local amenities include, a small park, numerous retail outlets, hairdressing and barbershops, public houses and a local workingman’s club all accessible for him to take advantage of. Making use of these facilities should increase the likelihood of integration with the local community resulting in enhanced social skills however, during his placement the author failed to observe him taking advantage of any local facilities. Disability excludes people from socially necessary activities (ONS 2001) combine this with staff inexperience, shortages and unfamiliarity of client and we can begin to illustrate the reasons for the inability to access these local community activities.
For a significant duration a large proportion of his day has been spent with the local day care services where he attends Monday to Friday 09.00 – 15.00. Astonishingly non-of his care team knew precisely what type of educational, vocational or leisure pursuits he participated in whilst there, making evaluation and continuity unrealisable. Most people value their day care services for the support and social contact they receive from it (Curry & Cupples 2001) but in order to assess its significance to enhance the person we must first ascertain its suitability. Day services are often not tailored to meet the needs and abilities of the individual (DoH 2001), in Steve’s instance no one knew whether they did or not. Continuing assessment and evaluation substantiates the value of a service, because someone has attended a service for a prolonged period it does not imply that the service is benefiting the individual (Curry & Cupples 2001). These factors should have been recognised at his quarterly and annual PCP reviews however, no explanation was offered for this oversight. The author accompanied Steve on one occasion to the day services he attends finding little in the way of stimulation for him. It ought to be recognised that the day services were in a transitional period due to renovation work taking place on their regular venue that was being modernised to meet the DoH (2001) recommendations, this should hopefully offer a more tailored service.
People with learning disabilities have the same right of access to mainstream health services as the rest of the population (DoH 2001, Barr 1997), an opportunity that Steve receives full benefit from. He is registered with a local GP, as intended by the DoH (2001), district nurses are at his disposal, dental and chiropody requirements are also met locally. Professionals often fail to perceive a person with learning disabilities as a valued individual, which may exhibit itself in a failure to provide explanations and involve the patient in decisions about their care (Barr 1997, Fox & Wilson 1999), but the author failed to witness any of these manifestations. Only co-operation, understanding, politeness and empathy were displayed towards him, prerequisites if people with learning difficulties are to continue to receive care from mainstream services (Bollard 1999).
The opening declaration of the NHS Trusts Learning Disability Service Philosophy (2002) states, "Each person’s specific needs are identified and individual plans of care are devised to overcome to minimise any problems and improve functional ability". And goes on to add in its, Statement of Intent (2002), "...and should be brought to the attention of all newly appointed staff as part of their induction". These two sections of the individual home operational policy work in conjunction with each other and recapitulate in these two quotes, the ideology of the PCP approach and the trusts intention of a committed, educated workforce from commencement of employment, again compatible with the principles of the DoH (2001).
The Learning Disabilities Service Philosophy (2002) also endeavours to provide to its users, "...a safe and stimulating environment...which each person will be given the opportunity...to develop and acquire skills, concepts and activities enabling development of socially value lifestyles". A bold proclamation and one in the authors’ opinion which fails Steve on all considerations, the overcrowding of the accommodation (Stanford & Shepherd 2001, Rose 2002) and staff shortages (Larson & Larkin 1999) are not conducive to providing opportunities and offering a stimulating environment. The ability to develop and acquire skills demands continuity (Gates 1999), an opportunity lost due to the lack of knowledge of his activities whilst at day services and the difficulties in evaluating specific care plans. Finally the ability for the ‘development of socially value lifestyles’ has been previously shown to fail in large institutions (Gates 1999) and it seems to be failing Steve in his present climate.
The significant factors overriding all others in determining whether or not Steve maintains or enhances his development in the author’s opinion are staff shortages and retention. The limitations due to shortages and retention had repercussions for him in nearly every area discussed throughout this paper. Often the RNLD’s had to perform duties usually executed by health cares due to absence or they were covering the adjoining bungalow leaving less time for identifying individuals needs. The extensive support needs of overcrowded accommodation (Rose 2002) leads to an increased turnover of staff (Larson & Larkin 1999) the outcomes being unfamiliar staff incapable of meeting his requirements. Frequently only the necessities such as bathing, preparing meals and meeting continence needs were met due to deficiency or illness of staff. At the time of leaving his placement there was over one hundred and eighteen hours vacant plus two RNLD’s and a health care off sick. With support down to this level we can begin to understand why such factors as communication with day services had broken down, local social networks were not being utilised and the fundamental package of his care the PCP is failing him. These are not uncommon problems and are one’s recognised by the DoH (2001), but whether its vision for the future will finally have an impact on his life is a question in reality to soon to answer.
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