Part 1
Introduction to learning
disability nursing
Chapters
1What is learning disability nursing?2
2Nursing and midwifery standards4
3The six Cs6
4The student nurse perspective7
Don’t forget to visit the companion website for this book at
www.ataglanceseries.com/nursing/learningdisability to
do some practice cases on these topics.
1
1
What is learning disability
nursing?
Introduction
Learning disability nursing is a person-centred profession whose
primary aim is to support people with learning disabilities either
directly or indirectly through improving or maintaining their
health and wellbeing, and bringing about their social inclusion in
their communities.
What do learning disability nurses do?
Learning disability nurses work with people with learning disabili-
ties from birth through to death, those who may require a range of
supports throughout their lives. This support will range from none,
or minimal, support through to intensive holistic nursing care
aimed at meeting the multidimensional needs of people with learn-
ing disabilities. Much of the care planning and delivery of learning
disability takes place in local community settings. Learning disabil-
ity nurses must be competent in preparing robust, professionally
prepared care plans based on a systematic nursing assessment.
Much evidence exists of the positive contribution of learning disa-
bility nurses to the lives of people with learning disabilities. Learning
disability nurses currently work in a wide range of organisational
settings that include the NHS, local authorities and the third sector.
Typically they are likely to work in inter-professional teams and for
a variety of agencies. Recent changes in health and social care are
dictating new and exciting roles that are being undertaken by learn-
ing disability nurses, for example nurses working in mainstream
healthcare teams in acute hospitals, mental health services and pri-
mary care. The Strengthening the Commitment Learning Disability
Nursing (UK, Chief Nursing Officers, 2012) report has asserted that
learning disability nurses are needed to ensure that people with
learning disabilities of all ages, today and tomorrow, have access to
the expert learning disabilities nursing they need, want and deserve.
Three primary areas of practice in the NHS are:
•Health facilitation – supporting mainstream access.
•Inpatient services – for example, assessment and treatment, and
secure services.
•Specialist roles – in community learning disability teams.
Other, broader, developments in healthcare roles, such as the
modern matron, specialist epilepsy nurses and nurse prescribers
are all providing new areas of practice for learning disability
nurses. Also learning disability nurses work as consultants who are
able to offer valuable clinical, supervisory expertise along with
both regional and national professional leadership.
The purist form of nursing – the context
of learning disability nursing
Learning disability nursing is often referred to as the purist form of
nursing; unlike colleagues in other fields of nursing, they do not
concentrate on specific manifestations of physical ill health or
trauma, or mental health and wellbeing, or children, or childbirth
for that matter; rather they offer support to people with learning
disabilities, and their families that is all embracing and quite
literally from the cradle through to the grave. In order to offer
competent, compassionate and comprehensive nursing interven-
tions that meet the multidimensional needs of people with learning
disability, it is helpful to adopt a structured approach to working. A
comprehensive needs assessment (physical, psychological, social,
spiritual and emotional) should first be completed. If a nurse is
required to work with someone with learning disabilities and their
family, it is necessary that their needs are assessed and incorpo-
rated into an individual care plan, taking their desires, wishes and
aspirations into account. The nurse must work closely with the
client’s family, care providers, and other professionals, as this
approach will bring very important and essential information, as
well as informing the development of a care plan, its approach,
delivery and management. This detailed assessment is followed by
the construction of a written care plan that is implemented, and
followed up with ongoing review/s and evaluation/s. This very
structured approach, using partnership working, and incorporat-
ing the multidimensionality of people, coupled with the person at
the heart of planning, ensures that learning disability nurses
provide holistic person-centred care and support.
A modelled approach
In response to social and political influences, learning disability
care and models of support, care planning has changed considera-
bly over recent years, as has the practice of learning disability
nurses. For example, during the last century, many people with
learning disabilities were located in asylums and, or, long-stay
hospitals that were dominated by a medical model of care, empha-
sising the biological needs of people, and the need to ‘cure’ physical
problems. Most people with learning disabilities have now moved
out of long-stay hospitals, but there remains a concern that the
powerful effects of the medical model may continue to influence
care provided in smaller community-based residences. It has been
argued that the use of the medical model in the past pathologised
and objectified people with learning disabilities, leading to them
being seen as ‘less than human’. Therefore, nurses need to consider
adopting a ‘nursing model’ to guide their care in practice, to ensure
that they offer holistic nursing support. The use of any model must
hold the person with learning disabilities central to the care
planning process, and all must be mindful that they use a model to
promote what is best for that person. There are numerous nursing
models that can be adapted and used in health and social care
settings. Some nursing models are regularly used in learning
disability nursing practice. An example of a useful nursing model is
that of Roper, Logan and Tierney (2002) this is well known and
widely used within nursing profession. The model focuses on
holistic care and is based on the concept of health rather than
illness and disease. The model focuses on understanding the needs
of people in terms of the activities of daily living they perform. The
model embraces the idea that independence and dependence oper-
ate along a continuum relating to each activity of living separately.
2
Nursing and midwifery standards
Learning disability nursing: specific
competencies for entry to the register
Professional values
Learning disabilities nurses must promote the individuality,
independence, rights, choice and social inclusion of people with
learning disabilities and highlight their strengths and abilities at all
times while encouraging others do the same. They must facilitate
the active participation of families and carers.
Learning disabilities nurses must understand and apply current
legislation to all service users, paying special attention to the pro-
tection of vulnerable people, including those with complex needs
arising from ageing, cognitive impairment, long-term conditions
and those approaching the end of life.
Learning disabilities nurses must always promote the autonomy,
rights and choices of people with learning disabilities and support
and involve their families and carers, ensuring that each person’s
rights are upheld according to policy and the law.
Learning disabilities nurses must use their knowledge and skills to
exercise professional advocacy, and recognise when it is appropri-
ate to refer to independent advocacy services to safeguard dignity
and human rights.
Learning disabilities nurses must recognise that people with
learning disabilities are full and equal citizens, and must promote
their health and wellbeing by focusing on and developing their
strengths and abilities.
Communication and interpersonal skills
Learning disabilities nurses must use complex communication
and interpersonal skills and strategies to work with people of all
ages who have learning disabilities and help them to express
themselves. They must also be able to communicate and negotiate
effectively with other professionals, services and agencies, and
ensure that people with learning disabilities, their families and
carers, are fully involved in decision-making.
Learning disabilities nurses must use the full range of person-
centred alternative and augmentative communication strategies
and skills to build partnerships and therapeutic relationships with
people with learning disabilities.
Learning disabilities nurses must be able to make all relevant infor-
mation accessible to and understandable by people with learning dis-
abilities, including adaptation of format, presentation and delivery.
Learning disabilities nurses must use a structured approach to
assess, communicate with, interpret and respond therapeutically
to people with learning disabilities who have complex physical and
psychological health needs or those in behavioural distress.
Learning disabilities nurses must recognise and respond
therapeutically to the complex behaviour that people with learning
disabilities may use as a means of communication.
Nursing practice and decision making
•Learning disabilities nurses must have an enhanced knowl-
edge of the health and developmental needs of all people with
learning disabilities, and the factors that might influence them.
They must aim to improve and maintain their health and inde-
pendence through skilled direct and indirect nursing care. They
must also be able to provide direct care to meet the essential and
complex physical and mental health needs of people with learn-
ing disabilities.
•Learning disabilities nurses must be able to recognise and
respond to the needs of all people who come into their care includ-
ing babies, children and young people, pregnant and postnatal
women, people with mental health problems, people with physical
health problems and disabilities, older people, and people with
long-term problems such as cognitive impairment.
•Learning disabilities nurses must use a structured, person-cen-
tred approach to assess, interpret and respond therapeutically to
people with learning disabilities, and their often complex, pre-
existing physical and psychological health needs. They must work
in partnership with service users, carers and other professionals,
services and agencies to agree and implement individual care plans
and ensure continuity of care.
•Learning disabilities nurses must lead the development, imple-
mentation and review of individual plans for all people with learn-
ing disabilities, to promote their optimum health and wellbeing
and facilitate their equal access to all health, social care and spe-
cialist services.
•Learning disabilities nurses must work in partnership with
people with learning disabilities and their families and carers to
facilitate choice and maximise self-care and self-management and
coordinate the transition between different services and
agencies.
Leadership, management and team working
•Learning disabilities nurses must exercise collaborative man-
agement, delegation and supervision skills to create manage and
support therapeutic environments for people with learning
disabilities.
•Learning disabilities nurses must take the lead in ensuring
that people with learning disabilities receive support that crea-
tively addresses their physical, social, economic, psychological,
spiritual and other needs, when assessing, planning and deliv-
ering care.
•Learning disabilities nurses must provide direction through
leadership and education to ensure that their unique contribution
is recognised in service design and provision.
•Learning disabilities nurses must use data and research findings
on the health of people with learning disabilities to help improve
people’s experiences and care outcomes, and shape future
services.
•Learning disabilities nurses must use leadership, influencing
and decision-making skills to engage effectively with a range of
agencies and professionals. They must also be able, when needed,
to represent the health needs and protect the rights of people with
learning disabilities and challenge negative stereotypes.
•Learning disabilities nurses must work closely with stakehold-
ers to enable people with learning disabilities to exercise choice
and challenge discrimination.
We need a common patient centered culture which produces, at the
very least, the fundamental standards of care to which we are all
entitled, at the same time as celebrating and supporting the provision
of excellence in healthcare, (Francis, 2013).
Compassionate care and nursing makes all the difference to the
experience of individuals. This requires that safe, high quality,
compassionate care must be at the heart of everything we do, con-
tinually striving to improve, and speaking out if they witness
standards which are wholly unacceptable.
Essential to creating a positive culture of safe, compassionate
care is real, effective staff engagement to meet the demands of
Francis. Compassionate care must be at the centre of everything
the NHS does. This involves a clear and well-functioning system of
accountability.
Safeguarding the health and wellbeing of those in your care
means these people should not be exposed to abuse. Abuse is
defined as ‘a violation of an individual’s human and civil rights
by any other person or persons'. (No Secrets, DOH, 2000/Raising
concerns: Guidance for nurses and midwives, NMC, 2013)
The 6 Cs
Care
Care is our core business and that of our organisation and the care
we deliver helps the individual person and improves the health of
the whole community. Caring defines us and our work. People
receiving care expect it to be right for them, consistently, through-
out every stage of their life.
Compassion
Compassion is how care is given through relationships based on
empathy, respect and dignity – it can also be described as intelli-
gent kindness, and is central to how people perceive their care.
Competence
Competence means all those in caring roles must have the ability
to understand an individual’s health and social needs and the
expertise, clinical and technical knowledge to deliver effective care
and treatments based on research and evidence.
Communication
Communication is central to successful caring relationships and to
effective team working. Listening is as important as what we say
and do and essential for ‘no decision about me without me’.
Communication is the key to a good workplace with benefits for
those in our care and staff alike.
Courage
Courage enables us to do the right thing for the people we care for,
to speak up when we have concerns and to have the personal
strength and vision to innovate and to embrace new ways of
working.
Commitment
A commitment to our patients and populations is a cornerstone of
what we do. We need to build on our commitment to improve the
care and experience of our patients, to take action to make this
vision and strategy a reality for all and meet the health, care and
support challenges ahead.
Why the 6Cs are needed
In order to maximise wellbeing and improve health outcomes, we
will develop skills as health promoting practitioners, making every
contact count for people. Learning disability nurses work in ways
to reduce the health inequalities experienced by people with a
learning disability and consider quality of care is as important as
the quality of treatment. When a person reflects on their contact
with a nurse they think about other issues as well – the environ-
ment they received care in; whether they were treated kindly, with
respect and dignity; and whether they had to tell their story more
than once. The people that we care for, and in many instances their
families and carers, are our partners in care and our practice must
reflect that. We must take note of:
•Person-centred Planning
•The Mental Capacity Act 2005
•Death by Indifference (2007)
•Health Care for All (2008)
People with learning disabilities are 58 times more likely to die
before the age of 50 than the general population (Disability Rights
Commission, 2006).
3
The six Cs
Universal issues
There are issues that are universal to all higher education under-
graduate students, such as taking three years out of your life with
no guarantees about what a degree may mean for the future.
However, the education and learning processes prepare us to
be lifelong learners – which everyone needs to be to advance
career aspirations and goals. Then there are the challenges of
negotiating your way around a large geographical area with
seemingly endless corridors that feel like they go nowhere you
need to be! And also developing the necessary skills to access
4
The student nurse perspective