AN AUDIT OF PHYSICAL HEALTH NEEDS OF ADULTS WITH PROFOUND LEARNING DISABILITY IN A HOSPITAL POPULATION

Ambulation, Object Manipulation, and Multiple Disabilities: Extending the Applicability of a Robot

This study further tested the applicability of a robot with people with severe multiple disabilities. The robot was used to help two adults with blindness, deafness, motor disabilities, and low functioning levels ambulate and transport objects and enable them to reach a couch on which they could sit and put away the objects. Both adults learned to use the robot, succeeded in transporting and putting away objects, and achieved robot-assisted ambulation times of about 31 minutes per session.

Constipation management in people with intellectual disability: A systematic review

BACKGROUND

Constipation can lead to serious health issues and death. This systematic review summarizes international research pertaining to the management of constipation in people with intellectual disability.

METHOD

Studies published from 1990 to 2017 were identified using Medline, Cinahl, PsycINFO, Web of Science, email requests and cross-citations. Studies were reviewed narratively in relation to identified themes.

RESULTS

Eighteen studies were reviewed in relation to three themes: laxative receipt; interventions (dietary fibre, abdominal massage and macrogol); and staff issues (knowledge and training). Laxative polypharmacy was common. Studies report positive results for dietary fibre and abdominal massage although study quality was limited.

CONCLUSION

The main management response to constipation in people with intellectual disability is laxative use despite limited effectiveness. An improved evidence base is required to support the suggestion that an individualized, integrated bowel management programme may reduce constipation and associated health conditions in people with intellectual disability.

Meaningful choices: consent to treatment in general health care settings for people with learning disabilities

A small scale qualitative research project explored the experiences of I3 learning disabled people receiving care and treatment in general hospital settings. Using grounded theory to analyse the data, the question of consent to treatment emerged as an area of significantly varying practice. Some respondents reported that they were forbidden to sign consent for their own operation, whereas others who could have been deemed able, opted to let a significant other sign on their behalf. Evidence suggests that consent is primarily being sought as a legal requirement, and rarely as a strategy for ensuring people with learning disabilities understand the nature of their forthcoming treatment. One respondent reported that his attempt to withdraw consent for treatment was ignored. The respondents had received treatment in a total of seven different hospitals, all of which emerged as having markedly different approaches to obtaining consent from patients with learning disabilities. The current attention addressing the health care needs of people with learning disabilities, bolstered by the publication of 'Signposts for Success' (NHS Executive I998) last year, is welcomed. But if such work is to make a significant contribution to the well-being of people with learning disabilities then it must run in tandem with developments in the understanding of consent. Ultimately this must lead to the introduction of practices that respect the wishes of people with learning disabilities, and are enabling, at the same time ensuring that action is taken, where necessary, in the best interest of others. Recommendations include the need for additional training for general hospital staff and, where possible, the involvement of learning disability nurses in preparing people for planned admissions.

Identifying the factors affecting the implementation of strategies to promote a safer environment for patients with learning disabilities in NHS hospitals: a mixed-methods study

Background

There has been consistent evidence that people with learning disabilities experience health inequalities and poor NHS health-care provision, leading to avoidable harm and premature, avoidable death.

Objectives

To describe the factors in NHS hospitals that promote or compromise a safe environment for patients with learning disabilities, in the light of national recommendations that hospitals should (1) identify patients with learning disabilities, (2) provide reasonably adjusted services, (3) involve carers as partners in care and (4) include patient and carer views in service development.

Design

A 21-month mixed-method study carried out between 2011 and 2013, using questionnaire surveys, interviews, observation and monitoring of safety incidents.

Setting

Six NHS hospitals in the south of England.

Methods

The study employed mixed methodologies in three stages. Stage I involved mapping the systems and structural changes within each hospital site, with senior strategic managers asked to provide data on relevant policies. Stage II examined the effectiveness of implemented measures. Methods for this stage included an electronic questionnaire survey sent to all clinical staff (n = 990); face-to-face semi-structured interviews with clinical staff and strategic hospital managers (n = 68); semi-structured face-to-face interviews with adults with learning disabilities who had used the hospital in a 12-month period (n = 33); questionnaire survey (n = 88) and semi-structured interviews (n = 37) with carers of patients with learning disabilities who had been a patient during the 12-month period; and participant observation with patients (n = 8). Stage III assessed generalisability to other vulnerable patient groups and involved expert panel discussions with senior managers and senior clinicians at four sites (n = 42).

Results

Examples of good practice were not consistently replicated hospital-wide. The most common safety issues were delays and omissions of treatment and basic care. The main barriers to better and safer hospital care for people with learning disabilities were (1) the invisibility of patients with learning disabilities within hospitals, owing to a lack of effective flagging systems and a lack of staff knowledge and willingness to flag this group; (2) poor staff understanding of the specific vulnerabilities of people with learning disabilities, the reasonable adjustments to services that these patients may need and the Mental Capacity Act (Great Britain.Mental Capacity Act 2005. Chapter 9. London: The Stationery Office; 2005); (3) a lack of consistent and effective carer involvement and misunderstanding by staff of the carer role; and (4) a lack of clear lines of responsibility and accountability for the care of each patient with learning disabilities. The main enablers were the learning disability liaison nurse (LDLN), provided that this role was properly supported by senior management and carried sufficient authority to change practice; and ward managers who facilitated a positive ward culture and ensured consistent implementation of reasonable adjustments.

Conclusions

The vulnerabilities of people with learning disabilities can, and do, lead to compromised patient safety in NHS hospitals. Further research is needed as follows: (1) identifying the most frequently needed reasonable adjustments within the hospital care pathways of people with learning disabilities and their cost implications; (2) identifying the most effective structures for ensuring clear lines of responsibility and accountability for the care of patients with learning disabilities, including support needed by ward managers in order to carry day-to-day accountability; (3) investigating practical and effective ways of flagging patients with learning disabilities across NHS services and within NHS hospitals; (4) investigating, implementing and evaluating protocols for shared care; (5) evaluating LDLN posts nationwide; and (6) extending research recommendations (1) and (3) to patients with dementia and those with mental health problems.

Study registration

Comprehensive Clinical Research Network Portfolio, 10998; Integrated Research Application System Coordinated System for gaining NHS Permission, 74907.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Assessing pain in people with profound learning disabilities

People with profound learning and multiple disabilities are at risk of pain because they experience complex and severe health conditions and frequently undergo surgical procedures that cause pain. Pain assessment in this client group requires a skilled approach, although there is little evidence available to guide nursing practice. In the absence of pain assessment measures specifically designed for use with people with profound learning disabilities, the nurse will need to rely on careful observation and interpretation of the client's communicative behaviour, clinical judgement and knowledge of the person during assessment. Intuition is also an important attribute and can be a valuable source of knowledge when assessing clients who are unable to verbalize their experience of pain. These issues, along with implications for nursing practice, are explored.

Eating disorders in adults with intellectual disability

There is an increasing focus on the nutrition of people with intellectual disability (ID), but less interest in the range of eating disorders (EDs) that they may exhibit and the bio-psycho-social impact of these conditions. Despite diagnostic and methodological difficulties, psychopathology and ED research studies suggest that 3-42% of institutionalized adults with ID and 1-19% of adults with ID in the community have diagnosable EDs. Weight surveys indicate that 2-35% of adults with ID are obese and 5-43% are significantly underweight, but the contribution of diagnosable EDs is unknown. Such data and case reports suggest that EDs are associated with considerable physical, behavioural, psychiatric and social comorbidity. Review papers have focused on the aetiology and treatment of pica, rumination, regurgitation, psychogenic vomiting and food faddiness/refusal. Emerging clinical issues are the development of appropriate diagnostic criteria, multimodal assessment and clinically effective treatment approaches. Key service issues include staff training to improve awareness, addressing comorbidity and access issues, and maintaining support for adults with ID and EDs, and their carers. Research should confirm the multifaceted aetiology and comorbidity of EDs. Then multicomponent assessment and treatment models for EDs can be developed and evaluated.

Learning-disabled people's experience of general hospitals

As more people with learning disability move from long-stay hospitals into the community, contact with general hospital services will increase. Yet, how people with learning disability experience general hospital settings has remained a largely unresearched area. Despite the Department of Health's (DoH's) 1992 guidelines regarding learning-disabled people's access to hospitals, research reveals several areas where the needs of people with learning disability have not been considered. This small-scale study sought to hear from learning-disabled people themselves about their hospital experiences. Thirteen interviews were conducted over 3 months. The interviews were then transcribed and, using grounded theory, a series of key concepts developed. Findings highlighted that, particularly in the areas of 'fears about treatment', 'communication', 'general nursing', 'consent to treatment' and 'doctors', learning-disabled people had a lot to say, much of which was critical of service provision.