Critically Explore and Reflect in a Systematic Manner the Delivery of Care to an Individual with a Learning Disability.
The aim of this assignment is to critically explore and reflect in a systematic manner the delivery of care to an individual with a learning disability. I will aim to describe learning disability nursing practice. This will be done with reference to holistic, person-centred approaches, the use of nursing models, within the framework of the nursing process and within the operation of the multi-disciplinary team. These processes and structures will guide and enable me to review and identify an individual’s health care need.
Throughout the process of the care delivery ii will be guided and supported through clinical supervision, which will be facilitated by my mentor. Supervision can enable you to develop and assist your learning through understanding your situation and experience (Canham & Bennet, 2002; Thompson, 2002;Bulman & Schutz, 2004). In recent years reflection has become an increasingly significant part of modern nursing practice, which Wolverson (2000). Mentions can enhance the quality of an individual’s care and develop the self-awareness of the nursing practitioner.
For the reflective element of the assignment I have chosen to utilise Gibbs (1988) reflective model (appendix) I will not strictly adhere to the model. Nevertheless, I will aim to describe my situation, explore my feelings, evaluate and analyse my practice together, conclude on the experience and explore what I would do if the situation arose again. I aim to demonstrate my personal and professional development, which will endeavour to guide me through the transition from being a student to a registered learning disability nursing practitioner.
During my placement with the adult community service I was given the opportunity to work closely with a lady with a mild learning disability who was experiencing some difficulties in dental health. From a personal point of view I chose the lady because of my interest in dental health, as in the past I had successfully supported individuals in this area of health care. The identity of the lady will remain confidential, which is in accordance with the NMC (2008) I will refer to the lady as Jane and all other information that I will mention have been changed.
As part of the initial assessment I will aim to discuss my involvement and the therapeutic relationship that I developed with Jane. Feely (1994); Tait & Genders (2002) and Carpenito-Moyet (2007) consider the assessment to be the most important interaction the practitioner has with the individual, as it involves them looking at the individual as a unique human being. To enhance my knowledge and understanding of Jane’s needs I will aim to describe Jane’s circumstances leading to her care, her health and medical history, her and her family’s perception of her needs and also Jane’s bio-psychosocial profile. Reflection Description
From a multi-disciplinary review it was decided that Jane would benefit from a comprehensive assessment, to ensure that Jane’s health care needs could be identified and reviewed. In order to provide a systematic approach in providing Jane’s care the nursing process was used. The problem-solving cycle consists of five interrelated steps. For this care stud I will follow the adopted version (appendix) of the five-stage model of the nursing process (Hogston, 2002 in Aldridge et al 2005) To simplify the structure of the assignment Ii will discuss and reflect the stages of the nursing process separately as practice moves on. Health Assessment
The planning of care commences with the health assessment, which is a continuous process throughout the stages of the nursing process (Tait & Genders 2002; Pearson, Vaughen & Fiztgerald 2005). Part of this initial assessment involved gathering data in relation to Jane, her health and what influences health. Alridge et al (2005) believe this is central to identifying an individuals problems and what potential problems could develop. Although Jane was the main source of information I was to liaise with the multi-disciplinary team which included her sister, social worker, support worker and speech and language therapist.
I will now introduce Jane who is pleasant and charming 65 year old lady. Jane has a mild learning disability and on occasions can experience difficulties when communicating with others. Jane has lived independently since the loss of her father ten years ago and is able to advocate her daily needs. She has weekly contact with her sister. Jane has a support worker who spends one hour a day, five days a week who helps with some Jane’s household chores, they include shopping, cleaning, outings and holidays. Jane’s hobbies include evening classes where she takes part in music and cookery with her peers twice a week.
Jane also enjoys working with her peers who have learning disabilities at the garden sister. She takes pleasure from all aspects of gardening work. Jane receives some support from many of the support staff at the garden centre. Over the years Jane has developed many friendships with both her peers and the staff. Friendships are important to most people including those people with a learning disability (Tait & Genders, 2002; Brackenridge & McKenzie, 2006). Kelly (2000) reveals that an absence of meaningful friendships could lead to deterioration in a person’s quality of life.
Jane has developed many skills at the garden centre and she has been able to transfer many of these skills to her home. For instance, Jane is very proud of her well kept garden and she is also able to decorate her home with support of her sister. Jane and her families’ perceptions of her needs. Jane attended private mainstream school as a child, she enjoys reflecting on a happy childhood of playing with her sister and how she enjoyed attending private school. Jane lost her mother when she was 5 years old and was brought up with her sister by their father. Jane lost her father 10 years ago and has lived independently ever since.
Jane is aware that she has a learning disability and reports that she does need some help with certain aspects of her life and takes some time to do everyday tasks. For instance, her sister supports Jane with any financial issues, the support worker helps with daily living activities, her community nurse will assist her with health care needs and her social worker is on hand for any other issues. Jane has always been close to her sister and they still remain in contact. Jane’s sister is aware that Jane has a learning disability and is more than willing to attend Jane’s multi-disciplinary reviews and plays a great part in Jane’s life.
Bio-psychosocial profile of Jane Jane is an independent lady who likes to keep busy; she is able to care for herself with nominal support in her daily living activities. She has many friends in work; she takes part in an evening class, enjoys time with her support worker and has quality time with her family. Jane accesses the community for many of her activities and appointments which include GP, podiatry, practice nurse appointments, work, evening classes, haircut, bank, post office and family visits.
O’Briens (1987) philosophy is for services to empower individuals to have presence in their community, support the making of choices, enhance and encourage mutual respect and participation within their community. O’Brien’s (1997) philosophy of community presence is essential to Jane’s daily activities; however Jane feels she is unable to access some of her appointments independently as some of the professionals in the primary health care lack understanding of her communication needs.
At times Jane does find it difficult to communicate her needs in a new situation and when meeting new situation and when meeting new people; this can result in her becoming anxious, distressed and loss of confidence. Jane requires some level of support to access certain health care appointments, as she does not understand the medical ‘jargon’ that is often used by professionals and she also feels anxious in a clinical environment. Jane’s health and medical history Jane’s previous health has been very good and she has not endured any major illness or health worries.
Jane suffers from the occasional cold or flu over the winter months and now has the flu injection. There has been a long history of Jane refusing to attend the dentist due to a bad experience many years ago. Jane does have an understanding of how important dental health is and she can and will clean her teeth. Jane reports she would like to gain confidence in going to the dentist with support of her learning disability nurse. My role as a nurse is to promote and maintain health, Whitehead (2004) & Hames & Carlson (2006) believe this could be achieved through educating and raising an individual’s awareness in relation to health issues.
Jane’s circumstances leading to the need of care Jane attended a check-up appointment at the dental surgery six months ago, but when she got there she became very anxious and could not go through with the appointment. Cumella et al (2000) strongly believe that extra time may be necessary for individuals with a learning disability to attend the dentist and the environment. Over the last few weeks Jane mentioned she has been in pain with toothache, because of this she has been taking time off work.
Furthermore, Jane had not been sleeping well due to the pain even though she had taken analgesic. Description of my involvement with Jane Following the initial referral meeting I was introduced to Jane at her place of work by her social worker. I sat listening and observing Jane and her social worker discussing what Jane had been doing in relation to her hobbies and daily activities. Jane chatted freely with her social worker. After Jane and her social worker finished talking I asked if I could meet Jane the following week to which she agreed.
The NMC (2008) Code of Conduct states that consent must be obtained from an individual before any treatment; in order to comply with the code I asked Jane’s consent before I began the assessment process and before any treatment was offered. In obtaining Jane’s consent I discussed the case study, assessment process and what it would involve. For instance, the case study would require me as a student to write and reflect on my own involvement with an individual from my placement area. I went on to explain to Jane that her identity and any other information would be kept confidential.
I gave Jane the opportunity to digest what information had been discussed and she verbally consented and was happy for me to commence with the case study and assessment process. Over the next few weeks I visited Jane at her work and home. Here I began to develop a therapeutic relationship with Jane where we chatted over a cup of tea and we went for a walk. Morrison (1997) describes the principles of therapeutic relationship as acceptance, interest, honesty, acknowledging and accepting people for whom they are, which I believe to be essential to Jane’s care.
Rogers (2003) suggests interpersonal process between a nurse and a person is about mutual growth towards a person’s self-realisation. However, McConkey, Morris & Purcel (1999) argue that there is a risk in forming relationships between nursing and care staff and people with learning disabilities, as it could lead to problems with the relationships being misunderstood. Nevertheless, Shepeard (1998) mention a humanistic approach in which the person is valued unconditionally is vital to an empowering and a mutually rewarding relationship.
I believe developing a therapeutic relationship with Jane was central to the assessment process; this opportunity gave me time to get to know Jane and identify and review her needs. Additionally, at the time Jane was able to develop her trust in me, as the NMC 2008 code clearly states that building trusting relationships will greatly improve the care being provided. In order for me to support Jane in this area of health and develop my understanding of Jane’s comprehension level and communication needs, Ii felt it necessary to carry out a communication assessment.
Elis, Gates and Kenworthy (2004) states communication can be a complex process, as each person is a unique individual, with exceptional understandings of the world, influenced by origin, upbringing and life experiences. To carry out the communication assessment I began to work in partnership with my mentor, Jane and her speech language therapist; this was to ensure a successful assessment could be carried out and completed. Young and Chesson (2006) mention the involvement of an individual prior to the planning stage of their care is very important.
Young and Chesson (2006) go on to mention that this could improve a person’s quality of care and could assist in a better service and outcome of intervention. I applied Money and Thurman’s (1994) Communication Model (appendix) which explores different means, and ways of how individuals communicate in their everyday lives. Money and Thurman’s (1994) model of communication identified in the ‘means’ section that Jane uses short verbal sentences with the support of symbols and pictures.
From the ‘reasons’ section of the assessment Ii indentified that Jane might benefit from me asking the questions through using short sentences with the support of visual pictures. The ‘opportunity’ section identified that Jane does access appointments for instance- podiatry, practice nurse and she enjoys going to have her haircut. Having completed the communication assessment and identifying Jane’s communication needs, I then was able to continue to gather the data and information regarding Jane. Having gathered the relevant data and information Ii utilised the activities of daily living model which was part of the nursing assessment process.
The activities of daily living is a holistic nursing model that was devised by Roper, Logan and Tierney (1996). They include * Maintaining a safe environment * Communication * Breathing * Eating and drinking * Elimination * Personal cleansing and dressing * Controlling body temperature * Mobilising * Working and playing * Expressing sexuality * Sleeping * Dying Murphy et al (2000) question the efficiency of applying Roper, Logan and Tierney’s (1996) model in mental health nursing, they found there to be inequality between individuals information in the assessment and the subsequent assessment information and problem identification.
Nonetheless in learning disability practice Aldridge et al (2005) states practitioners tend to use Roper, Logan and Tierney’s (1996) model as a holistic assessment tool which can be adapted for the individual. In addition to the twelve activities of daily living my placement had an additional activity of ‘choice’; this I believe to be an advantage to ensure all individuals are given the opportunity of choice in their everyday lives. Through reflective supervision with my mentor we reviewed the activities of daily living. We indentified that Jane’s appetite and sleep pattern had changed.
In addition, Jane had been having time off work which was very unusual for her. Having reviewed the activities of daily living I felt it necessary to carry out a health-screening assessment to gain further information and knowledge regarding Jane’s loss of appetite, change in sleep pattern and her time off from work. The organisation of my placement has a health-screening tool in use which can establish a baseline regarding an individual’s change in health (Health Screening Tool, 2002). Barr et al (1999) states there are limitations of using