A mental health nurses perspective of the issues surrounding the treatment of patients with a dual diagnosis of psychiatric disorder and learning disabilities in mainstream mental health units. This essay is going to explore from a mental health nurses perspective the issues surrounding the treatment of patients with a dual diagnosis of psychiatric disorder and learning disabilities in mainstream mental health units. Including a discussion around prevalence, provision of services, access to services, government policy and whether staff in mainstream mental health units have the knowledge and skills necessary to provide effective care for this potentially vulnerable service user group.
The contemporary concept of learning disabilities focuses on the physical and social difficulties that can occur as a consequence of being labelled a person with a learning disability and how any impairments a person may have affect them (Swain et al, 2004) however it neglects to identify the mental health issues people with learning disabilities regularly and more commonly face
If people who meet the diagnostic criteria for borderline learning disability are included the prevalence of learning disabilities in the UK equates to 12 % of the population or around 8 million people (Hassiotis et al, 2008)
It is generally recognised that people with a learning disability have a higher rate of psychiatric disorder compared with the general population with the prevalence estimated at 40 – 50 % (Raghavan and Patel, 2005). In comparison to 10 – 20 % of the general population (The Office for National Statistics, 2000) Various factors have been cited as being contributory towards this vulnerability including brain damage, sensory impairment, chronic physical ill health, epilepsy, repeated loss or separation issues, poor self-image, coping mechanisms and social skills, communication difficulties and family problems (Fraser & Nolan 1995, Hardy et al, 2007)
Mental health nurses are specifically trained to treat a diverse group of people including children and young people, working age adults, the elderly and new mothers all with mental health problems. Experiences from clinical practice demonstrate an increase in the number of people with learning disabilities admitted to general acute mental health hospitals and the increasing incidence of complications that can often come along with the care of this group of people. These include problems with assessment and treatment, usually stemming from communication difficulties, behavioural issues and barriers to collaborative working between the learning disabilities and mental health teams. They can often lead to an increase in length of stay in hospital and inappropriate or inadequate care being delivered.
Problems arise for the most part when a person with a learning disability develops a psychiatric disorder to the extent that requires acute psychiatric admission. It is now more common to find that they are being admitted to general psychiatric beds under the care of general adult psychiatrists and mental health nurses, many of whom have had little training in the assessment and treatment of mental illness in this group. The communication difficulties people with a learning disability may face can make assessment extremely complex. People with learning disabilities often require a longer stay and may also be vulnerable (i.e. Abuse and exploitation) without additional support on the ward. People with a learning disability may also have unusual presentations of common mental disorders due to brain injury or other long standing conditions such as epilepsy leading to difficulty in diagnosis and an idiosyncratic response to treatment.
Furthermore, people with learning disabilities represent a diverse group with a varied range of complex mental health needs, which mainstream staff may feel ill-equipped to meet. Boundary disputes between general adult and learning disability services frequently lead to a reduced quality of care for people with complex needs
Death by Indifference (Mencap, 2007) highlighted alleged care failings in general hospitals and primary care settings It led to the establishment of an independent government inquiry in England. The inquiry unfortunately did not extend to mental health services It found that there is little evidence concerning the quality of care received by people with learning disabilities in these settings but anecdotal evidence from practice has indicated that it is reasonable to believe mental health services face the same kind of problems as general medical care.
It seems pertinent to tackle these issues head on in order to meet the needs of this client group who have a diverse range of needs that can span across all branches of nursing and whose care can suffer as they seem to be regularly forgotten or pushed to the bottom of the pile
Until 20 years ago, people with learning disabilities did not normally come into contact with mainstream services. Most people with a learning disability who had complex needs including mental illness, were cared for in specialist mental handicap hospitals, and all medical and psychiatric care was provided on site. Deinstitutionalisation has transformed their care and now this group can live in the community and access mainstream health services, regardless of the degree of their disabilities. This process has been guided by the principle of normalisation since the early 1970s, which is a philosophy that remains influential today. Normalisation represents a fundamental statement of human rights stating that patterns of life and everyday living which are as close as possible to the regular circumstances of society should be made available to all mentally ill and learning disabled people (Nirje, 1976).
Closely associated with the principal of normalisation is the concept of mainstreaming, which advocates the use of standard rather than specialised services, for example, schools,
Employment and health care it is now a firmly established principle and features heavily in government policy which supports the use of mainstream services and the interrogation of the learning disabled population back into society but also recognises the need in some cases for specialist services. (The Department of Health, 1992) stated that: “wherever possible people with learning disabilities should be enabled to use ordinary health services as well as specialist assessment and treatment services”.
Advocates of normalisation generally support the mainstream approach; they may argue that specialised services lead to labelling, stigmatisation and negative professional attitudes. The argument for this approach at first glance appears sound and is supported widely by literature. It is, for example, current policy in the UK and USA. However, in practice mainstream community mental health and inpatient teams have found it increasingly difficult to meet the needs of people with learning disabilities and psychiatric disorders (US Public Health Service, 2002).
Each of the four UK countries has its own policy structure addressing how the needs of people with learning disabilities should be met in a mental health environment. England’s policy is set out in the following reports. Valuing People: A new strategy for learning disability in the 21st century (Department of health, 2001), Health Services for People with Learning Disabilities (Department of Health, 1992) and Mental Health: National Service Framework, (Department of Health, 1999), The common themes and issues that underpin this policy structure, include: promoting collaborative working between mainstream mental health services and specialist learning disability services; allowing people with learning disabilities to access mainstream mental health services wherever possible but creating small specialist inpatient services for those whose needs cannot be met by mainstream services, implementing a changing role for specialist learning disability services to providing support and facilitation for mainstream services including providing mainstream mental health and care staff with adequate training on the needs of people with learning disability; applying a care programme approach for people with learning disability and mental health problems and creating mental health promotion materials which are made accessible for people with a learning disability.
Advice is available to help care providers and staff support people with learning disabilities in accessing mainstream mental health care settings (Hardy et al, 2006). The Green light toolkit (Foundation for People with learning disabilities et al, 2004) is one example of a guidance document that demonstrates how policy structure and specific policies are being implemented in practice. It is used throughout England as an audit tool to measure how the National Service Framework for mental health (Department of Health, 1999) is being implemented for people with learning disabilities. The toolkit provides a gold standard that can be used by local mainstream mental health services to measure services against. It offers a traffic light scoring system and provides guidance on how services can be improved, covering areas such as local partnerships, planning, accessing services, care planning and workforce planning. After a green light toolkit assessment, each local area should develop an improvement plan from the action points identified and have a time frame to implement the necessary changes. Anecdotal evidence from observations in practice suggest that the green light tool kit is still being used in practice today but similar areas for improvement are identified time and time again such as access to health promotional materials in understandable formats. This would suggest that although assessments of services are being undertaken the outcomes of these assessments and action points are not being carried forward into practice. The Disability Rights Commission (Disability rights commission, 2006) supports this view by saying that previous guidance documents intended to help people with learning disabilities gain access to mainstream health services have had limited effect.
A working group from the royal collage of psychiatrists (Royal College of Psychiatrists, 1996) acknowledged that enabling people with learning disabilities to access mainstream mental health services can be a complex and demanding task requiring input from specialists in the psychiatry of learning disability. To respond to this statement they have advocated two principles for the mental health nursing of people with learning disabilities: joint working between mental health and learning disability teams with the use of Mainstream psychiatric facilities at every possible opportunity as well as stressing that provisions for specialist services are still to be available if needed.
The independent government inquiry instigated by Death by Indifference (Mencap, 2007), while not extending to mental health services, promoted research into the experiences reported by people with learning disabilities of acute mental health units. This provides a mixed picture. The negative experiences are similar to concerns expressed by other patients. These include: lack of control and information; theft of property; intimidating multi disciplinary meetings; poor food and poor care. However the presence of learning disabilities may alter their significance for example, service users with learning disabilities may find it harder to understand information about their admission and treatment, unless it is shared in a format which is appropriate to their cognitive and communication skills. Psychotropic medication may further impair already poor cognitive functioning and may represent an additional limitation on individuals’ capacity to understand and take an active part in their treatment. Relatives and paid carers are likely to have a much more significant and long-standing role in supporting the service user than would be the case with other adults with mental health problems, Often a person with a learning disability has specific routines that only someone close like a carer would know and following these routines can make nursing them much easier. this is something to which mainstream services in particular seem to pay little attention. Not stressing involvement with carers in particular with a client from this group can lead to either a lack of support for carers or carers feeling pushed away by services and left without a role which in itself can lead to the presentation of depression and low mood in the carer. (Scior and Longo, 2005) Finally, the risk that signs and symptoms of mental health problems will be misattributed to a person’s learning disability (diagnostic overshadowing) is specific to this group. These issues need to be considered by practitioners however, evidence indicates that healthcare professionals often lack the knowledge, skills and experience necessary to meet the healthcare needs of people with learning disabilities. (Fraser, 1999)
The Royal College of Nursing (Royal College of Nursing, 2008) commented that the recent development of an expectation of the mainstream mental health services to respond to the needs of the majority of people with learning disabilities and co-morbid mental illness has often proved an unrealistic goal for the mental health nurse.
It has been proven that special expertise and training as well as the use of specialist mental health teams are required for the assessment, diagnosis and treatment of mental illness in the learning disabled population. Although it is theoretically possible to train staff in mainstream settings, the small number of cases gives little opportunity for staff in the various disciplines to gain the necessary skills. Additionally, mainstream mental health staff often feel that caring for this group of vulnerable people is not part of their role, and the resources of adult mental health services are already stretched (Day, 1988). The funding implications that arose from such a massive shift in service responsibility that came out of the implementation of the mainstreaming approach never seem to have been adequately addressed (Bouras et al, 1995)
Collaborative working between professional groups in healthcare is vital across the board for improving standards of care for patients and their carers (Pollard,2004). In relation to this professional rivalries between mental health and learning disabilities teams are common and the understanding of each other’s role is poor leading to mainly ineffective collaborative working (Bouras et al, 1995) There has also been no apparent or definitive negotiation between the two service teams in the UK to develop clear local operational policies or service agreements and only vague definitions of who is entitled to access which service exist, which can sometimes lead to a patient receiving inappropriate treatment, being bounced between services or, in rare cases, even being denied care altogether as neither team is willing to take responsibility for that patients care.
Distinguishing between psychiatric disorders and behavioural issues in people with learning disabilities is not always a straightforward process. Both empirical and conceptual issues relating to the nature of such behavioural disorders question both the validity and reliability of a diagnosis of mental illness in a person who has a learning disability (Krose et al, 2000) This raises the question what does a nurse treat first? As with dual diagnosis of a drug addiction and mental illness, in many cases the drug problem needs to be tackled first before the full extent of the mental illness can be seen (Drake,2007).However, with a learning disability this is not a possibility as a learning disability is a long standing condition that cannot be treated. The question is therefore, is the behaviour being exhibited by a patient due to their mental health problems or the learning disability?
When a person with a learning disability requires admission to hospital due to a psychiatric illness, the first objective is to agree on whether the general or learning disability psychiatrist acts as the responsible clinician. The admission of a person with learning disability often happens as a last resort in response to an emergency that cannot be managed elsewhere such as in the community or via the use or respite services. The community learning disability team should be able to offer some training to nursing staff or even carry out specific pieces of work directly with the patient.
The allocation of a named nurse is extremely important and, if available, someone with special skills or interest should be appointed in order to develop a more effective therapeutic alliance with the patient. The increased vulnerability of people with learning disabilities to abuse even during admission should be considered and protection from this potential risk given. This may need to be in the form of separation from ‘high-risk’ patients or an increased level of nursing observation such as is policy with under 18s admitted to adult acute psychiatric units. In all cases, the importance of collaboration with the learning disability team should be stressed. This becomes particularly important during discharge planning. In the scenario of an admission under a Mental Health Section, people with learning disability and mental health problems are entitled to all the provisions of the Care Programme Approach and Section 117 after-care.
It is also essential that mental health nurses have a good working knowledge of mental health law and legislation. Experiences from clinical practice have demonstrated that often mental health legislation is misused or disregarded for people with co morbid learning disabilities which denies them the safeguards and protection of the law that legislation such as the mental health act was designed to put in place (Mental Health Act, 1983). The relevant legislation should be applied to this group of people if and when it is appropriate to do so and the same categories of detention used as for other individuals experiencing mental ill health. Although it is important to note that a person with a learning disability can still be sectioned if it is deemed they behave abnormally aggressively or seriously irresponsibly, without any signs of mental illness it is therefore important to determine that that there be actual mental health problems present if a person is admitted under section to a mainstream mental health hospital.
Assessment is a specific part of the nursing process where mental health nurses can struggle when dealing with people with learning disabilities For example, The Mental State Examination, which constitutes an essential component of the formulation process and is essential for assessing risk and formulating a treatment plan, may be problematic. This could be for a number of reasons, including high rates of compliance or an eagerness to please in certain interview situations (Sigelman et al, 1982). Moss argues that people with learning disabilities are also less likely to complain or approach members of staff to ask for help which may further complicate the Assessment and risk management process. (Moss,1999) Simple language and direct questioning including communication and in depth discussion with carers could be a way to overcome this difficulty. Higher levels of nursing observation may also be useful, not only in ensuring a person’s safety on the ward but also in giving vital information regarding a person’s mental state (Appleby,1999)
(Gibson, 2007) highlighted some key factors that nurses without specialist training may find complicate effective assessment and intervention The two main factors that affect mental health nurses are: intellectual distortion, which may result from cognitive deficits in areas such as memory and concentration which can make comprehension and communication of thoughts and feelings difficult; and Cognitive disintegration, which can occur in situations where the person is overwhelmed by the anxiety of the demands being placed on them, resulting in an inability to martial thoughts and bizarre behaviour
Communication is central to making a sound and accurate assessment. It is estimated that upwards of 50% of people with learning disabilities have significant communication difficulties (Matson, 1998) A nurse needs to address the particular communication needs of each individual as each will vary in their abilities, This is another point in which collaborative working becomes very important as if the person is involved with a learning disabilities team, that team may be able to provide the nurse with accurate information about the levels of a person’s communication and how best to manage these issues.
Many of the problems in relation to management of people with learning disability by mental health nurses relate to the lack of knowledge skills and training (Lennox & Chaplin, 1995). Evidence suggests that qualified nurses regularly feel out of their depth and unsupported when dealing with this client group and observations in practice indicate a certain amount of avoidance tactics from mental health nurses when it comes to volunteering for the named nurse roll which could be due to a lack of confidence in this area.
The current pre-registration nurse education programme for mental health nurses was originally validated by the English National Board (English National Board ,2000), and the curriculum follows the Nursing and Midwifery Councils’ Fitness For Practice Guidelines (United Kingdom Central Council for Nursing, Midwifery and Health Visiting ,1999), which states that students undertaking pre-registration programmes must have certain other specialities included. However, learning disability, as either a practical or theoretical component of the branch programme, is not one of them. With government policy (Department of Health, 2001) stating that people with learning disabilities should wherever possible access generic services, there would appear to be the need for a more specific and in-depth approach to learning disability education for all students throughout their pre-registration education.
Experiences from local preregistration nurse education show that currently nursing education provides a 12- month common foundation programme for nurses who intend to train in all areas of nursing including Adult, Mental health, Midwifery, child and learning disability nursing. Although not required by the NM, Learning disability theory is taught but placements in this area are not common. After common foundation period of training, student nurse education in mental health has little or no further opportunities to gain learning disability experience.
Comparisons with learning disabilities mental health can be made to both child and adolescent mental health, as well as to older people’s psychiatry in that they are both specialist groups with their own issues and mental health nurses are expected to study these client groups in detail during their branch training in order to become familiar with the complexities of this type of mental health nursing. As these areas are mandatory specialities in order to meet the requirements of qualification as a mental health nurse (English National Board, 2000) and, coupled with the government’s policy for people with learning disabilities to access generic mental health services, it would appear essential that mental health nurses address the speciality of people who have learning disabilities and additional mental health problems during their pre-registration education as they do with other specific patient groups.
Many senior mental health nurses have received no learning disability training at all. This lack of training may result in problems with communication and understanding, as well as negative attitudes toward people with learning disability. On the flip side, nurses in learning disability have similarly limited training in the area of mental health, although there are newly available post-registration courses. One such course gives an experienced nurse from either branch a six month secondment to the other nursing discipline which is backed up by 2 modules of theory. Anecdotal evidence gained from speaking to a mental health nurse who has recently completed this course has shown that general nursing skills that every nurse should be competent in upon qualification can be transferred across the board to other branches of nursing. The feeling of this nurse is that currently, mental health mainstream services see only those with mild or borderline learning disabilities coming into the service and the assessment and treatment process for these people is not much different to that of non learning disabled people. Currently specialist services provide the majority of care for the patients with more complex needs. (Scior and Longo, 2005)
In conclusion the evidence presented in this essay suggests a number of issues that need to be addressed if mental health nurses are to meet the needs of their clients with a co morbid learning disability effectively. There are: pre and Post registration training for mental health nurses, collaborative working between the mental health and learning disability teams and provision and access to services.
It seems that specialist learning disability in-patient units with a mental health focus offer a more positive experience for the patient than mainstream mental health units, and therefore should be developed further(Scior and Longo, 2005). However, realistically mainstream services are highly likely to continue to provide care for this group, if only because of the resource limitations in specialist services and the fact that 30% of NHS trusts provide no specialist admission facilities (Bailey & Cooper, 1997). There seems a need now for major changes to be made to the structures and day-to-day practices in these services. Such changes should include initiatives to promote more positive attitudes and behaviour towards individuals with learning disabilities through training and regular input from specialist learning disabilities services. Closer attention must be paid to the need to make information about diagnosis and treatments accessible, in media such as leaflets using simple language videos and audio information (Forster et al, 2001) and the need for stronger involvement of and co-operation with service users’ regular carers.
Current practice experience has shown however that in the most part mental health services in this area only seem to come into contact with patients who have a borderline or mild learning disability as there is a bountiful supply of specialist beds. Currently only in rare cases would mainstream mental health units be admitting a person with severe or profound learning disabilities whereby small alterations to practice and transferable nursing skills would not be enough to give that patient the best care available.
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