Learning disability is defined as a significant lifelong difficulty in learning and understanding, practising the skills needed to cope with everyday life, and that there is evidence that these difficulties started before 18 years of age (Gates et al, 2015). This essay will discuss critically, recent theories and methods applied in order to prioritise and safely meet the health and care needs of Carlos who has fragile X syndrome and atypical autism. Using appropriate models with vast evidence-based practice to deliver effective packages of healthcare while collaborating with Carlos, family members, carers, and multidisciplinary team. Lastly, it will discuss critical analysis of ethical dimension of evidence-based knowledge that underpins nursing intervention on Carlos while analyzing the integration of ethical – legal principles of person-centered practice.
The nursing theory is defined as ‘a creative and rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenomena’ (Chinn et al, 2010). Nursing theory was established to help structure and evaluate the complexities of care, required by the service user (Alligood, 2014; Gates et al, 2015). Nursing theories help nurses to ascertain which direction and to reflect and examine the plan of care, and provides management strategies, carry out investigations on new health conditions to help in decision–making. Nursing theories act as a foundation for further research and practice in the field of nursing (Graneheim and Lundman, 2004). Some of these theories are as follows; Orem’s self–care model of nursing, focused on individual’s ability to care for self to maintain a healthy life (Orem, 1991). The Neuman systems model, Watson’s theory of caring, Florence Nightingale's Environmental theory, Henderson’s nursing need theory, Rogers’ Science of Unitary Human Being, and many more.
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Roper, Logan, and Tierney’s Activity of Living (RLT) model which identified 12 activities of living as behavior type that is exhibited by all, such as maintaining a safe environment, communication, breathing, eating and drinking, eliminating, personal cleansing, and dressing, controlling body temperature, working and playing, mobilizing, sleeping, expressing sexuality and dying (Wilson et al, 2019). RLT has been commonly used in United Kingdom, it has an advantage of being simple to understand. These 12 activities of living link up medicine and nursing in the treatment of diseases, thereby enabling the working together of multidisciplinary team and sharing of information. RLT also reveals the current healthcare practice (Department of Health, 2015; Wilson et al, 2019).
On the other hand, RLT model, though commonly used in UK, failed to address the psychological and social dimension, which allow health care practitioners to consider determinants of health. RLT dimension covered about 12 activity of living, without considering if these service users can perform these activities (Public health department, 2017; Wilson et al, 2019). Others say RLT assessment was like a checklist (Walsh, 1998; Wilson et al, 2019).
RLT as stated above does not address the concern, for example, the service user’s pain or the religious beliefs, however, there are opinions that if RLT model is used properly, it will cover the holistic assessment which will help in planning of care (Wilson et al, 2019).
Furthermore, some of the nursing theories were borrowed or used in conjunction with other professional bodies (Fawcett and DE Santo – Madeya, 2013) while some are specifically nursing theories, such as Orlando and Peplau used by mental health nurses, these two theorists made great contribution in the past and current practice of mental health nursing. Moulster and Griffiths learning disability model was also for people with learning disability (Moulster et al, 2019). To care for people with learning disability, collaborate with colleagues and with other multidisciplinary team, motivate, guide with holistic approaches and render adequate healthcare services (Gates and Mafuba,2015; RCN, 2012; Nogueira and Rodrigues, 2015). The next paragraph will discuss the methodological aspect relevant to this essay.
The methodology is defined as a system of doing things (Hawker, 2006). Mostly the method to be adopted will be from gathering evidence from the scenario, textbooks, articles, journals, theories/ models, tools and frameworks from different authors. In order to carry out assessment and management of Carlos from the scenario chosen, Moulster and Griffiths model and Health equality framework (HEF) tool will be used (Moulster et al, 2019; Atkinson et al, 2015).
Moulster and Griffiths model focuses on person-centered approach with the aim to support people with learning disability to live normally and improve their wellbeing from early life to the time they die (Gates et al 2015). Therefore, learning disability nurses need to be skilled, knowledgeable, trained and competent in the use of Moulster and Griffiths model and health equality framework in their day-to-day care with people with learning disability (Nursing and Midwifery Council Code 2018) Moulster et al, 2019). A set standard by the nursing and midwifery council, must be followed, to guide the nurses to prioritise people, practice effectively, preserve safety, and to promote professionalism and trust (NMC Code, 2018). It is a systematic process of identifying the clients’ problems, asses, initiating the plans or assigning others to implement it and evaluating the extent to which the plan will be effective in resolving the problems identified ( Wilson, 2019, Locsin 2009,NMC Code, 2018; Wilson et al, 2019). Also guides nurses to make decisions and attend to the care need of the patient (Moulster et al, 2019).
As reviewed by Wilson et al (2019) it demonstrates that nursing model was developed to direct the nurses to identify needs of patients under care. Evidence available indicated that most of the nursing models share the same philosophy but may have different approaches from each other (Wilson et al, 2019). More so, nursing models that are in use today have the service user participation at the centre of their needs.
Some unique nursing models are: Moulster and Griffiths, Orlando and Peplau, Patient-centered approach of nursing, Roper–Logan and Tierney (RLT) model of nursing, Person-centered care approach, Orem self–care model of nursing (Gates et al, 2015, Royal College of Nursing, 2016; Wilson et al, 2019). Learning disability nurses require decision – making model to help use the nursing framework effectively, hence Moulster and Griffith's nursing model (Moulster et al, 2019). On the other hand, some of these models are not used universally by all the nurses, for example, Roper–Logan, and Tierney (RLT) is commonly used in United Kingdom (Wilson et al, 2019). Additionally, RLT does not have psychological or social dimension. Current nursing policy and other practitioners complained that RLT is a simple model. However, RLT still falls under one of the current models in use (Public Health England, 2017; Wilson et al, 2019).
Moulster and Griffths model build its strong understanding and good relationship with people with learning disability and their families to utilize a framework as a tool to guide in supporting their diverse needs (Lleweyln and Aafjes – van 2017, Moulster et al, 2019). Moulster and Griffiths model focuses on person-centered, evidence-based, outcome-focused and reflection (Moulster et al, 2019). This model is made up of seven stages which fitted into the four stages of the nursing process. There are four main principles that the nurses need to follow to effectively care for Carlos with this model. In the person-centered model, the nurses need to attend to the client as an individual and holistically. Carlos preferences, taste in choice, beliefs, right, family, lifestyles and background are to be applied in their care (Joseph, 2018; Equality Act, 2010)). In the case of Carlos, consent is obtained and with the relationship already established, it becomes easier to get Carlos involved in the assessment (NMC, Code, 2018; Wilson et al, 2019; Mental Capacity Act, 2005).
Carlos was provided with easy read and pictorial format to help him understand what he needs to prepare ahead of time and be involved in his care (Moulster et al, 2019; Delves - Yates, 2018). Extra time is allocated with Carlos to ensure he does not become anxious. Carlos’ mother, who is the carer is also involved and easy read provided to her too (Care Act, 2014). Communication between the nurse, Carlos, and the mother should show clarity of purpose (McCorMack and McCance, 2017). The person-centered model has varieties of care plan format that is being used by clients, carers, and their relatives. To optimize patient care, Health Equality Framework (HEF), which is a measuring tool, will be used in conjunction with Moulster and Griffiths model to measure health care services covering 29 determinants of health inequalities and effect of nurses’ involvement in its reduction (Moulster et al, 2019; Atkinson et al 2015). The factors under consideration are grouped into 5 key elements such as; social factor; genetic, biological and environmental; communication and health literacy and access to quality services with addition of decision-making tool, are used by families of people with learning disabilities and learning disability nurses and different organisations.
HEF when used changes people’s perception about timely intervention which are achieved within a short period of time (Moulster et al, 2019), the next paragraph will examine the assessment aspect of the framework with relevant to the case scenario under investigation.
The learning disability nurse commenced assessment by first building up a relationship through interaction to gain Carlos consent. Carlos mother was present as his carer (The Care Act, 2014). Information concerning his health condition was already included in his vocabulary in easy read format, to help Carlos understand and be involved in his assessment and care. A conducive environment which was free of crowd and noise and anything that might distract him (Wilson et al, 2019; NMC Code,2018). Safeguard all personal details of Carlos confidentiality were strictly maintained and ensure that every assessment carried out with Carlos are recorded and explained to him. The effect the assessment will have on Carlos, as he struggles to comprehend words spoken to him are considered, so short and simple assessment to respect the rights, beliefs and diversity of Carlos and his family (The Care Act, 2014; Equality Act, 2010).
From the assessment, the nurse picked up Carlos social interests was going out on Saturdays and Sundays for bus ride, window shopping, buy some journals, have lunch, visit his grandma and enjoy lunch with her. The social determinant domain showed score 4 with marginalisation on the initial HEF profile (see appendix ……). However, other social domain which are to engage Carlos on meaningful activities and socialising that require improvement was picked up by the nurse too. These were evidenced on the HEF assessment tool (Atkinson et al, 2015). Other determinants from other domains, also impacted on Carlos sudden withdrawal and isolating himself from socialising, from visiting his grandma and have lunch might lead him to have lack of confidence and low self–esteem (Novotney, 2019; Valtorta et al, 2015). This challenged the learning disability nurse in this context to appreciate how these issues could impact on Carlos ability to co-operate in his care thereby affect his health condition (Valtorta et al, 2015). Social withdrawal considers frequently withdrawing from social activities and social interaction, which may lead to people experiencing anxiety, low mood, loss of interest or pleasure, feeling of guilt or low self–worth, disturbed sleep or appetite, low energy and poor concentration (Flint and Kendler, 2014; Robin et al, 2002).
Carlos had diagnosis of Fragile X syndrome and atypical autism, with its signs and symptoms that affects his communication, noise, seizures and pain on his legs. The initial HEF profile score showed that Carlos had high score of 62% which indicates that his health condition might deteriorate if no intervention is done (Valtorta et al, 2015).
His sister who also supports in his care, informed the nurse of Carlos being sick after taken his medication, but thought he was well enough to go out for shopping as usual, which helps Carlos to be cheerful and be in good mood, social involvement of family had been researched, findings indicates, it will reduce the symptoms Carlos is having (Huang, et al, 2018). The next paragraph will address the planning needs in this framework.
Carlos health needs were developed from the assessment. To allay his anxiety and build confidence in himself so that he can go out and enjoy himself. To make reasonable adjustment with other multidisciplinary team, to enable Carlos access other health facilities. For example, providing a sensory environment that will have calming effect on Carlos. Sensory environment is specially designed environment which enable people with special needs to enjoy a very wide range of sensory experiences for therapy, learning, stimulation, relaxation and fun. To provide picture book, photo of grandma to help his communication Carlos. There may be barriers to have effective communication with Carlos, such as lack of coordination, concentration and hypercreativity (Goodwin et al, 2015). Some of the tools used to carry out this assessment includes sensory profile questionnaire, sensory processing measure questionnaire (Bruno et al, 2014). ,…
To make reasonable adjustment by double booking appointment slot for extra time which might be early hours or late or GP home visit, where Carlos will not be agitated due to noise or crowd. Regular health check plan for routine health check. Referral to be made to speech and language therapist to assess Carlos with his new communication tools, such as the picture book, easy read vocabulary and objects. Referral to the psychologist to assess his behaviour, physiotherapy and occupational therapy. Referral to psychiatrist and epilepsy nurse, to review his seizures and anxiety.
The social worker will have to review Carlos accommodation and living environment is conducive (no noise). The learning disability nurse to visit more regularly to guide Carlos on how to know when he is in pain or experiencing trigger or anxiety. This direct the nurse to appreciate the role of multidisciplinary team in caring for this group of client. As argued by Rosell et al (2018) that multi-disciplinary team increase focused patient care and define areas for improvement, in this case, all the multidisciplinary team can work together to provide the safe care to Carlos. The next paragraph will continue the implementation.
The initial HEF profile of 62%, formed the baseline from which the outcome was measured and monitored for Carlos. The HEF profiling can be repeated to allow changes where necessary. The final profile indicated that the information gathered was used by learning disability nurse and the multidisciplinary team to work on all aspects that health inequality was impacting on within the time.
Creating easy read vocabulary and easy read information pack for Carlos, providing a quiet environment and avoiding crowded area will help reduce his anxiety. Ensuring Carlos takes his anti-epileptic medication at the right time to reduce the occurrence of epileptic seizures. The family’s contributions evidenced family involvement in care helped to support Carlos to comply with his care and decision-making (Mental Capacity Act, 2005; The Care Act,2014; Atkinson, 2015). Using HEF profile provides area that health inequality is highest, which might indicate to be the area impacting on the individual’s health. This information might add to help the GP in arriving at a decision.
Carlos communication improved as he continued to use his easy-read vocabulary and pictorial objects for understanding and clarity as a result of the intervention provided. The sensory environment helped calm him down to be more engaged with his care. Carlos mother and sister were trained by the nurse to monitor and record epileptic seizures which is used in his review. Special shoes were provided by the occupational therapist to help reduce the pain on his legs. Carlos medications were reviewed by the pharmacists, to ensure there is no drug interaction or side effect. Carlos was referred to join fragile X syndrome society by the multidisciplinary team, where he can feel free to verbalise, make friends and have lunch together (www.fragilex.org). Initially, Carlos was reluctant to attend, so he was accompanied by his mother and learning disability nurse for proper introduction into the club (Care Act, 2014). Carlos later developed interest and started interacting with other people with the aid of his pictorial objects and vocabulary. Carlos HEF profile score has reduced to 29%, which shows there is great improvement in his health and well-being.
Reflection is defined within healthcare as the active process of reviewing, analyzing, and evaluating experiences drawing upon theoretical concepts or previous learning, in order to inform future actions (Reid,1993). On reflection on caring for Carlos, it had been apparent, that as a learning disability nurse, it is essential to familiarise myself with Carlos and the family, respect their right, belief, and diversity and encourage Carlos to participate in his care.
I should have a detailed evidence of further arrangement for Carlos care (Dougherty and Lister, 2015). Continuous monitor of the learning outcome by using Moulster and Griffiths model and HEF tool in practising while on placement will increase the experience and confidence to perform my duties well and impact others with my knowledge and experience (NMC, 2018; Moulster et al, 2019).
Moulster and Griffiths still places client at the centre of their care, where learning disability nurse act as facilitator in highlighting social inclusion and emphasising on the right of people with learning disability to enjoy good health and wellbeing. Moulster and Griffiths model dictates the inequalities from the social environment and areas where services can be provided if reasonable adjustment is provided. This model can be used widely by other nursing care. However, there may be limitations in using Moulster and Griffiths and HEF, since not all the people with learning disabilities are ill. Evidence – based practice does not always rely on research made, but evidencing your own experiences, knowledge and skills and training in that profession.
This essay has explored a case scenario, regarding care of Carlos, identified framework of Moulster and Griffiths, in conjunction with HEF to respond to the need of Carlos. Throughout the essay, the conceptual framework provided direction from planning, implementation and evaluation of the care. It can be concluded that HEF was used as outcome measurement for Moulster and Griffiths, while Moulster and Griffiths remains as the 4 key principles of evidence-based, person-centered, demonstrating outcomes and supporting reflection Moulster et al, 2019).
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