PROJECT FINDINGS
4.3 NOMINAL GROUPS: STAFF CONCENSUS OF ISSUES RELATING TO THE CARE OF PEOPLE WITH LEARNING DISABILITIES
4.3.1 Preliminary nominal group
For ease of reference, the preliminary nominal group will be referred to as NG1. This group was conducted in January 2008 as a session on the trust nurse induction programme in a room in the hospital‘s training and
development centre.
4.3.1.1 Participants of NG1
Information about the participants of NG1 can be found in Appendix R4.1, which includes Table 4: Profile of participants of NG1.
4.3.1.2 Findings of NG1; consensus of participants
The following ideas were generated in response to the question: what challenges do we currently face when working with people with learning disabilities? Responses were recorded in rounds by going around the room and asking each participant to offer an idea which was then recorded on a flip chart. Three rounds had taken place when no further ideas were offered.
None of the participants passed, but on several occasions, they affirmed ideas that had already been recorded. In total 27 ideas were recorded on the flip charts and after brief discussion in the group similar ideas were consolidated (with agreement being given by the participant who suggested the original idea). After consolidation, sixteen items remained (shown in Table 5) which were then scored by the participants. Only seven of the seventeen ideas (41%) received scores from the participants.
Consensus of agreement was reached about the seven most important challenges faced by the participants when working with people with learning disabilities. Usually in NGs, items with the lowest scores are eliminated but as ten of seventeen ideas received no scores, differences in these items could not be distinguished and therefore all ten of the un-scored items were eliminated. When offered the opportunity to add or re-rank the ideas, one participant stated that she was confident that the ideas she had scored
represented the most important challenges and that re-ranking would not alter her allocation of scores. All participants then stated that they agreed with her so re-ranking was not carried out. It was concluded, therefore, that consensus had been reached regarding identification of the most important challenges that nurses face when working with people with learning
disabilities. The consolidated ideas and scores are presented in ranked format in Table 5 below, which also shows the thematic summary of each (used for thematic comparison with the results of the follow-up NG). In response to the question ―What challenges do we currently face when working with people with learning disabilities?‖ consensus of opinion identified the most important challenges as being (in summarise form)
difficulty with communication, time pressures and accessing specialist skills.
The facilitator documented her observations of the participants‘ behaviour and non-verbal communication at two points; during the five minutes that participants were given to consider and list their ideas, and at the end. At first, the participants appeared a little reluctant and uncomfortable, but they seemed to enjoy partaking in the NG after the silent ideas section had commenced. Several participants seemed apparently uncomfortable once again as the round robin exercised of collating ideas begun, but were visibly relieved when they realised they could pass on rounds of ideas. The
participants were very compliant with the exercise and several stayed after the group (into a break time on the Induction Programme) to ask questions about learning disabilities.
Eight participants opted to complete the free comments forms that were distributed to all participants. This generated thirteen comments, ten of which reiterated ideas identified in the NG. The remaining feedback comments were:
―We don‘t have enough understanding on how to deal with such patients and if we address this issue it would be a great leap forward‖
―This session has made me think about things. I don‘t come across patients with learning disabilities very often but know I need to respond more appropriately‖
―All the points raised in the group are very valid. Unfortunately I think time is our biggest restriction. Good discussion‖
The participants were provided with the facilitator‘s contact telephone number and email in case they had any questions or concerns about the group of if they wanted copies of the report summarising the findings. At the time of writing, the facilitator had not been contacted by any of the
participants. NG1 took a total of 63 minutes to administer.
Table 5 Consolidated ideas from NG1
Participant responses Summary of idea Total of scores
Rank We have difficulties in communication (for
example when a patient may not be able to describe what they need)
Difficulty with communication
72 1
We face time pressures – patients with learning disabilities may need more time to communicate
Time pressures 18 2a6
We do not sufficiently use skills of other members of the healthcare team and use MDTs more effectively when looking after people with learning disabilities
Accessing
specialist skills 18 2b
We find it hard to involve patients sufficiently in their care
Involving patients 12 4
We need to get rid of their stereotypes and remember individuality / assumptions about a patient‘s ability may reduce independence
Dealing with stereotypes
6 5
We are over reliant on carers and need them to stay all the time to provide information
Over reliance on carers
6 6
We experience difficulties in ascertaining whether the patient understands what they have been told or in establishing the best method of giving a patient
information
Checking the patient has understood
6 7
We face challenges of assessing patients effectively and forming care plans
We can be affected by our patients not feeling comfortable in a hospital
environment / clinical settings can further exacerbate communication difficulties We do not necessarily know how to access specialist learning disability services for skills / advice
We would benefit from having a care plan / information from the patient‘s home/ community
We can be affected by bureaucracy (e.g.
targets in A&E not conducive to increased time needed for communication)
6 Some ideas were had joint rankings. In these cases, the rank has been split into a and b (but this does not indicate an order of priority as both were scored equally).
We do not necessarily have skills or experience to know how to deal with patients reactions / behaviour (for example, agitation, affection)
We might fear dependency levels of patients with learning disabilities due to a lack of specialist skills
We can face difficulties in conveying the complex needs of a patient with learning disabilities in nursing handover
We are unsure whether it is acceptable to use carers to ―speak for‖ patients/ how do nurses establish who is patient‘s
advocate
4.3.2 Follow-up nominal group
For ease of reference, the preliminary nominal group will be referred to as NG2. This group was conducted in June 2008 as a session comprising part of the bi-monthly Nursing Sisters‘ Meeting.
4.3.2.1 Participants of NG2
Information about the participants of NG1 can be found in Appendix R4.2, which includes Table 6: Profile of participants in NG2.
4.3.2.2 Findings of NG2; consensus of participants
The following ideas were generated in response to the two questions:
Question 1: ―Have hospital passports made a difference to how you work with patients with learning disabilities? If so, how?‖
Question 2: ―What challenges do we still face when working with patients with learning disabilities?
Responses to Question 1 were recorded in rounds using the same method as for NG1. Only one round took place in which ideas were recorded, and all participants then passed in the following round indicating that there were no new ideas. In total fifteen ideas were recorded on the flip charts; these were consolidated to eight (see Table 7) following a discussion in the group. As in NG1, the participants declined the opportunity to re-rate ideas, however the group concluded that they did not want to disregard any items as firstly, they felt they were all important and secondly because there were only eight ideas. Therefore agreement was reached about the eight most important ways in which passports have made a difference to nurses working with patients with learning disabilities. In response to the question ―Have hospital passports made a difference to how you work with patients with learning disabilities? If so, how?‖ consensus of opinion showed that the three most important were with (in summarised form) understanding the patient‘s needs, gaining rapport and providing information.
Exactly the same process was repeated for Question 2. Twenty nine ideas were generated in three rounds, and after discussion, these were
consolidated to ten ideas. When offered the opportunity to add further ideas, two new ones were added that the group felt were individual and should not be combined with existing ones. In response to the question ―What
challenges do we still face when working with people with learning disabilities?‖ consensus of opinion showed that the three most important challenges were (in summarised form) understanding legal issues, identifying a single communication system and involving patients.
The participants of NG2 appeared used to group work and readily took on the task by silently writing their ideas. Throughout the session, three nurses had to separately leave the room to respond to bleeps. This is a real
consequence of conducting group work in a work based environment, but as the staff were used to bleeps, it did not seem to have a disruptive effect.
Some of the nurses seemed to be visibly moved having read the Death by Indifference (Mencap 2007) excerpt. This contributed to some very heart-felt group discussion, especially as one participant had worked at the hospital were one of the patients featured in the Mencap report had died. She explained to the group that although she had not been part of the team looking after the patient, the whole organisation had been affected by the investigation, publicity and the resulting changes in practice and policy.
Two participants opted to complete the free comments forms that were distributed to all participants; their comments were:
―Passports seem like an excellent move forwards and will remove a lot of the frustrations / issues that have been faced recently‖.
―Passports need to include information of how to cope with distressed or agitated patients‖.
The participants were provided with the facilitator‘s contact telephone number and email in case they had any questions or concerns about the group, though at the time of writing, the facilitator had not been contacted by any of the participants. NG2 took a total of 85 minutes to administer, which include the time taken for the ensuing discussion.
Table 7 Consolidated ideas from NG2 for Question 1
Question 1: “Have hospital passports made a difference to how you work with patients with learning disabilities? If so, how?”
Participant listed these responses / ideas
Summary of idea Total of scores
Rank understanding patient‘s behaviour, needs
and routine to be able to create a therapeutic environment
Understanding patient‘s needs
63 1
gaining rapport with the patient Gaining rapport 35 2 sourcing information and ensuring
consistency / reliability of information (e.g.
points of contact / where to start looking for further info)
Providing information
19 3
supporting compliance with intervention / treatment
Helping compliance
12 4a
allowing carers flexibility (e.g. re visiting – can stay / go realizing that patient‘s needs can be identified)
Flexibility for carers
12 4b
assessing patients needs for specific equipment / approach
Understanding equipment needs
9 6
understanding preferred method of
communication (such as getting pens and paper for alternative communication)
Understanding communication method
9 7
Removing pressure of time required to initially assess patient
Reducing time pressures
9 8
Table 8 Consolidated ideas from NG2 for Question 2
Question 2: “What challenges do we still face when working with