lable at ScienceDirect

Nurse Education in Practice 11 (2011) 165–167

Contents lists avai

Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Guest Editorial

Care for people with an intellectual impairment or mental health problems:Moving forwards

Introduction

Mencap (2010) have recently announced ‘Getting it right’,a campaign which invites NHS Trusts to commit to the implemen-tation of a Charter in an attempt to improve standards for patientswith intellectual disabilities (learning disabilities) utilising main-stream NHS services. This follows two previous reports producedby Mencap (2004, 2007) which identified sub-standard carewhen people with intellectual disabilities have accessed bothprimary care and acute NHS services and provided recommenda-tions for change, to date these recommendations have remainedlargely unaddressed.

Valuing People (2001) called for minimisation of specialistservices for peoplewith intellectual disabilities and amove towardsmainstream NHS provision, there is no specific National ServiceFramework for this vulnerable patient group. This was the next(arguably) logical step following the shrinkage and dissolution ofthe long stay hospitals, however education of the healthcare work-force remains addressed despite repeated recommendations(Mencap, 2004; Disability Rights Commission, 2006; Mencap,2007; Michael, 2008; Parliamentary & Health ServiceOmbudsman, 2008; Mencap, 2010).

‘Death by indifference’ described the disturbing circumstancesin which six patients with intellectual disabilities died whilst inthe care of the NHS, in response the Government commissionedHealthcare for All (Michael, 2008), an Independent Inquiry whichrecommended that all undergraduate and post qualification clinicaleducation for health professionals should include a mandatoryelement in the care of people with intellectual disabilities.

Transferable skills

People with intellectual disability cannot be viewed in isolationif the NHS is to tackle the inequalities of vulnerable patients whoaccess mainstream NHS provision. Clark and Griffiths (2008) dis-cussed the transferable skills that were essential for health profes-sionals working with a variety of patient groupswho have cognitiveimpairment for various reasons and adopted the term ‘intellectualimpairment’ claiming that many of these patients presented withsimilar issues such as communication problems and challengingbehaviour which mainstream NHS staff found problematic in rela-tion to care delivery. The exact numbers of people with intellectual

1471-5953/$ – see front matter � 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.nepr.2010.10.007

disability are unknown but estimates of prevalence in the UK arecalculated at approximately 2.5% (Dept of Health, 2001), accuratefigures remain elusive of those who have borderline intellectualdisabilities and are formally unknown to services, many have co-morbid mental health problems (Clark, 2007). Patients who havevarious types dementia of which there are approximately 165,000new cases diagnosed annually (Matthews and Brayne, 2005), thoseliving with the disability of traumatic brain injury whose numbersare estimated at 500,000 (Tennant, 2005), or people with severeand enduring mental health problems whereby cognition isaffected may also pose challenges to mainstream NHS healthprofessionals, as may patients who have transitory cognitiveimpairments such as those who abuse substances, delirium, stroke,or meningitis.

People with intellectual disability, other intellectual impair-ments (as discussed above) and/or mental health problems havegreater physical and mental health issues than the general popula-tion (Disability Rights Commission, 2006; Khran et al., 2006;Higgins & O’Toole, 2008) including coronary heart disease, obesity,diabetes, sensory impairments, gastrointestinal and oral healthproblems, epilepsy, depression and psychosis. Poor coping mecha-nisms and communication issues compound access, diagnosis,treatment and care (Fraser and Nolan, 1995; Clark and While,2008). Diagnostic overshadowing, whereby symptoms in thepatient are attributed to the initial diagnosis (for example intellec-tual disability, dementia or severe mental health problem) andother illnesses are therefore overlooked as a consequence thuspreventing further investigation or treatment is common andoften compounded by communication problems and challengingbehaviour (Kelly, 2008).

The way forward

The ‘getting it right’ campaign (2010) makes a series of recom-mendations for NHS Trusts to adopt including on-going awarenesstraining in intellectual disability for all NHS staff and the appoint-ment of specific liaison nurses for intellectual disability in hospi-tals. Expertise in intellectual disabilities is at an all time lowwith fewer nurses being trained in the speciality (Dept of Health,2007), calls have been made for research and development stan-dards in intellectual disabilities to be similar to those of otherspecialities, however Griffiths et al. (2007) argue that this is not

Guest Editorial / Nurse Education in Practice 11 (2011) 165–167166

the case with the majority of work in this area described as ‘limitedin quality and it’s ability to provide generalizable or trustworthyinsights’.

While and Clark (2010) call for clinical nurse specialists in bothacute and primary care services who will adopt the ‘disorderapproach’ seen in other specialities such as incontinence or dia-betes whereby they will be complimented by nurses with specialinterests in intellectual disabilities, intellectual impairment andmental health problems at ward level. Effective change in thecare of these patient groups can only come about through effectiveleadership and While and Clark (2010) state that this must comefrom a transformational approach from the Government and theprofessional regulatory bodies.

The transferable skills required by health professionals inorder to care for these vulnerable and complex patients mustcome from generic health professionals and it would be finan-cially prohibitive to engage liaison nurses specialising in intellec-tual disabilities alone unless they have the transferable skillsapplicable to the other groups, including the knowledge of acutehospital care and understanding of the importance of researchand development. The clinical nurse specialist model proposedby While and Clark (2010) is more financially efficient, educatesthe workforce in all the complex and vulnerable groups referredto in addition to promoting a career trajectory, work towardsthis model has already commenced at one Central LondonUniversity.

Addressing the problem

It is imperative to address the care needs of people with intel-lectual disabilities, the broader spectrum of intellectual impair-ment and mental health and the impact that such conditionsmay have when these groups of patients access mainstreamservices in the pre-registration curriculum. Barriball and Clark(2005) described the phased and innovative approach that theirparticular university had adopted in the pre-registration pro-gramme for adult, child and mental health student nurses inorder to provide programmes which gave opportunities forstudents to develop both skills and confidence when caring forpeople with intellectual disabilities. They described a longitudinalapproach to teaching and learning which included short socialcare placements for students in intellectual disabilities, work-shops given by actors with intellectual disabilities and participa-tion in a health screening project. It is essential that nursesdevelop and enhance the skills needed to formulate and actionappropriate plans to meet the needs of complex patients utilisinga bio-psychosocial approach throughout their careers, educationand training in this speciality must not end with registration.The transferable skills that have been shown to be applicable toa range of client groups along with the importance of collabora-tive working and communication must be at the core of any preor post-registration educational intervention.

A structured approach

Courses for qualified nurses need to mirror that of pre-registra-tion programmes in influencing practice, but with current timeand economic restraints, the release of staff to attend courses is likelyto become ever more problematic given fiscal cuts in the NHS.Furthermore, it would be unrealistic to expect all nurses to be ableto attend despite the need for all to regularly engage with thesepatient groups.

In recognition of the necessary skills, knowledge and attitudesthat are needed to ensure quality care for these patient groupsone London University is now offering a post-registration course

for adult trained nurses in the care of patients with mental healthproblems and intellectual impairment. It concentrates on a flex-ible approach to patient care and highlights the use of transfer-able skills drawing on collaborative working and inter andmultidisciplinary communication. A scenario approach is utilisedto enhance teaching and learning relating to these patient groupswhen cared for on the hospital ward, out-patient or primary caresetting, emergency care and risk assessment are highlightedthroughout. The course has proved popular and is highly evalu-ated, it has now been extended to midwives due to servicedemand. Despite the clear need and positive feedback, this isthe only course of its type in the United Kingdom. In order toprovide credible and high quality education in this speciality itis necessary for lecturers to have dual registration (either mentalhealth or learning disabilities coupled with adult nursing)however this is increasingly rare. Thus, there is an imbalancebetween the education needed and those able to provide it espe-cially to senior nurses.

Conclusion

A plethora of recent reports have time and again illustratedthat a growing number of people are receiving care from nursesthat is sub-standard. The lack of knowledge and awareness ofthe needs of people with all forms of intellectual impairmentand/or mental health problems would seem to be a major influ-ence on that care. Only with a structured approach to educationalprovision to nurses at all stages of their career and the necessaryexpertise to provide it can we begin to address this issue,however current fiscal constraints on the NHS may producebarriers to necessary progress for these vulnerable groups ofpatients.

References

Barriball, K.L., Clark, L.L., 2005. All preregistration students should develop skills inlearning disabilities. British Journal of Nursing 14 (3), 166–169.

Clark, L.L., 2007. Learning disabilities within mental health services; are weadequately preparing nurses for the future? Journal of Psychiatric and MentalHealth Nursing 14, 433–437.

Clark, L.L., Griffiths, P. (Eds.), 2008. Learning Disability and Other IntellectualImpairments: Meeting Needs throughout Health Services. Wiley, Chichester.

Clark, L.L., While, A., 2008. Meeting the needs of people with intellectualdisability within primary care. British Journal of Community Nursing 13(12), 550–555.

Department of Health, 2001. Valuing People; a New Strategy for Learning Disabilityfor the 21st Century. Dept of Health, London.

Department of Health, 2007. Good Practice in Learning Disability Nursing. Dept ofHealth, London.

Disability Rights Commission, 2006. Equal Treatment; Closing the Gap. A FormalInvestigation into the Physical Health Inequalities Experienced by Peoplewith Learning Disabilities and/or Mental Health Problems. DRC, London.

Fraser, W., Nolan, M., 1995. Psychiatric disorders in mental retardation. In:Bouras, N. (Ed.), Mental Health in Mental Retardation; Recent Advances andPractices. CambridgeUniversity Press, Cambridge, pp. 79–92.

Griffiths, P, Bennett, J, Smith, E, 2007. The size, extent and nature of the learningdisability nursing research base: A systematic scoping review. InternationalJournal of Nursing Studies 46, 490–507.

Higgins, S., O’Toole, M., 2008. Meeting the health needs of people with intellectualimpairment. In: Clark, L.L., Griffiths, P. (Eds.), Learning Disability and OtherIntellectual Impairments: Meeting Needs throughout Health Services. Wiley,Chichester, pp. 15–40.

Kelly, M., 2008. Challenging behaviour. In: Clark, L.L., Griffiths, P. (Eds.), LearningDisabilities and Other Intellectual Impairments; Meeting Needs throughoutHealth Services. Wiley & Sons, Chichester, pp. 179–196.

Khran, G., Hammond, L., Turner, A., 2006. A cascade of disparities: health and healthcare access for people with intellectual disabilities. Mental Retardation andDevelopmental Disabilities Research Reviews 12, 70–82.

Matthews, F.E., Brayne, C., Medical Research Council Investigators, 2005. The inci-dence of dementia in England and Wales: findings from the five identical sitesof the MRC CFA study. PloS Medicine 2, e193.

Mencap, 2004. Treat Me Right! Better Healthcare for People with a LearningDisability. Mencap, London.

Guest Editorial / Nurse Education in Practice 11 (2011) 165–167 167

Mencap, 2007. Death by Indifference. Mencap, London.Mencap, 2010. Getting It Right Charter. Mencap, London.Michael, J., 2008. Healthcare for All. Report into Access to Healthcare for People

with Learning Disabilities (WWW document). http://www.iahpld.org.uk/Healthcare_final.pdf (accessed 27.09.09).

Parliamentary & Health Service Ombudsman, 2008. Six Lives; the Provision ofPublic Services to People with Learning Disabilities. Office of the Parliamentary& Health Service Ombudsman, London.

Tennant, A., 2005. Admission to Hospital Following Head Injury in England; Inci-dence and Socio-economic Association (WWW document). http://www.biomedcentral.com/1471-2458/5/21 (accessed 28.03.10).

While, A., Clark, L.L., 2010. Overcoming ignorance and stigma relating to intellectualdisability in healthcare: a potential solution. Journal of Nursing Management 18,166–172.

Allan Hicks*, Louise L. ClarkKings College London, James Clerk Maxwell Building,

57 Waterloo Road, London SE1 8WA, UK* Corresponding author. Tel.: þ44 2078483527.E-mail address: allan.hicks@kcl.ac.uk (A. Hicks)