2 How we have approached the challenges
Unity and collaboration
A key feature of the implementation of the Strengthening the Commitment initiative has been the way the four countries have worked together to address the challenges and opportunities to create a modern learning disability nursing service fit for the 21st century. Partnership working across all four countries has been central to our work and every country has contributed to a shared understanding of the agenda and of how to approach it.
Inevitably each of the countries has worked at a different pace as each approached the challenges from a different starting point. The Chief Nursing Officers of each country have been actively and visibly committed to strengthening the role of learning disability nurses and recognise the benefits of having specifically prepared nurses to support people with learning disabilities. All recognise the crucial role that learning disability nurses play in the care of people with learning disabilities whether in specialist hospital services or within community services, in championing health improvement and working to tackle the health inequalities experienced by people with learning disabilities.
A commitment to implementation
Across all four countries there has been a commitment to implementing the recommendations in Strengthening the Commitment and to set up systems to monitor progress. A clear programme of work has meant that the strategy has been driven forward nationally and locally and regular reporting processes have ensured all countries kept the strategy firmly in view. There has been progress on all seventeen recommendations and regular reviews of action plans to strengthen services for people with learning disabilities.
High level leadership
A UK-wide Strengthening the Commitment Steering Group has provided strategic leadership and a clear work plan with deliverables. The Steering Group has coordinated activities and initiatives across the four countries and has been the focus for great achievement and celebration. Membership of the Steering Group, see Appendix 1, has included the leads from each of the four countries, student representatives, academics, the independent and voluntary sectors, the Royal College of Nursing, and practising learning disability nurses.
Visible, high profile leadership within and across all four countries has been a key factor in ensuring that the challenges set out by Strengthening the Commitment have been kept clearly in view. Members of the Steering Group have acted as role models and a focus for the aspirations of many learning disability nurses by being visible, approachable and actively expanding the horizons of learning disability nursing.
Recently, the UK Strengthening the Commitment Steering Group has been joined by the Deputy Chief Nurse, representing the Chief Nurse, from the Republic of Ireland seeking support and partnership working to modernise learning disability nursing provision in her own country.
The UK Strengthening the Commitment Steering Group has established positive working relationships with key national organisations such as the Royal College of Nursing, MENCAP, the Royal Society of Medicine, the Council of Deans of Health and many others. Such partnerships have ensured that learning disability nursing is regularly considered and reviewed by key stakeholders.
Throughout all four countries there have been examples of initiatives being spearheaded by senior leaders to demonstrate the importance placed on developments such as the Health Equalities Framework (HEF).
Nurturing future leaders
Leaders at all levels of the profession must be supported. A UK-wide initiative by the UK Strengthening the Commitment Steering Group focused on nurturing future leaders within the profession. A leadership programme for 3rd year students attended by 42 people from across the UK included a two-day leadership workshop which explored the development of practice, research and writing for publication with the opportunity to discuss issues in small groups with leadership coaches. The evaluation of the workshop highlighted the value participants found in developing their personal leadership abilities and their confidence to use these abilities to bring about change in practice.
'It's made me brave … I can go into situations and ask questions.'
Amy Hodkin, student
Engagement with frontline practitioners and networking
Implementing the strategy has been grounded in working with frontline practitioners to engage them with the aspirations and practical planning resulting from the initiative. There has been bottom-up engagement with action plans throughout the NHS, the independent and voluntary sectors. Clinicians at all points of their careers have engaged with the process and networking has flourished.
There has been an explosion in the use of social media and communities of practice have developed as a result with practitioners sharing good practice and experiences across the UK. Previously learning disability nurses and students tended to be fragmented and could feel isolated but use of Facebook and Twitter alongside numerous more conventional meetings and events, has enabled practitioners to become connected with Strengthening the Commitment as an anchor for the development of new ideas. As practitioners move out of their more traditional roles, it is the more important that they are able to stay connected with their colleagues and to exchange ideas and practice and to drive the profession forward.
A voluntary, social media based discussion and networking forum set up by learning disability nurses which has developed an international following. #ldnursechat is in talks with universities to promote the profession and to share networking skills.
Connects learning disability nurses, talking and sharing with everyone with a passion for learning disability care. Has 3,982 followers (at June 2015).
Academic networking and the evidence base for learning disability nursing
It was clear that the academic underpinning, research and the evidence base for learning disability nursing needed to be strengthened. The UK Learning and Intellectual Disabilities Nursing Academic Network (LIDNAN) was created to tackle this challenge and has proved highly successful. The aims of LIDNAN are to:
- Represent and promote learning disability nursing education, research and practice development
- Influence and respond to UK learning disability nursing agenda through well-informed debate, discussion and dissemination of material
- Act as a source of consultation and advice to learning disability nurses and others on learning disability nursing education and research
- Share good practice and innovations in the development and conduct of learning disability nursing education and research.
The network has achieved a great deal in the past three years and has established a model for collaborative working which strengthens the profession and ensures a robust academic and research base for the future. Its work plan consists of nine areas of activity including post-registration development. In Scotland the Career and Development Framework for Learning Disability Nursing in Scotland (NES, 2013) outlines the developmental needs of the registered nursing disability workforce, reflecting the key priorities for workforce development in Strengthening the Commitment.
Positive practice (UK wide)
Developing research capacity and capability in learning disability nursing
The following case study illustrates the work that UK LIDNAN has achieved to develop research capacity and capability among learning disability nurses.
Two reviews of learning disability nursing research (Northway et al, 2006; Griffiths et al, 2007) highlighted key limitations of learning disability nursing research relating to both quality and quantity. Strengthening the Commitment included two recommendations (16 and 17) relating to the need for practice to be evidence-based and calling for an extension of learning disability nursing research. To progress work in these areas a work stream concerning research was established under the auspices of the Learning and Intellectual Disabilities Nursing Academic Network (LIDNAN).
The aim was to increase research capacity and capability within learning disability nursing to promote better quality of service provision and enhance development of the profession thus linking to all of the key principles of Strengthening the Commitment.
Initial activities focused on developing wide engagement with research by raising awareness and stimulating discussion and interest. A research session was included in the leadership workshop held in July 2013 for 3rd year student nurses. A Facebook group, twitter feed and blog were established in March 2014 and by May 2015 the Facebook group had grown to 1,254 members.
At the Positive Choices conference in 2014 a survey was undertaken of delegates (310 responses) to determine factors affecting the use of research in practice, sources of information used and priorities for future learning disability nursing research. The findings of this survey suggest that whilst practitioners use a variety of sources to access evidence there are barriers to using such evidence to develop practice. Key priorities for future research were identified as being access to healthcare and health promotion, service user perspectives, and the outcomes of nursing interventions.
A paper detailing findings from this study relating to the teaching of research has been published (Northway et al, 2015). In December 2014 the University of South Wales hosted a research event attended by over 50 delegates from many parts of the UK including students, clinically based staff and academics. All delegates engaged in undertaking a strengths, weaknesses, opportunities, threats (SWOT) analysis that has been used to inform development of a position paper regarding learning disability nursing research.
This work stream is still in its relatively early stages. Nonetheless there has been a great deal of activity and many more learning disability nurses are now engaged in discussions regarding research. This engagement has been at all levels of the profession including students, clinicians and academics and from across the UK.
It has been encouraging that many nurses want to be actively involved in research - the challenge now is to develop frameworks that enable this to happen. The position paper has been presented to the UK Strengthening the Commitment Steering Group and to the Academic Network: discussions are currently taking place as to how its recommendations will be taken forward.
Ruth NorthwayUnit for Development in Intellectual Disabilities
School of Care Sciences
Faculty of Life Science and Education
University of South Wales,
Telephone: 01443 483177
Members of the working group were: Helen Atherton (University of Leeds), David Charnock (University of Nottingham), Nicky Genders (University of South Wales), Joann Kiernan (Edge Hill University) and Sue Read (University of Keele)
UK Learning Disability Consultant Nurse Network
The UK Learning Disability Consultant Nurse Network (UK LDCNN) has provided a vital focus for innovation and development across all four countries. The open sharing of ideas and initiatives has meant that ideas have spread quickly and readily. A major piece of work undertaken by members of the UK LDCNN was to develop an outcome measure for learning disability nursing practice: the Health Equalities Framework (HEF). The HEF provides a clear example of nurse leaders stepping up to meet the challenges to the profession laid out in Strengthening the Commitment. Its UK wide dissemination demonstrates the value of a collaborative four-country approach and the UK Strengthening the Commitment Steering Group was an invaluable reference group at all stages of its development.
Strengthening the Commitment (recommendation 9) called on nurse leaders to develop outcomes focused frameworks to evidence the value of the learning disability nursing contribution.
The Health Equalities Framework
The Health Equalities Framework (HEF) is a systematically developed, evidence based outcomes framework which was developed by four members of the UK LDCNN (Dave Atkinson, Phil Boulter, Crispin Hebron and Gwen Moulster). It measures the extent to which services are delivered to reduce the impact of service users' exposure to determinants of health inequalities. Exposure to these determinants is known to be associated with premature, avoidable deaths and grossly impoverished quality of life.
All four countries are supporting its rollout and pilot work is ongoing in Northern Ireland and Scotland and has recently been concluded in Wales. In England, where the framework was initially developed, increasing numbers of services are making routine use of the HEF as key outcome measure. Subjective feedback from practitioners suggests the HEF guides nursing practice, validates nurses' decision making and informs caseload management.
The HEF not only measures the difference that services make to individual service users but also allows comparison of differing models of service delivery and informs commissioning decisions by aggregating anonymised data. Outcomes data is set against the context of profiles of population needs so that regional differences can be recognised and explored. The tool can therefore also inform public health strategy for people with learning disabilities.
The HEF, along with supporting materials, have been made freely available to services, practitioners and families alike. It is increasingly being recognised as having value across multidisciplinary teams and has been presented, and well received, internationally. A number of further HEF related initiatives are ongoing including: development of a free HEF app, development of a new HEF for children and young people with learning disabilities and a project which links the HEF to best practice care pathways.
Independent and voluntary sectors
The independent and voluntary sectors have a critical role to play in providing a range of services for people with learning disabilities. Many learning disability nurses are employed in the independent and voluntary sectors. However, the actual numbers of those employed are not known as employment figures for the independent and voluntary sectors are not collected nationally. The four UK health departments together with key partners and representatives from the independent and voluntary sectors have formed an Independent Sector Collaborative and have held three engagement conferences. The aim has been to establish better understanding of, and planning for, a high quality and sustainable registered learning disability workforce across all sectors. As major employers, it has been important to ensure that the independent and voluntary sector providers are engaged in workforce planning with student nurse education commissioners.
Commissioning arrangements vary across the four countries. The independent and voluntary sectors also offer a varied range of clinical placements and experience for student nurses. Exposure to the independent and voluntary sectors at an early stage in nurses' careers increases understanding and improves flexibility and transferability between sectors and employers. It also increases career options, for example, there has been an increase in the number of learning disabilities nurse consultants employed in the independent sector.
Promoting learning disability competence in other fields of nursing
There are concerns about the numbers of learning disability nurses as demand for learning disability nursing is likely to grow. There are also concerns that many staff working in general health and social care settings are seeking to expand their knowledge of how to improve how they communicate with and respond to the needs of people with learning disabilities and have little access to training. Strengthening the Commitment called for those who develop or deliver education to 'ensure that nurses in other fields of practice develop the core knowledge and skills necessary to work … with people with learning disabilities who are using general health services'.
LIDNAN together with the UK Council of Deans of Health (CoDH) published a report (Beacock et al., 2014) that addressed the question of how to best promote learning disability competence in other fields of pre-registration nursing education. The report's recommendations highlight a number of areas in which higher education provision and the framework that govern it could be developed. The recommendations include:
- a standard competency framework should be developed to support consistent delivery of learning disability competence, based on the priority areas identified in the literature
- people with learning disabilities, their families and carers should be involved in all aspects of curriculum design and delivery
- the role of learning disability nurses and how they support people across a range of settings should feature as part of education delivery
- that HEIs consider a range of activities and models as a means of delivering learning disability education.
In Scotland a series of 'Thinking Space' events facilitated by NHS Education for Scotland brought key stakeholders together to develop plans to ensure student nurses in other fields of practice are prepared to support people with learning disabilities. A number of recommendations were made including:
- supporting students to evidence achievement of Nursing and Midwifery Council (NMC) outcomes through an e-portfolio and placements with people with learning disabilities
- clarifying the roles and responsibilities of the learning disability lead (LDL), recommending an LDL for each institution offering nursing programmes and measuring their impact
- networking among the universities currently offering learning disabilities courses and those who do not.
Email: Scott Taylor