Staffs Values and Attitudes towards Patients with Learning Disabilities - Essay Example

Critical Incident: Staff’s Values and Attitudes towards Patients with Learning Disabilities (Forensic Patients) Learning disability is defined as having significantly reduced ability to understand new or complex information and to learn new skills (impaired intelligence) with reduced ability to cope independently (impaired social functioning) that started before adulthood with a lasting effect on development. (Valuing People, 2001). In 1999, 210,000 people were afflicted with severe and profound learning disabilities comprising of 65,000 children and young people, 120,000 working age adults and 25,000 older people. Around 25 per 1000 people or 1.2 million suffered from mild to moderate learning disabilities in the United Kingdom. Distribution of severe and profound learning disabled people is even and uniform across the country and across the socio-economic groups. For mild to moderate learning disabilities, a link has been established with poverty and rates are therefore higher in deprived and urban areas. Increase of severe and profound learning disabled patients is approximately 1% annually over the next 15 years. Only less than 10% of the learning disabled work and are highly dependent on social security benefits. Public expenditures for learning disabled services was over £3 billion with £1.4 billion spent on health and £l.6 billion on social services. Furthermore, about £308 million was spent by social services and £177 million by health on supporting disabled children, though not all of them have learning disabilities (Valuing People, 2001). People with learning disabilities may be categorized as vulnerable adults when they are aged 18 and over and “who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation” (No Secrets, n.d.). If a person with a learning disability is convicted of a violent crime, he may be considered a forensic patient while the caring for this type of patient has been termed as forensic nursing. Forensic nursing is a specialty of mental health nursing, and has a specific group of skills and interventions developing around patient offending and antisocial behavior in a range of settings from high security to community care (Kettles et al, 2002). Forensic nurses are nurses they specialize in the care, treatment, rehabilitation and management of individuals who have either violated criminal law or been deemed to pose a high level of dangerousness (Whyte, 2000). Forensic nursing care includes education, approaches, assessment, the security-therapy ‘onion’ (where the outer layers of nursing security enable nursing care and nurse therapy layers inside), specialist practice like socially constructed narrative interventions, community care and rehabilitation (Kettles and Wood, 2006). Forensic nursing is evolving into a multi-dimensional service with three areas of enhancement: (1) risk assessment; (2) professional, legal and ethical aspects of care; (3) interpersonal competencies. This makes forensic nurses more specialized than other types of nurses because, for example, in the second area (professional, legal and ethical aspects of care) it is not only important to know about the Mental Health Act but also of the Criminal Procedures Act, the Children Act, Common Law, the Incapable Adults Legislation, the Data Protection Act and criminal justice processes (Kettles and Wood, 2006). This paper aims to critically examine the proper attitude and values staff caring for forensic patients must exhibit as provided by laws and government policies. The care of people with learning disabilities has been around for a very long time. For example, in Sweden, it started in the middle of the 19th century. It began with the development of services for the mentally retarded. These were concentrated in often large institutions catering to a big number of learning disabled patients wherein services were adjusted to meet the special needs and demands were changed to meet the capabilities of the mentally retarded patient. The intention behind this was optimistic – a preparation for the retarded person to be included into normal society (Ericson, 1985). This trend continued to prosper in the Scandinavian countries until the 20th century. The first four decades were characterized by a change of perception of learning disability. There was a growing fear of the negative effects of the mentally retarded on society in general. Because of these, the previously optimistic intention behind care for learning disabled patients transformed into a pessimistic one – a separation between the mentally retarded and normal society. This change was translated into more restrictive measures in the care of patients with learning disabilities. The institutions once used to train the mentally retarded became prisons to protect society from their disabilities. As such, the people with learning disabilities lived in miserable conditions – partly due to the fact that society at that time was under economic and political conflict (the two World Wars) and very limited resources (Ericson, 1985). This downward trend against people with learning disabilities has since been reversed. In 1943, the Swedish government adopted the “principle of normalization” that sough to create a welfare society with the disabled included as far as possible in the ordinary system of social services that were under development. This required that society develop social and health services that would allow those citizens that had lived a life of need to live a good life. This “normalization” saw a shift from institutionalized care for the disabled to more inclusive community services. Nirje, a representative of the parents’ movement in Sweden at that time, further detailed normalization into eight points: (1) normal rhythm of the day; (2) normal rhythm of the week; (3) normal rhythm of the year; (4) opportunity to experience the normal developmental phases of the life cycle; (5) that ones’ own choices, wishes and demands be respected; (6) that one lives in a bisexual world; (7) that one has a normal economic standard and; (8) that the standards of physical facilities available to the mentally retarded are the same as those apply for non-handicapped citizens (Ericson, 1985). The “normalization principle” was realized in Sweden over the next 20 to 40 years after its implementation. The effects have been seen in the services for integration and inclusion. Although not all mentally retarded have been exposed to societal inclusion in the form of services, there has been considerable difference (Ericson, 1985). Currently, forensic patients are admitted in a variety of venues including high security hospitals, medium secure units, low secure units, acute mental health wards, specialized private hospitals, psychiatric intensive care units, court liaison scheme and outpatient, community and rehabilitation services (Kettles and Woods, 2006). Forensic nursing has seen an evolution as a service distinct from other forms of nursing. There has been much debate over this and criticisms point to forensic nurses feeling they are “glorified custodians who strut around swinging a capacious bunch of keys in a quest for domination of those under their care” (Collins, 2000). Although this may be a bit exaggerated, it is possible that some staff members charged with caring for the forensic patients may show disrespect and hostile attitudes towards the forensic patients. It is possible that some simply perform their duties with taking into consideration the personal feelings and welfare of the forensic patients. This is especially true because of the risks associated with this profession. Security, safety and vulnerability are issues in the UK because forensic nurses also perform the role of not only care-giver but also security to forensic patients. Some known characteristics of forensic nurses are: (1) ability to work with patients while understanding and working within the parameters provided by danger and cultural systems, probability measurement and risky behavior, offending behavior, recidivism and criminal justice systems, responsibility to and protection of the public and ethical and professional functioning; (2) varying security needs being applied to patients as they move up to and down from high security care through differing security levels; (3) offense-specific care, such as use of psychodynamic and dialectical behavior therapies for homicidal patients or sex offender therapies for pedophile patients (Kettles and Woods, 2006). Some of the consequences of taking this profession are fulfillment from performing appropriate care, management, treatment and rehabilitation of criminals who have multiple pathologies and risk of receive anger, hostility and aggression leading to worst possible scenarios of being held hostage or receiving physical and psychological injury and even death (Kettles and Woods, 2006). These consequences, when weighed by forensic nurses, may push them to take preemptive steps to ensure their own safety when taking care of forensic patients. This may include excessive hostility and disrespect of the patient with a learning disability. Furthermore, discrimination is a common problem faced by people with learning disabilities. However, these inappropriate values and attitudes may violate the inherent human rights of the forensic patient. The Human Rights Act of 1998 stipulates based on the European Convention of Human Rights that all prisoners have the right to proper medical treatment (Your Right, 2004). The Universal Declaration of Human Rights stipulates that all human beings are born free and equal in dignity and rights (Article 1); that no one may be subjected to cruel and degrading treatment (Article 5); that all are entitled equal protection against any discrimination (Article 7) (Universal Declaration of Human Rights, 1948). The Disability Discrimination Act of 1995 also ensures that no discrimination must befall any person with disabilities including forensic patients (implementation is covered by the Disability Rights Commission) (Valuing People, 2001). Other important legislation supporting forensic patients rights include the Race Relataions Act of 1976 and amended in 2000, Sex Discrimination Act of 1975 and the UN Convention on the Rights of the Child adopted the United Kingdom in 1992. These being the rights of all including forensic patients, the staff tasked with caring for them must uphold these in the values and attitudes towards the patients. Similar to the policies adopted by the Scandinavian countries, the United Kingdom has adopted the policy of Valuing People: A New Strategy for Learning Disability for the 21st century. The objective is that people with learning disabilities (including forensic patients) must no longer be marginalized and excluded from society. This policy comes 30 years since the last policy adopted to tackle this problem, Better services for the mentally handicapped. The government envisions that the rights, independence, choice and inclusion of people with learning disabilities are furthered by this policy. The main problems identified with services for patients with learning disabilities are lack of choice and control over their lives, needs of patients are often unmet and may also lead to death, social isolation and inflexibility of day services to individual needs (Valuing People, 2001). The main focus of the Valuing People strategy is to solve problems with (1) families with disabled children especially for those with severely disabled children; (2) young disabled people at the point of transition into adulthood; (3) carers in particular those caring for people with complex needs; (4) choice and control; (5) health care; (6) housing choice; (7) day services; (8) employment; (9) people from minority ethnic communities; (10) inconsistency in expenditure and service delivery; and (11) partnership (Valuing People, 2001). To allow this vision of an inclusive society with choice, rights and independence for people with learning disabilities, several policies and guidelines have been set place including the establishment of the Learning Disability Development Fund, learning disability partnership boards, local frameworks for person-oriented projects, modernization of day services, the Connexions Service and the Implementation Support Fund (Valuing People, 2001). With regards to the health of forensic patients, they have greater needs since they are more likely to experience mental illness, chronic diseases, epilepsy and physical and sensory disabilities. Poor oral health and age-related diseases such as stroke, heart disease, chronic respiratory diseases and cancer are also prevalent among forensic patients. Inadequate diagnosis and treatment may also lead to specific diseases such as heart disease, hypothyroidism and osteoporosis (Valuing People, 2001). This inadequacy is from the fact that people with learning disabilities also often have problems with communication. Therefore, the values and attitudes of staff must be that of patient and careful attention to the medical needs of the forensic patient. When it comes to life fulfillment of patients, services must allow for adequate social inclusion and independence. However, these services have often been provided by large institutions which include high security and specialized long-stay hospitals for forensic patients. It has been found that the most severely disabled people often receive the poorest service (Valuing People, 2001). Since most learning disabled people are exposed to little social interaction, it is important that they receive this important aspect of treatment from their care-givers. Therefore, the attitudes of staff towards their forensic patients must be that of friendliness and cordiality since they are most likely part of the small group of people to whom these forensic patients interact. Quality of service is a big issue with forensic patients. Quality assurance for learning disability services must be further developed. The Care Standards Act of 2000 was set in place to ensure this. The best quality services must be accorded most especially to people with additional and complex needs such as those with severe and profound disabilities (including those with sensory impairments, epilepsy, autistic spectrum disorder together with learning disabilities, behavior that challenges carers and service providers and conditions associated with old age. Quality service is defined as people with learning disabilities receiving the same level of support and protection from abuse and harm from other citizens and that they lead lives that are safe – given their vulnerabilities (Valuing People, 2001). Because forensic patients are also classified under vulnerable adults, they may be susceptible to abuse. Abuse is defined as the violation of an individual’s human and civil rights by any other person or persons. It may be a single or repeated act, physical, verbal or psychological and neglect or omission. A vulnerable person may be persuaded to enter into a financial or sexual interaction without the consent of the person or if he cannot consent or may be involved in a relationship that may result in harm to and exploitation of the person subjected to it. The types of abuses that forensic patients may be exposed to include: physical abuse – hitting, slapping, pushing, kicking, misuse of medication, restraint or inappropriate sanctions; psychological abuse – emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or supportive networks; neglect and acts of omission – ignoring medical or physical care needs, failure to provide access to appropriate health, social care or education services, withholding of the necessities of life such as medication, adequate nutrition and heating; and discrimination abuse – racist, sexist, that based on a person’s disability, and other forms of harassment, slurs or similar treatment. They may also be subjected to neglect and poor professional practice – isolated incidents of poor or unsatisfactory professional practice, pervasive to ill treatment or gross misconduct, repeated instances of poor care known as institutional abuse. These abuses may be done by relatives, family members, professional staff, paid care workers, volunteers, other service users, neighbors, friends and associates, people who deliberately exploit vulnerable people and strangers. Patterns for abuse include: serial abuse, long term abuse, opportunistic abuse, situational abuse, neglect of a person’s needs, institutional abuse, unacceptable treatments, failure of agencies to uphold anti-racist and anti-discrimination laws, failure to access key services, misappropriation of benefits and money, and fraud and intimidation. In determining the degree of abuse, factors that are considered are the vulnerability of the victim, nature and extent of the abuse, length of time of occurrence, impact to the victim and risk of repeated and intensified abuse (No Secrets, n.d.). Forensic nurses may be susceptible to abuse their patients in these forms and patterns. In summary, the forensic nurse must have values and attitudes that cater to the best interests of the forensic patient. He or she must still apply and integrate general mental health, psychiatric nursing and psychological principles and evidence together with forensic knowledge like the criminal justice system, risk, safety, security and forensic practice, role, interventions and skills within a secure environment and in the community (Kettles and Wood, 2006). He or she must provide the best quality service given the special needs of the forensic patient. Furthermore, he must interact with the patient cordially and with respect to uphold the rights of the patient. REFERENCES Valuing people: A new strategy for learning disability in the 21st century. (2001). Retrieved 8 May 2007 from http://www.archive.official-documents.co.uk/ document/cm50/5086/5086.pdf Ericson, K. (1985). The Principle of Normalization: History and experiences in Scandinavian countries. Retrieved 8 May 2007 from Uppsala University, Department of Education Website: http://www.skinfaxe.se/ebok/hamburg.pdf Kettles AM, Woods P & Collins M (Eds) (2002) Therapeutic Interventions for Forensic Mental Health Nurses. London: Jessica Kingsley Publishers. Whyte L (2000) Educational aspects of forensic nursing. In: D Robinson & A Kettles (Eds) Forensic Nursing and Multidisciplinary Care of the Mentally Disordered Offender. London: Jessica Kingsley Publishers. Kettles AM and Woods P (2006) A concept analysis of ‘forensic’ nursing. The British Journal of Forensic Practice. 8: 16-27 Collins M (2000) The practitioner new to the role of forensic psychiatric nurse. In: D Robinson & A Kettles (Eds) Forensic Nursing and Multidisciplinary Care of the Mentally Disordered Offender. London: Jessica Kingsley Publishers. Your Rights: The Rights of Prisoners: Medical Treatment. (2004). Retrieved 8 May 2007 from http://www.yourrights.org.uk/your-rights/chapters/the-rights-of-prisoners/medical-treatments/ Universal Declaration of Human Rights. (1948). Retrieved 8 May 2007 from http://www.un.org/Overview/rights.html Read More