A Reflection on Anti-Discriminatory Practice in Nursing

A reflection on Anti-Discriminatory Practice in nursing using Driscoll’s (2007) reflective model

Introduction

The Nursing and Midwifery Council (2014) requires all nurses develop the knowledge and skills required to care for all service users irrespective of their chosen field of nursing, in order to meet their basic physiological and physical needs throughout the lifespan of care. This includes meeting patients’ needs in a manner that promotes anti-discriminatory practices, such as when caring for people with learning disabilities. Accordingly, as this author has chosen to pursue the field of adult nursing, this essay will use the process of reflection to explore anti-discriminatory practices when caring for service users with learning disabilities.

The process of reflection is recognised to be an invaluable learning tool for broadening depth of understanding, strengthening professional values and bridging the gap between theory and practice amongst nurses. Using the process of reflection will therefore evidence this author’s growing insight into the field of learning disability nursing. This reflection will demonstrate an understanding of the knowledge and skills required to meet the needs of service users with learning disabilities and their family members in diverse contexts. Furthermore, the work intends to show a critical understanding of how both team and inter-professional working can enhance anti-discriminatory practices, including assessing and managing risk or, safeguarding, for individuals and the wider public. Driscoll’s (2007) reflective cycle will be used to facilitate this reflection.

What? (Driscoll, 2007)

The Department of Health (2017, p.10) defines a learning disability as any condition which presents as a “significant reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning), which started before adulthood”. Thus, learning disabilities encompass a diverse range of different conditions, including autism and Attention Deficit Disorder, and which have an equally diverse range of causes that may develop prior to or, after birth (Al-Mahrezi, Al-Futaisi and Al-Mamari, 2016). Across the UK, it is estimated that approximately 1.5 million people experience some form of learning disability, with around 905,000 of these people over the age of 18 years (NHS Digital, 2018). Importantly, despite legislation requiring all professionals and organisations to promote equality in terms of basic human rights and opportunity (The Equality Act 2010. Ch.15, s.6; The Human Rights Act 1998, Ch.42, s.1), both national surveillance data and research demonstrates that this population group is vulnerable to a range of inequalities in health and wellbeing outcomes (Clough, Shehabi and Morgan, 2016; NHS Digital, 2018). For example, men and women with learning disabilities are found to have a life expectancy that is 14 years and 18 years lower than their non-affected counterparts, respectively (NHS Digital, 2018). In terms of access to health care, people living with learning disabilities are also significantly less likely to receive screening as part of preventative public health care initiatives, such as cervical cancer screening for women (Osborn et al., 2012). Equally, people with learning disabilities are disproportionately more likely to live in deprivation, to be employed and to have access to educational and vocational opportunities, versus those who do not have a learning disability (Ali et al., 2013; NHS Digital, 2018).

Especially pertinent to this work, discriminatory practices and a lack of adherence regarding policy to promote better outcomes for this population highlights that these trends are underpinned by discriminatory practices (Ali et al., 2013). For instance, people with learning disabilities admitted to hospital are frequently subject to diagnostic overshadowing, describing where health care professionals are likely to focus solely on the diagnosis of a learning disability, rather than properly exploring the presenting physical needs (Iacono et al., 2014). A lack of upholding autonomy for people with learning disabilities is also well-described, driven by discriminatory views about a lack of capacity to make autonomous decisions, even though incapacity is not present (Dowling et al., 2019; Pols, Althoff and Bransen, 2017). Moreover, it is frequently cited that many professionals, including nurses, lack the skills and knowledge to support the communication needs of people with learning disabilities, despite the requirement for all nurses to tailor their communication based on the physical and psychological status of the individual (Nursing and Midwifery Council, 2018).

So What? (Driscoll, 2007)

Such gaps in knowledge, understanding and practices, combined with discriminatory views, therefore represents an urgent need for nurses and other health care professionals to examine their approaches to care delivery for this vulnerable population group (Dowling et al., 2019; Pols et al., 2017). Accordingly, on reflection, this author recognises that they hold a broad concept of learning disabilities affecting the ability of an individual to exercise their basic right to autonomous decision-making, as is common across the evidence base (Gates and Mafuba, 2015; Krahn and Fox, 2013). Yet, this is a belief that is discriminatory in nature and more importantly, is not founded in evidence. Instead, such discriminatory views are founded in historical concepts of learning disability, which propagated the belief that those affected lack the potential to realise normal lives, such as living independently, working and raising families (Krahn and Fox, 2013). In turn, this often led to institutionalisation for people with learning disabilities, as well as stigma that affected both the individual themselves and their families. Now however, there is increasing recognition that environmental factors and social stigma are perhaps the most disabling factors that drive inequities for those with learning disabilities – such as the inability of health care professionals to empower individuals and their families to make autonomous decisions, as they would for any other patient (Emerson et al., 2011).

Alternatively, such discriminatory beliefs can lead to professionals adopting an overzealous approach to assessing, managing and safeguarding service users with learning disabilities; such as when determining whether discharging to the home setting is safe following recovery from ill-health; or, when supporting young adults with learning disabilities to move into independent living accommodation (Emond Pelletier and Joussemet, 2016). Thus, rather than properly enabling shared decision-making processes and empowering people with learning disabilities to exercise autonomy and fulfil their potential, these practices surrounding care and support are in fact discriminatory, disempowering and ultimately, a failure to transition to anti-discriminatory professional behaviours and attitudes (Devi, 2013). Therefore, this raises the important duty for all health care professionals to both scrutinise their perceptions of learning disabilities and thereafter, examine how they can make adjustments to their practice, and the practice of others (Daley, Phipps and Branscombe, 2018). In contrast, research however demonstrates that where professionals practice in an anti-discriminatory fashion, promoting equality of opportunity, positive risk management and tailoring their practices to the needs of people with learning disabilities; thereafter, outcomes and the degree to which inequalities thrive, significantly improve (Emond Pelletier and Joussemet, 2016). For example, promoting autonomy amongst people with learning disabilities promotes greater satisfaction with services amongst both service users and their family members. Positive risk management can also facilitate people with learning disabilities gaining employment and having the opportunity to live independently, reducing the caregiving burden on families and the psychological toll associated with the caregiving role (Daley et al., 2018).

Now What? (Driscoll, 2007)

In turn, this therefore leads to the skills, knowledge and behaviours that professionals must cultivate in order to practice in an anti-discriminatory manner. Foremost, reframing concepts of learning disabilities and their implications for the individual’s ability to partake in all aspects of normal daily life is crucial (Taylor et al., 2017). Accordingly, for this author, engaging in the process of reflection has reframed beliefs regarding how learning disabilities may impact the individual’s ability to engage in shared decision-making and moreover, the duty to promote such engagement (Gates and Mafuba, 2015). In turn, this leads to perhaps some of the most important skills required of all professionals tasked with caring for people with learning disabilities, relating to the need to tailor communication in a manner than enables proper assessment, management and shared decision-making (Ali et al., 2013). For instance, there is a plethora of work which describes how effective communication for people with learning disabilities should feature the use of communication aids, such as diagrams and pictures, when conducting any conversations about care interventions. By using such aids, typically, people with learning disabilities can engage in these conversations in the same manner as any other person without a learning disability (Dalby and Knifton, 2012). Consequently, this author will now explore the use of such communication aids over the next three-months, documenting a list of aids that can be easily used in any care environment, when conversing with this service user population.

Furthermore, working in collaboration with other professionals, and as part of a wider team is then cited to be crucial to maximise opportunities to practice in an anti-discriminatory manner. For example, in order for professionals to facilitate educational and vocational opportunities for young and older adults with learning disabilities, creating strong professional relationships with those working in the training and education sector is essential. Where health care professionals have such relationships, they can then properly explore reasonable adjustment for an adult with learning disabilities, such as the potential to use learning assistants to support day-today learning and assessments. Alternatively, working in collaboration with social workers can be highly advantageous in completing risk assessments and management in a comprehensive, holistic manner (Taylor et al., 2017). Nurses can impart their health-related knowledge to these professionals, who are otherwise not trained or educated in the context of how learning disabilities may present psychological or, physical needs that can be met through reasonable adjustments (Gates and Mafuba, 2015). Equally, working in partnership with occupational therapists can enable modifications to home settings, that minimise the risks that may arise from independent living, rather than simply trying to eliminate any risk by not advocating independent living placements (Ali et al., 2013). Therefore, working in collaboration with other professionals, either in isolation or, as part of a multidisciplinary team is fundamental for promoting anti-discriminatory practices including positive risk management, ensuring a diverse skill mix can meet an individual’s wide-ranging needs (Dave and Knifton, 2012). Accordingly, this author will now set the learning goal of exploring how the various different professionals across the health and social care sector can contribute to collaborative working when caring for people with learning disabilities, in order to maximise their opportunities and promote basic human rights.

Finally, there is clearly a need for all health care professionals to challenge perceptions and practices that are discriminatory in nature (Gates and Mafuba, 2015). In further support, this observation resonates with the requirement for all registered nurses to challenge both organisational and individual practices that are discriminatory in nature, as well as acting as a role model for the principles of high-quality care during all of their endeavours (Nursing and Midwifery Council, 2018). Consequently, this author will seek to address any discriminatory beliefs observed in either organisational processes or, amongst colleagues, advocating on behalf of people with learning disabilities, and conveying evidence regarding how discrimination drives inequalities in outcomes.

Conclusion

This work has therefore evidenced this author’s growing insight into caring for people with learning disabilities in an anti-discriminatory manner, including the importance of a positive approach to risk assessment and management, and the need for multidisciplinary, collaborative working. For people with learning disabilities, discriminatory beliefs and practices concerning their ability to fulfil the potential and pursue freedom of opportunity has driven profound inequalities in outcomes, which also then have a detrimental impact on their families as caregivers. However, when professionals adopt anti-discriminatory practices, reframing their perceptions of learning disabilities, the outcomes of those affected and their families can be significantly improved. Examples of such practices include promoting shared decision-making through the use of communication aids, and facilitating the opportunity to love independently or, pursue vocational opportunities, by implanting reasonable adjustments to environments and usual ways of working. This therefore requires nurses and other professionals to develop a sound understanding of how other professionals can contribute to such efforts, establishing interprofessional relationships and then, being commitment to realising change for people with learning disabilities. Equally, all health care professionals must challenge existing processes, procedures and practices that propagate discrimination, whether at the organisational or, individual level.

References

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Al-Mahrezi, A., Al-Futaisi, A. and Al-Mamari, W., 2016. Learning Disabilities: Opportunities and challenges in Oman. Sultan Qaboos University Medical Journal, 16(2), pp.e129-131.

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Dalby, D. and Knifton, C., 2012. Learning Disability Nurse Survival Guide. London: Quay Books.

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Osborn, D., Horsfall, L., Hassiotis, A., Petersen, I., Walters, K. and Nazareth, I., 2012. Access to Cancer Screening in People with Learning Disabilities in the UK: Cohort Study in the Health Improvement Network, a Primary Care Research Database. PLoS ONE, 7(8), p.e43841.

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Taylor, J., McKinnon, I., Thorpe, I. and Gillmer, B., 2017. The impact of transforming care on the care and safety of patients with intellectual disabilities and forensic needs. BJPsych Bulletin, 41(4), pp.205-208.

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