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Part 1 - Reflective accounts using Gibbs' Model

Communication in learning disability (Down’s Syndrome focus) in relation to diagnosis
of dementia
In these reflective accounts, names of patients, places and staff have been changed to protect
patient confidentiality in accordance with the Nursing and Midwifery Council Code of
Conduct (2008)
...
One of the patients,
Robert, was a 50 year old gentleman with Down’s syndrome and a history of violent
behaviour
...
As a child, Robert learnt
Makaton, a sign language designed specifically for people with Down’s syndrome, to
enhance his verbal communication (Sellars, 2006)
...
He was insistent that he was spending Christmas
at 'home'
...
My mentor told me that she had carried
out an assessment, but when I looked through Robert's notes and read the questionnaire, I
found that it was eight years old and lacked detail
...


Feelings
I felt very unsure about whether I should tell my mentor that I felt Robert would benefit from
a more recent dementia assessment, as this was my first placement and I had only been in the
ward for a few weeks
...
Furthermore, it is known that people with Down's Syndrome exhibit
neurological changes resulting in Alzheimer's dementia earlier in life than people without a
learning disability (Barton et al
...
When Robert showed no improvement despite
attempts to determine what he meant by 'home', I brought the issue up with my mentor, who
agreed that she would mention this to the consultant psychiatrist at the next opportunity
...
Having an open, honest relationship with my mentor allowed me to
express my concerns
...
Mitchell (2011, pp
...


Analysis
The lack of a simple dementia assessment tool specific to people with Down's Syndrome had
clearly been a major problem in identifying the cause of Robert's confusion
...
This incident has
highlighted to me the importance accurate record-keeping, and the consequences of poor
quality assessment tools
...
The other patients couldn't understand why this was
upsetting Robert
...
This resulted in a lack of continuity and

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stability in his care
...


Action plan
To support my nursing in future placements, I would like to gain more knowledge of tools to
aid my non-verbal communication with patients who have a learning disability
...
This will help me to have more effective
exchanges with patients who have a learning disability as I will be able to adapt to their
needs, and will allow me to deliver better care
...


Management of aggressive and challenging behaviour in a patient with schizophrenia

Description
The second skill I feel that it is important to reflect upon my development of is the
management of challenging behaviour
...
During my time in the ward, his mental state deteriorated somewhat
and Jack explained to staff that the ‘voices’ he heard were telling him to cause damage to his
room and to himself
...
Towards the end
of my placement, Jack’s behaviour had escalated
...
In particular, there was a serious
incident where Jack punched through the electrical plug sockets in his room
...
I was concerned
about Jack’s welfare, as he had abrasions on his hands after hitting the plug sockets and there
was a possibility of electrocution
...


Evaluation
Jack’s behaviour was discussed at multi-disciplinary meetings and handovers, where staff
debated the best way in which to manage Jack’s behaviour
...

Jack required encouragement to become involved in activities with other patients, however
reflected that he ‘really enjoyed’ taking part in baking cakes
...
Jack expressed a desire to see a pantomime, and
assisting him in organising this gave him something to look forward to
...
I explained to Jack what staff would be discussing at his meeting and
ensured that I had his consent
...
By utilising the advocacy
service, Jack felt more in control and was able to be more involved in decision-making
...
Although I didn’t need to use the techniques I learned during the
Therapeutic Management of Violence and Aggression session, I felt much safer knowing that
I could safely manage aggressive behaviour
...
It was vital to my success in this incident to remember the
vulnerability of the people I was working with, and also the safeguards put in place by the
ward manager and the university
...

An alternative approach in this situation could have been to address his placement first,
although I felt that without Jack having any positive relationship with staff, this would be
unsuccessful
...

His intimidation of staff and patients, and his choice to spend a lot of time alone in his room
seriously weakened the nurse-patient relationship, and consequently, he had little input in
decision-making with regards to his care
...
This information was not
effectively communicated to Jack previously, however, he was keen to use the service once it
was explained properly
...


Action plan

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Before my forthcoming placement, I would like to research the causes of challenging
behaviour in patients with dementia, as this will be relevant to my next placement in a care of
the elderly ward
...
Part 2 Skills development essay

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Part 2 - Skills development essay
Nurses in all clinical areas may encounter patients with a mental health problem or learning
disability (Alabaster, 2011)
...
It is therefore essential for all nurses to possess the skills to
care for this patient group to ensure that all patients are provided with equal care
...
Two
skills which are particularly important to develop when treating patients with a learning
disability or mental health problem are communication and the management of challenging
behaviour
...
Effective communication skills assist nurses to
determine the cause of aggressive behaviour and then resolve it
...
Diagnosing co-morbidities in a patient with a learning
disability or mental health diagnosis is potentially problematic
...
(2012, pp
...
Whitwham et al
...
17--21) developed a simple communication tool to determine whether a dementia
referral was necessary in people with Down's Syndrome, using reasons for recent dementia
referrals to produce the checklist
...
Although there were some exceptions, the researchers generally
found that 'higher scores on the checklist significantly correlated with a subsequent diagnosis
of dementia' and, in addition, the tool was successful in prompting staff to be more vigilant in
assessing for dementia in patients with Down's Syndrome
...


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Communicating a diagnosis of a co-morbidity to a patient with a intellectual disability
requires awareness that patient may find this news confusing or upsetting, and may provoke
an extreme reaction in some patients
...
It is integral to good nursing care to ensure that the patient receives
information in a way that is sensitive to their needs and their level of cognitive ability
...
In a recent study, interviews of staff and relatives caring for people with Down's
Syndrome and dementia were conducted to highlight issues when the diagnosis of dementia
was communicated (Furniss et al
...
318--327)
...
Furniss et al
...
researchers identified that there was a need for
professionals to possess the skills 'to identify and appropriately support the emotional needs
of all people supporting and living with people with Down’s syndrome and dementia'
...


Aggression and associated challenging behaviours are prevalent in 16% to more than 50% of
adults with intellectual disabilities, depending on definition
...
, 2008, pp
...
Tyrer et al
...
The results showed a
significant decrease in aggressive behaviours in all treatment groups, but the most dramatic
decrease was in the group which received the placebo
...
, 2005, pp
...
Furthermore, the study by Tyrer et al
...
Tyrer et al
...
One of the issues in such trials is
poor adherence, however it is argued that 'treatment that will reasonably secure a therapeutic
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benefit for a patient must continue' (Griffith, 2013, pp
...
It is important for nurses to
easily recognise warning signs of a psychiatric emergency
...


The causes of aggressive behaviour are widely debated, although awareness of possible
upstream causes of challenging and aggressive behaviour allows nurses to address these
issues and avoid such behaviour where possible
...
Guideline 131 - Management of Schizophrenia, published by the Scottish
Intercollegiate Guidelines Network (2013), contains reflections from patients with
schizophrenia whilst in hospital
...
Some were 'never told why they were
receiving particular treatments'
...

Another suggested cause of aggression is sedentary behaviour
...
conducted a
systematic review of twelve studies which found higher levels of sedentary behaviour in
patients with schizophrenia than their healthy peers (2013, pp
...
Furthermore,
evidence by Vance et al
...
294--313)
...


It can be concluded that the development of these skills facilitates improvement in the quality
of nursing care provided to people with a learning disability, and subsequently improves the
service user's quality of life (Royal College of Nursing, 2006)
...
Pollock (2011) states that it is 'beneficial' for patients with learning disabilities
to be cared for by nurses who have a good knowledge of speciality learning disability
services and are able to effectively inform the patient about these
...
Development of these skills ensures that
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people with learning disabilities are able to gain full access to healthcare and receive the
specialised care that they require
...
, 2011
...
In: C
...
NICOL, eds, Alexander's nursing practice
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London:
Churchill Livingston, pp
...
, BASNETT, F
...
and BROWNSNELL, M
...
Growing old
with

a learning disability
...
, HONEY, M
...
, eds,
Oxford Handbook of Nursing Older People
...

567–574

BLAIR, J
...
Care adjustments for people with learning disabilities in hospitals
...
21

FURNISS, K
...
, LOVERSEED, A
...
and DODD, K
...
The views of
people who care for adults with Down’s syndrome and dementia: a service
evaluation
...
318–327

GAGIANO, C
...
, THORPE, L
...
and VAN HOVE, I
...

Short and long-term efficacy and safety of risperidone in adults with disruptive behavior
disorders
...
629–636

GRIFFITH, R
...
Guarding against discriminatory treatment decisions
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513--515

MITCHELL, D
...
Communication and the cognitively impaired patient
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WEBB
and K
...
1st edn
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264--276

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NURSING AND MIDWIFERY COUNCIL, 2008
...
pp
...

http://www
...
org/Documents/Standards/The-code-A4-20100406
...
, 2011
...
In: L
...
LISTER, eds, The
Royal Marsden Hospital Manual of Clinical Nursing Procedures
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West
Sussex: Wiley Blackwell, pp
...
Meeting the Health Needs of People with
Learning Disabilities: Guidance for Nursing Staff
...
, 2013
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Practice Nurse, 43 (11)

SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK (SIGN), 2013
...
Scotland

SCOTTISH GOVERNMENT, 2003
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legislation
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uk/asp/2003/13/contents [Accessed: 17th January 2014]

SCOTTISH GOVERNMENT, 2006
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NHS Quality Improvement
Scotland
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, 2006
...
Paediatric
Nursing, 18 (9), pp
...
, WAMPERS, M
...
, DE HERT, M
...
and
VANCAMPFORT, D
...
Physical activity and sedentary behaviour in outpatients
with schizophrenia: A systematic review and meta-analysis
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588--596

TYRER, P
...
, AHMED, Z
...
, COORAY, S
...
,
MURPHY, D
...
, MEADE, M
...
, 2008
...
The Lancet, 371 (9606),

pp
...
, WADLEY, V
...
, ROENKER, D
...
and RIZZO, M
...
The effects
of physical activity and sedentary behavior on cognitive health in older adults
...
294--313

WHITWHAM, S
...
and BROOM, W
...
Should we refer for a dementia
assessment? A checklist to help know when to be concerned about dementia in adults
with Down syndrome and other intellectual disabilities
...
17--21

WORLD HEALTH ORGANISATION, 2000
...
World Health
Organisation, Geneva

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