The as well as aid the establishment

The
most significant component of the nursing process is the nursing
assessment (Weber and Kelley, 2016; Munroe et al., 2013). According
to Alfaro-LeFevre (2014), a nursing assessment can be defined as the
continuous collection of information to manage, prevent, predict and
detect health issues. Whilst, Nettina (2013) defines a nursing
assessment as an interactive and systematic procedure through which
the individual and nurse conjointly establish the individual’s needs
and concerns on which to plan the interventions that improve the
health status of the individual. Although many definitions of a
nursing assessment exist, a common theme is that it provides
information on which to plan the interventions to improve patient
outcomes (Dougherty et al., 2015; Howatson-Jones et al., 2012).
Furthermore, nursing assessments are a key requirement in the nursing
profession as, nurses are professionally duty-bound to assess and
respond to people’s physical, psychological and social needs (Nursing
and Midwifery Council, 2015). The first part of this assignment will
analyse a nursing assessment about a woman named Samara and the
second part will focus on the implementation of Cognitive Behaviour
Therapy (CBT) as an advanced therapeutic intervention.

Person-centred
care can be seen as the epitome of health and social care for people
with learning disabilities and is integrated within legislation,
professional codes of conduct and policies (Sharp et al., 2016,
Department of Health, 2012). Person-centred care involves
demonstrating respect for service users as individuals and
incorporating the individual’s opinions and point of view in the
process of decision making (McCormack and McCance, 2016). It is noted
that Samara did not have the capacity to consent to the assessment,
yet her opinions and views were paramount. Therefore, it can be
deduced that Samara’s involvement in the nursing assessment can be
seen as demonstrating person-centred care, which can be argued to be
good practice (McCormack and McCance, 2016).

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Furthermore,
the person-centred approach to care proposes that getting to know the
individual, helps nurses to understand their needs and problems
(Fawcett and Rhynas, 2012). Samara’s “dreams and wishes” are the
first questions on the nursing assessment, this can be argued to
demonstrate person-centred care as well as aid the establishment of a
rapport by communicating interest in Samara’s dreams and desires
(Gottlieb, 2012; Lay and Kirk, 2012). Critics contend the importance
of establishing a rapport with service users at the start of a
nursing assessment, as this stipulates the tone for effective and
accurate information exchange (Berman et al., 2016; Gulanick and
Myers, 2016; Silverman et al., 2013). Additionally, building a
rapport encourages trust and, successively, trust is critical for
maintaining a therapeutic relationship for the proposed interventions
(Price, 2017).

A
risk assessment is a mutually agreed plan, used to reduce identified
risks, and is discussed with the individual and staff involved
(Sellars, 2011). It is outlined in the nursing assessment and
scenario that Samara can be physically and verbally aggressive to
staff. In addition to this Samara’s personal hygiene is noted to pose
a risk to herself, staff and the residents. However, the nursing
assessment states that Samara has no risk assessments in place. Risk
assessments should be included in Samara’s care as a risk assessment
is a two-way procedure including an assessment not only of risks to
the person with learning disabilities but also of any risks they may
pose to others (Sellars, 2011). Furthermore, the inclusion of risk
assessments is not only to protect people with learning disabilities
from potential harm, but also as a way of recognising what is
required to enhance their quality of life (Neill et al., 2009; Gadow
and Riches, 2014).

Moreover,
quality of life is enhanced when multi-disciplinary integrated care
is demonstrated, particularly in learning disability services (NHS
England, 2015b). The nursing assessment states that
multi-disciplinary team assessments have been avoided due to Samaras’
preference. The inclusion of multi-disciplinary care has been shown
to reduce violence and aggression, increase staff motivation and
mental well-being and ultimately improve quality of care for the
individual (NHS England, 2015a, NHS England, 2015b).

It
is pointed out in the white paper ‘Valuing People’ that all people
with learning disabilities should have a health action plan
(Department of Health, 2001). However, it is evident that a health
action plan was not in place at the time of Samaras’ assessment. A
health action plan is a document whereby relevant knowledge is
contained in one place, including actions required to improve and
maintain the health of people with learning disabilities and any help
needed to achieve these actions (Garbutt, 2012; NHS England, 2016).
Additionally, Corbett (2007) suggests that the use of handheld
records assists with communication between carers and healthcare
professionals. Therefore, a health action plan would allow unfamiliar
staff to refer primary care staff to the relevant section of the
health action plan, which ultimately enhances communication between
Samara, staff and healthcare professionals (Corbett, 2007).

A
hospital passport is an important document used to improve care for
people with learning disabilities in a hospital (Phillips, 2012). The
aim of the hospital passport is to assist people with learning
disabilities to provide hospital staff with important information
about them and their health when they are admitted to hospital (Bell,
2012). It is clear that a hospital passport was not in place at the
time of assessment, although the nursing assessment does not state
Samaras’ hospital admissions, it is a proactive approach for
high-quality care for future possible hospital admissions (Bell,
2012).

Health
checks provide a way to detect, treat, manage, and prevent new health
conditions for people with learning disabilities (Lennox and
Robertson; 2014). The rationale behind health checks is that people
with learning disabilities have more difficulty than the general
population in recognising health problems and accessing treatment for
them (Public Health England, 2016). According to the nursing
assessment, an annual health check is not in place for Samara, it is
also evident that a urinalysis report and a blood test is lacking
from the nursing assessment. Samara’s decline in her personal
hygiene, her increased appetite, display of behaviours that may
challenge and sleeping pattern heightens the importance for her to
have a health check as the health check would include a systematic
physical and mental health examination which may identify any unmet
health needs (Robertson et al., 2014). Additionally, in accordance to
National Institute for Health and Care Excellence (2015) guidelines,
an annual health check allows primary care staff to be informed about
behaviours that may challenge and identify how it may be associated
with any physical health problems.

The
nursing assessment states that Samara experienced the bereavement of
her mother and sister 10 years ago and has recently moved houses.
Significant life events such as loss and a change of home environment
are particularly likely to be associated with relapse in any
individual (Royal College of Nursing, 2013; Gates, 2014). Samaras’s
mental health appears to be of concern as authors argue that sleeping
patterns consisting of sleeping very late, weight gain and changes in
personal hygiene can be indicative of depression (Royal College of
Nursing, 2013). Therefore, supporting Samara to have a health check
to identify any unmet mental or physical health needs is essential
for Samara to be provided with any required treatment (Robertson et
al., 2014).

According
to the nursing assessment, one of Samaras’ dreams and wishes is to
have a house of her own and live alone. In the document ‘Putting
People First” it is outlined that a key element of a personalised
adult social care system is to ensure people, regardless of
disability, are supported to live independently and have choice,
power and control over the support services they receive (HM
Government, 2007). With person-centred care being central to the care
provided to people with learning disabilities, it is important to
meet their health and social aspirations in personalised and creative
ways (Department of Health, 2015). Samara appears to be sharing a
house with 2 other residents, a possible nursing intervention is a
referral to Samara’s social worker for a reassessment. Considering, a
social workers role includes ensuring that the individual’s views,
wishes and feelings, irrespective of mental capacity, are involved in
the decision-making process (Department of Health, 2015).

It
is noted that Samara has poor muscle tone and weakness in her left
side, Case-Smith and Exner (2014) point out that poor muscle tone can
have an effect on activities of daily living. Therefore, a referral
to the Occupational Therapist is another possible nursing
intervention. Considering, Samara does not like skin contact from
others, an Occupational Therapist can assess and support Samara with
the provision of self-help devices in attending to personal care and
support Samara to restore muscle strength (Lundy and Bloxsom, 2014).

Neglecting
oral hygiene can cause pain, loss of teeth, disease, and has
detrimental consequences for people with learning disabilities health
(Gallagher and Scambler, 2012). Although Samara has required sedation
for the dentist in the past it is important that the least
restrictive option is tried that can meet the need (Department of
Health, 2014). Therefore, desensitisation about dentists to link a
perceived negative experience with a positive one may aid in Samara
cooperating with her dentist appointments (Turner and Green, 2015).
Additionally, individual barriers to oral health care include a lack
of perception of need by people with learning disabilities (Gallagher
and Scambler, 2012). Therefore, taking into account Samara’s
preference for easy read and pictorial formats, creating easy read
booklets about the importance of brushing teeth may aid Samara in
making healthy choices and decisions (Turner and Green, 2015)

People
with a learning disability are 10 times more likely to have an eye or
vision problem, so it is critical that they are encouraged to access
regular eye care (The Royal College of Ophthalmologists, 2015). It
appears that Samara has not recently had an eye test, therefore a
nursing intervention can include supporting Samara’s optician to
adopt reasonable adjustments to the examination routine to have
Samara’s visual needs met (Donaldson, 2017). Therefore, possible
reasonable adjustments may include: a preliminary visit to the
optician, a demonstration on support staff, adaptation to clinical
techniques where possible, taking into account the specific
communication needs of Samara and an easy read report of the findings
(Donaldson, 2017).

Another
nursing intervention includes regular meetings with Samara’s support
team to offer support and guidance. Support workers are a central
part of the healthcare team for many people with learning
disabilities (Tracy and Mcdonald, 2015). Thus, establishing a
proficient support team can promote the maintenance and achievement
of optimum health for Samara (Tracy and Mcdonald, 2015).

Approximately
between 30% and 50% of people with learning disabilities have at
least one mental health condition, in particular people with learning
disabilities experience elevated levels of depression in comparison
to the general population (McGillivray and Kershaw, 2015; Hartley et
al., 2015). Life events and genetic vulnerability are believed to
increase the risk of mental health problems amongst this population
(Vereenooghe and Langdon, 2013). Therefore, the prevalence rates give
a sufficient rationale for identifying and treating individuals who
are at risk of developing mental health problems (Hartley et al.,
2015).

Historically,
there was an over-dependence on behavioural and pharmacological
interventions for individuals with learning disabilities (Vereenooghe
and Langdon, 2013). Cited reasons for lack of provision of
psychotherapeutic interventions for this population may include
problems recognising mental health issues, a paucity of evidence,
lack of training amongst clinicians and previously, a perceived
‘therapeutic disdain’ towards people with learning disabilities
(Taylor and Knapp, 2013; Bender, 1993). ‘Therapeutic disdain’
refers to clinicians’ reluctance to comprehend and work with people
with learning disabilities (Bender, 1993). However, there is a
growing realisation that individuals with learning disabilities
should be empowered and supported to access psychological treatments
(James and Stacey, 2014). Therefore, this part of the assignment will
focus on the implementation of CBT as an advanced therapeutic
intervention for Samara’s mental health.

CBT
is a form of psychotherapy based on the presumption that
dysfunctional patterns of cognition cause emotional distress and
maladaptive behaviours (Beck and Haigh, 2014). The aim of CBT is to
assist individuals to challenge, identify, evaluate and alter
maladaptive behaviours and dysfunctional beliefs (Beck and Haigh,
2014). CBT encompasses multiple cognitive and behavioural techniques,
for example, problem-solving, thought challenging, behavioural
experiments, agenda setting, role plays, goal setting, activity
scheduling, relaxation skills and psycho-education (Beck, 2011). The
efficacy of CBT for treating and preventing depression among people
with learning disabilities is shown by van Zoonen et al. (2014),
Cuijpers et al. (2013) and Hassiotis et al., (2013). However,
Hartley et al. (2015), Unwin et al. (2016) and James (2017) opine
that although researchers demonstrate that CBT is well-tolerated,
feasible and may be effective in reducing symptoms of depression
amidst people with mild learning disabilities, there still remains a
paucity of research regarding CBT’s efficacy.

The
white paper ‘Valuing People’ outlined that people with learning
disabilities should have equitable access to evidence-based
healthcare, adjusted to their individual needs (Department of Health,
2001). However, Beail and Jahoda (2012) indicate that a significant
difference between people with learning disabilities and the general
population receiving psychological treatment from mental health
services is that the general population tend to seek help and
self-refer themselves, whereas people with learning disabilities are
usually referred by others. Therefore, in relation to Samara, it is
important that the learning disability nurse involves Samara in the
referral process to a CBT therapist and wherever possible, Samara
should be empowered to make an active choice and commence the therapy
willingly (Beail and Jahoda, 2012).

It
is important to note that, there are limits to using CBT, and
findings suggest that CBT has the potential to have positive outcomes
only with people who have mild to moderate learning disabilities
(Taylor et al., 2008; Hassiotis et al., 2013). As, research suggests
that people with mild to moderate learning disabilities have the
fundamental skills needed for the cognitive element of CBT, such as
oral communication skills (Pert et al., 2013; Hartley et al., 2015).
This is significant as Samara has a mild to moderate learning
disability, thus it can be argued that the skills associated with
Samaras’ diagnosis are harmonious with the CBT structure (Pert et
al., 2013).

Researchers
show that CBT can have positive effects, however, many argue that
this may be short-lived or not maintained beyond discharge (Pert et
al., 2013; Unwin et al., 2016). CBT clients are generally assigned a
homework task, which many people with learning disabilities may
struggle to complete. Thus, researchers suggest that long-term
effects may be seen with carer involvement in reinforcement
activities such as homework tasks (Lindsay et al., 2013; Hassiotis et
al., 2013). Furthermore, involving carers in the therapy process
would place them in a better position to identify and acknowledge any
early indications of relapse (Beail and Jahoda, 2012; Lindsay et al.,
2013). This can also help prevent ‘diagnostic overshadowing’ by which
clinicians attribute the symptoms presented to learning disabilities
(Nash, 2013). Additionally, studies demonstrate that the inclusion of
carers could benefit people with learning disabilities by reinforcing
and maintaining the techniques learnt, transferring skills to life at
home and support client engagement in therapy, which ultimately
improves the quality of life of service users (Darbyshire and Kroese,
2012; Unwin et al., 2016).

In
relation to Samara, she has recently moved houses and is supported by
support workers, therefore it can be argued that involving Samara’s
carers may increase the chances of positive outcomes and can reduce
the risk of relapse (Unwin et al., 2016). Thus, the learning
disability nurse can facilitate training for Samara and her carers to
understand the benefits of involving caregivers in CBT. However,
although there are benefits to carer involvement research indicates
concerns regarding confidentiality and privacy (Pert et al’s., 2013).
Hartley et al. (2015), as well as Unwin et al. (2016), suggest that
further research is required to examine the benefits of involving
carers in treatment and the impact on CBT outcome. Therefore, it is
important to note that if Samaras’s carers are involved in the CBT
sessions, confidentiality should be maintained and involvement should
be optional.

The
Equality Act (2010) obligates service providers to make ‘reasonable
adjustments’ to ensure equal access to services. Reasonable
adjustments can be defined as the requirement of public sector
organisations to adapt their provision or approach to facilitate
equal access to services for people with learning disabilities
(Public Health England, 2017). Some therapists acknowledge that they
need to be prepared to make appropriate reasonable adjustments for
people with learning disabilities in order to compensate for the
deficits in cognitive functioning (Jahoda et al., 2017).

As
Samara has not had input from the multi-disciplinary team, she may
lack some of the prerequisite skills for CBT. Researchers argue that
pre-therapy structured training can lead to significant improvement
in people with learning disabilities ability to link thoughts and
feelings (Bruce et al., 2010). Therefore, Samara may benefit from
preparatory training to gain an understanding of the concept of CBT
(Bruce et al., 2010). Also, as CBT treatment effects are argued to be
short-lived, another reasonable adjustment for Samara may include
booster sessions to sustain the positive impact of treatment (Unwin
et al., 2016). Moreover, considering some people with learning
disabilities have communication difficulties, provision of
information in an accessible format tailored to the individual may be
more meaningful (Mander, 2016). It appears that Samara prefers easy
read and pictorials, thus the learning disabilities nurse could
consider supporting and involving Samara by providing information to
refer to in Samaras preferred format.

Ultimately,
research showing the positive impact of CBT in preventing and
treating depression is well established (van Zoonen et al. 2014;
Cuijpers et al.,2013), however, studies outline the concern regarding
short-term effects of CBT for people with learning disabilities.
Therefore, for Samara to experience long-term effects of CBT the
learning disabilities nurse can support Samara’s carers by training
and involving them through the intervention. This would support
sustaining the techniques learnt, transferring these skills to home
life, and supporting Samara with the homework component (Unwin et
al., 2016). Furthermore, putting in place reasonable adjustments is
essential as researchers outline the significant improvement in CBT
when reasonable adjustments such as pre-therapy, adapting the methods
and materials to make it accessible and booster sessions are put in
place (Jahoda et al., 2017; Bruce et al., 2010). Considering studies
show that CBT can have positive effects amongst people with mild to
moderate learning disabilities, CBT may be an appropriate therapeutic
intervention in supporting Samara with her mental health (Darbyshire
and Kroese, 2012).

A
nursing assessment is a critical part of the nurse’s role in order to
gather information to identify the patient’s needs and establish
future interventions (Dougherty et al., 2015). Incorporating Samara’s
views and opinions in the nursing assessment, regardless of capacity
demonstrate good practice, as this can be seen as being
person-centred (McCormack and McCance, 2016). Additionally,
communicating interest in Samara’s dreams and wishes shows adherence
to the person-centred approach as well as aiding the development of a
rapport, which assists the therapeutic relationship (Lay and Kirk,
2012). It can be argued that good practice was shown, however, there
are many significant components of care lacking from the nursing
assessment which are fundamental for Samara’s care. For example risk
assessments, integration of the multi-disciplinary team, a health
action plan, a hospital passport, urinalysis, blood test and a health
check, all are significant aspects of care required for people with
learning disabilities.