an exploration of community learning disability nurses’ therapeutic role

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ORIGINAL ARTICLE An exploration of community learning disability nurses’ therapeutic role Marian Marsham, Oxleas NHS foundation Trust, Pinewood house, Pinewood Place, Dartford DA2 7WG, UK (E-mail: [email protected]) Accessible summary Community Learning Disability Nurses were asked to talk about how they felt they had helped people in their care feel better. They talked about helping as a positive approach to problems, making the most of existing help, understanding what it means to have a Learning Disability, using time and communication, and teaching and learning. This is important because it can help people to understand the needs of people with learning disability and what help Community Learning Disabilities Nurses give. Summary This literature review and primary qualitative research explores therapeutic role from the perspective of Community Learning Disability Nurses. Semi-structured interviews, based on Critical Incident Technique (Psychol Bull, 51, 1954, 327), and descriptive phenomenological methodology were adopted to elicit data amenable to systematic content analysis (Mayring 2000). This resulted in the identification of six inductive categories (therapeutic optimism, maximising support networks, time as a therapeutic tool, creative communication, understanding Learning Disability and initiating learning). Three deducted categories were derived from relevant literature (nature of the events, outcomes of therapeutic role, and therapeutic relationship). The sample consisted of seven practicing Community Learning Disability Nurses with two or more years experience managing an adult caseload, recruited via a professional networking forum. A conceptual model was developed indicating the multicomponent and interconnected nature of the therapeutic role. Keywords, Community learning disability nurse, critical incident technique, learning disability, phenomenology, therapeutic relationship, therapeutic role Introduction and literature review Despite a vital and unique contribution to the health of people with learning disability (Moulster & Turnbull 2004), the role of Community Learning Disability Nurses has historically been misunderstood (Turnbull 2004). Under- standing is clouded by a professional identity developed in reaction to socio-political changes (Turnbull 2004) and secondary marginalisation (Mitchell 2000). The role sits awkwardly with stereotypical views of nursing (Maben ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities doi:10.1111/j.1468-3156.2011.00702.x British Journal of Learning Disabilities The Ocial Journal of the British Institute of Learning Disabilities

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Page 1: An exploration of community learning disability nurses’ therapeutic role

O R I G I N A L A R T I C L E

An exploration of communitylearning disability nurses’therapeutic role

Marian Marsham, Oxleas NHS foundation Trust, Pinewood house, Pinewood Place, Dartford DA2

7WG, UK (E-mail: [email protected])

Accessible summary • Community Learning Disability Nurses were asked to talk about how they felt

they had helped people in their care feel better.

• They talked about helping as a positive approach to problems, making the most of

existing help, understanding what it means to have a Learning Disability, using

time and communication, and teaching and learning.

• This is important because it can help people to understand the needs of people

with learning disability and what help Community Learning Disabilities Nurses

give.

Summary This literature review and primary qualitative research explores therapeutic role

from the perspective of Community Learning Disability Nurses. Semi-structured

interviews, based on Critical Incident Technique (Psychol Bull, 51, 1954, 327), and

descriptive phenomenological methodology were adopted to elicit data amenable

to systematic content analysis (Mayring 2000). This resulted in the identification of

six inductive categories (therapeutic optimism, maximising support networks, time

as a therapeutic tool, creative communication, understanding Learning Disability

and initiating learning). Three deducted categories were derived from relevant

literature (nature of the events, outcomes of therapeutic role, and therapeutic

relationship). The sample consisted of seven practicing Community Learning

Disability Nurses with two or more years experience managing an adult caseload,

recruited via a professional networking forum. A conceptual model was

developed indicating the multicomponent and interconnected nature of the

therapeutic role.

Keywords, Community learning disability nurse, critical incident technique, learning

disability, phenomenology, therapeutic relationship, therapeutic role

Introduction and literature review

Despite a vital and unique contribution to the health of

people with learning disability (Moulster & Turnbull 2004),

the role of Community Learning Disability Nurses has

historically been misunderstood (Turnbull 2004). Under-

standing is clouded by a professional identity developed in

reaction to socio-political changes (Turnbull 2004) and

secondary marginalisation (Mitchell 2000). The role sits

awkwardly with stereotypical views of nursing (Maben

ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities doi:10.1111/j.1468-3156.2011.00702.x

British Journal of

Learning DisabilitiesThe Official Journal of the British Institute of Learning Disabilities

Page 2: An exploration of community learning disability nurses’ therapeutic role

& Griffiths 2008) and the social model of disability (Oliver

1990). The current demand for evidence of effectiveness and

quality highlights the inadequate Community Learning

Disability Nursing research base, particularly regarding

therapeutic role (Griffiths et al. 2007).

In other settings, therapeutic role is seen as the focus of

nursing intervention, whether viewed exclusively in terms

of nurse–patient interaction (Shatell 2004) or specific

nursing interventions for the patient’s well-being (Walsh

et al. 2007). Peplau’s nursing theory (1952) has enduring

influence, placing the interaction/relationship between

nurse and patient at the heart of care. This reflects the

development of more humanistic approaches known as

‘therapeutic nursing’ or ‘new nursing’. The therapeutic

relationship is now a moral certainty, making the dearth

of Learning Disability research all the more striking.

Despite the centrality of therapeutic role, nurses find it

hard to articulate (Martin 2001) and patients identify

interactions as therapeutic where nurses do not (Shatell

2004).

‘Getting to know the patient’ is seen as fundamental to

therapeutic nursing despite nursing often being organised

in a way that works against this (Luker et al. 2000). A core

characteristic of the therapeutic relationship is reciprocity,

as a partnership develops with active ‘give and take’

between both parties (Fingfeld-Connett 2008, Li 2004). This

assumption of reciprocity raises boundary and self-disclo-

sure issues. Some patients preferred nurses who shared

information about themselves (Shatell 2004), although the

closest therapeutic bonds relied on some emotional distance

(Ramos 1992). Therapeutic role can have managerial aspects

such as smoothing transitions and coordinating care (Burton

2000), linking with current Community Learning Disability

Nursing practice. Community settings are seen as most

conducive to therapeutic role (Kubsch 1996).

The outcomes of therapeutic role are not directly

observable but are desirable and necessary (Burton 2000).

Where nursing is delivered in the absence of therapeutic

role, patients risk dehumanisation and depersonalisation

(Shatell 2004). Patients experience over-dependence and loss

of self-reliance (Milton 2008). Nurses risk ‘burnout’ (O’Con-

nell 2008). Nursing care is limited, focusing on tasks and

medical instruction (Kubsch 1996; Ramos 1992). In psychi-

atric nursing, defensive practice and increased risks are

associated with nontherapeutic approaches (Bowles 2000).

Where care is delivered in the context of therapeutic role

patient experience is improved (Shatell 2004). This seems

mainly because of developing their ability to cope (Scanlon

2006) and having a more open awareness and better

understanding of their health (Cameron et al. 2005; Luker

et al. 2000). Patient independence (Milton 2008) and empow-

erment increase (Li 2004), although nurse empowerment is

also an outcome (Kubsch 1996). Behaviour change (less

acting out) is cited (Milton 2008).

Nurses’ outcomes paradoxically include anxiety (Walsh

et al. 2007) and stress reduction (Fingfeld-Connett 2008),

with few clues to differentiate the experiences. Nurses value

therapeutic role and want to develop it (Walsh et al. 2007),

mirroring the outcome of increased capacity for change

(Fingfeld-Connett 2008). Personal growth and openness to

entering into future therapeutic relationships are increased

for both parties (O’Connell 2008). Other outcomes include

shaping the contribution of other caregivers (Burton 2000),

achieving organisational aspirations (Li 2004), and reducing

risk and preventing crisis (Bowles 2000).

Trust, empathy and the nurse’s emotional maturity are

key features of therapeutic role (O’Connell 2008). Personal

qualities of the patient are generally not considered other

than being a barrier to therapeutic nursing. Fingfeld-

Connett (2008) and Martin (2001) question the possibility

of therapeutic relationships with people with cognitive or

emotional impairments. Literature that challenges this view

is lacking, although the high level of skill required in

establishing therapeutic role with those who do not have

verbal communication is acknowledged (Aldridge 2006).

This study comprises a literature review and primary

research aiming to explore (and articulate) the interventions

constituting therapeutic role of Community Learning Dis-

ability Nurses, based on the research question: ‘What is the

Community Learning Disability Nurses’ lived experience of

their therapeutic role with adult service-users?’

‘Therapeutic role’ is defined as the goal-focused pattern of

intervention(s) by the Community Learning Disability

Nurse which is separate from medically directed interven-

tion, and adds, in it’s own right, to the person optimising

their health and well-being (Kubsch 1996; Spilsbury &

Meyer 2001; Walsh et al. 2007).

Method

Research design

The primary research utilised semi-structured interviews

with individuals based on Critical Incident Technique

(Flanagan 1954) and descriptive phenomenology to elicit

thick data, which when transcribed, was amenable to

systematic analysis, resulting in identification of emergent

themes relating to therapeutic role. Descriptive phenome-

nology aims to discover universal aspects of a phenomenon

about which little is formally known. The study follows the

interpretivist tradition associated with phenomenological

research. In this tradition, epistemological assumptions

about the world are based on multiple realities composed

of personal understandings of the subjective experience,

rather than one objective reality. Husserl (1859–1938)

developed the concept of ‘lifeworld’ to describe the every-

day conscious ‘lived experience’ of a phenomenon, inform-

ing the individual’s personal understanding of reality

2 M. Marsham

ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities

Page 3: An exploration of community learning disability nurses’ therapeutic role

(Husserl 1931 cited by Creswell 2007). ‘Lifeworld’ is

intersubjective and through a process of seeking to under-

stand the subjective experience, ‘universal essences’ emerge

which can be applied beyond the individual (Wojnar &

Swanson 2007).

Descriptive phenomenology methodology comprises four

key steps: bracketing, analysing, intuiting and describing.

These are components of the approach and ongoing cogni-

tive tasks for the researcher (as above). Dependability was

enhanced as tasks were completed using reflective diary

keeping, third party critique from supervisor and retaining

reflexivity regarding the continual influence of personal

bias, demonstrated by foregrounding the researcher’s role

using first person narrative (Greenhalgh 2006).

Traditionally, phenomenology uses in-depth interviews,

where interviewees determine structure (Creswell 2007).

However, there are benefits of using a flexible framework to

assist participants to focus on their own experience (Starks &

Brown-Trinidad 2007), particularly because of the abstract

nature of therapeutic role, and the subsequent risk that

interviewees may lose their focus resulting in longer inter-

views, but not necessarily more or better data (Gillham 2005).

Therefore, a semi-structured interview design allowing the

same open questions and probes in each interview was used.

Questionnaire survey was discounted because of the open

nature of the questions to be asked, and the need to respond

to and explore the constructions that formed the basis of the

participants’ responses (Gillham 2005).

Telephone interviews may have been more accessible,

requiring less time commitment, and reducing interviewer

effects (Shuy 2003). However, face-to-face interviewing

allows insight into the interviewees’ subjectivity through

nonverbal communication, a more natural social context,

and allows more latitude in the self-expression of intervie-

wees’ reality. This aligns with the underlying epistemolog-

ical assumptions; the data are the result of the interaction

between researcher and interviewee and would be signifi-

cantly impaired by more distant methods (Shuy 2003).

Observation was considered, particularly as qualitative

research without observation is limited (Rapley 2004).

However, as little was known about the topic, the focus of

the research being Community Learning Disability Nursing

and the considerable practical and ethical constraints

involved, observation was considered inappropriate.

Focus groups could have extended the narrative by

producing data from the group’s synergy, which is lacking

in 1:1 interviewing (Green & Thoroughgood 2004). How-

ever, focus groups work best with a tightly defined content

focus (Gillham 2005). Practical constraints of respondents’

availability and the potential need for more than one

researcher to manage the group (Green & Thoroughgood

2004) negated this methodology.

Therefore, semi-structured interviews derived from Crit-

ical Incident Technique (Flanagan 1954) were chosen for

data collection, being well matched with the philosophy and

methodology of descriptive phenomenology.

Critical Incident Technique is a flexible method of

eliciting data in a reflective manner that ‘generates infor-

mation and uncovers tacit knowledge’ (Schluter et al. 2007,

p.107). Critical incidents are demarcated episodes that have

impacted on outcome (Flanagan 1954). However, significant

events can encompass nonevents and the mergence of

multiple events in the mind of the participant (Norman et al.

1992; Schluter et al. 2007). The advantages are that a

reflective approach may capture the invisible aspects of

practice, be reality based and raise issues pertinent to

practitioners (Rolfe 1998). It has been used in nursing

research to facilitate understanding of role and interactions

across multiple settings, and addresses nursing complexity

more rigorously than in-depth interviews (Kemppainen

2000).

Sample

Seven practicing Community Learning Disability Nurses

with >2 years experience managing an adult caseload were

recruited by email via a professional network.

Data collection

Each interview was allocated 60 min maximum, digitally

sound recorded and transcribed. Brief field notes were

included in data analysis. Participants were asked to select a

significant event from their own practice that was indicative

of therapeutic role prior to interview to enable appropriate

selection and articulation. Questions about the suitability of

their ‘event’ or the definition of therapeutic role were

answered in broad terms, using the same example across

interviews to promote consistency and dependability, and

reduce bias (Rapley 2004). They were not given sight of the

interview schedule to protect credibility, enable thick

description to ‘flow’ and to reduce risk of their assumptions

unduly influencing responses. Participants were requested

not to discuss their event with anyone to promote credibility

and trustworthiness, and ensure they remained close to

their subjective experience.

Each interview utilised the interview schedule frame-

work. Additional prompts included summarising, reflecting

key phrases and clarifying.

Analysis

Descriptive phenomenology requires ‘transcendental sub-

jectivity’ essentially ‘fresh eyes’ to ensure the researcher

remains close to the ‘lifeworld’ but does not impose their

own meaning/assumptions onto analysis (Wojnar & Swan-

son 2007). Husserl asserted this could be achieved through a

process known as bracketing, which involves separation of

CLDN’s therapeutic role 3

ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities

Page 4: An exploration of community learning disability nurses’ therapeutic role

phenomena from the world, inspection, dissection to define

and analyse it, and suspension of preconceptions (Creswell

2007). As a practicing senior Community Learning Disabil-

ity Nurse, researching the therapeutic role, I needed to

acknowledge and separate my assumption that Community

Learning Disability Nursing therapeutic role is possible and

exists. I had to become open to acknowledging that the

findings may reveal that Community Learning Disability

Nurses do not experience therapeutic role, and alternative

roles are experienced. Following the interview, I made

reflexive notes and as soon as possible listened to the

recording to immerse myself in the data and assist with the

continual bracketing process prior to the next interview.

Each interview was transcribed in turn. Once all interviews

had been transcribed, they were read individually whilst

listening to the recording to check for accuracy. Then all

transcripts were re-read, in conjunction with field notes, as a

whole data set.

Formal analysis procedures began after completion of the

interviews to reduce bias in data collection and analysis.

Data were analysed by hand, using scissor and paste

technique according to content analysis procedure (May-

ring 2000), which utilises themes deducted from objectives

and literature review in addition to themes inducted from

primary research data. The first interview was analysed for

themes relating directly to the research question and to a

level of abstraction that would allow the category to remain

close to data and describe the themes. Inductive category

definitions were formulated using the emergent themes.

The remaining transcripts and field notes were analysed

consecutively for themes and where possible were assigned

the existing categories. New categories were systematically

developed, as ‘nonassignable’ themes emerged. New cate-

gories were checked against all analysed data, as some data

were applicable to more than one theme/category and to

promote confirmability through formative checking. Cate-

gories were thus revised until I was content, through

means of a summative reliability check that the categories

were clearly defined, accurately reflected emergent themes

and that the focus of the research question had been

retained.

Three categories were deducted from research objectives

and literature. Text was assigned to the categories; subcat-

egories were developed and revised formatively, with a

final summative reliability check against all the data,

ensuring the focus on the research question.

The bracketing process continued throughout, by remain-

ing cognisant of the research question, and the definition of

therapeutic role to reduce bias. I also identified connections

between my own experiences and interpretations of pas-

sages in the text and set them aside to attempt to understand

the data as the participants had experienced it. Memos were

simultaneously kept to track category revisions and to

evidence decision-making and creative/reflective thinking.

These were made available to the research supervisor to

enhance trustworthiness.

Findings

The seven participants were interviewed over a 9-week

period at their, or the researcher’s, workplace or university.

The mean interview duration was 35 min. The sample was

characterised by the participants’ professional experience

(mean post-registration experience: 15.7 years) and in their

Community Learning Disability Nursing roles (mean com-

munity experience: 12 years). Two participants held the

Community Learning Disability Nursing Specialist Practice

award (for 20 and 9 years, respectively).

Deductive categories

The nature of the self-selected significant events

This category was coded as general characteristics of the

event described at the beginning of the interview, but not

excluding new descriptors such as health needs. All partic-

ipants talked about the totality of their work with the person

(spanning a few weeks to 8 years) rather than a single event,

scene-setting with descriptions of the person. All participants

gave extensive histories, characterised by negative experi-

ences such as abuse, domestic violence, trauma, loss and

bereavement, bullying and aversive healthcare experiences.

Needs and social circumstances were diverse, predomi-

nated by long-term conditions management and living

alone with support. Medically directed tasks included

relapse prevention and recovery, self-management tasks,

facilitating outpatient appointments and escalating treat-

ment pathways. Participants utilised a holistic model of

health and worked with a range of professionals, carers and

family. Events were described as atypical or extreme but not

uncommon.

Community Learning Disability Nursing therapeutic role

outcomes

Outcomes included disclosure and investigation of abuse,

avoiding readmission, developing coping skills, referral to

other services, reduced challenging behaviour and in-

creased healthcare access. Carers’ knowledge and skills

increased and was more widely applied.

He’s been out of hospital now for 3 years and in that 3 years

he’s had 5 episodes where he could have gone in easily, ah

easily in one way or another, so I would say, yeah, because of

that style and the way that I work with him he’s avoided

admission (5)

For the participants, this resulted in a sense of value,

pride, satisfaction and achievement. Where therapeutic role

4 M. Marsham

ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities

Page 5: An exploration of community learning disability nurses’ therapeutic role

had not been successful, participants expressed feelings of

guilt and discouragement.

I tried all sorts of different approaches and none of them

seemed to work basically which I found quite, can’t say

disheartening, yes disheartening, I suppose (1)

Therapeutic relationship

This category derived from literature was demonstrated in

the participants’ experiences. Other goals became futile

where it had not been possible to establish a therapeutic

relationship, and the establishment of the relationship

became a goal in its own right.

It made me realise that this isn’t working any more, not

making much of a difference, and it’s not positive, and I just,

just did not build a relationship with the person (1)

I think actually just being able to engage with her has been an

achievement (6)

The therapeutic relationships facilitated disclosure of

deeply held feelings, sense of partnership, professional

friendship and working together towards mutually agreed

goals, with the person with Learning Disability retaining the

veto. Data acknowledged this may be the person’s only chance

to talk or experience a helping/nonabusive relationship.

The client felt very reluctant to engage ……..because

they’re not used to being on a one to one where they can

just talk (3)

Boundaries, rules for information sharing, getting to

know the person, being able to appreciate the significance

of sharing small things were key themes.

Part of (it), I think, is allowing him to direct if that’s what he

wants and I constantly check out when I’m doing stuff with

him ‘is this what you want? Is this what you want because if

it isn’t I say ‘it’s ok to say no’ and I think that level of

openness and honesty helps him (7)

Even though he’s fiercely independent, I think there’s, there’s

a part of him that likes to be looked after and, and cared for

and valued and stuff, and I think when you do those small

things (change light bulb, carry shopping bags, taking

rubbish down) it makes the difference…………other nurses

might think ‘I’m not doing that’ because they might worry

that they’re deskilling him or he’s losing his independence or

something, actually just small things are the things keeping

him out of hospital and keeps his mental health positive (5)

The theme of trust and empowerment was also important.

Straight away there was trust …..so I think compliance

became just that little bit easier, you know, his ability to want

to take part, was very important (4)

The participants experienced development of the thera-

peutic relationship as a process requiring them to be

nondirective, make a good start, be forgiving not punitive

(E.G interpretation of nonengagement) and to employ

practical and creative ways to initiate.

The thing I’ve learnt about working with this man, it’s not so

important to be a nurse, it’s more important just to be a

person, just to be human (5)

For the first couple of months really, I think I visited him

once a week in order to build a relationship so that we could

start to look at the reason for referral and achieving the long

term goal……….that fact that we now had a good foundation

meant that we were able to talk that through, share that

information in a very trusting way that wouldn’t have been

there if I had just rushed in to deal with blood glucose levels

(2)

Inductive categories

Therapeutic optimism

This derives from participants’ experiences of being open to

possibilities, making opportunities, aspiring to success and

goal attainment, tackling the seemingly impossible by doing

things differently and seeing persons abilities not disabili-

ties.

What we did think at the start was possibly this man might

be able to self inject with supervision and again as a learning

disability nurse it was very good that we, we looked at the

possibility…. It’s very important to give everybody the

opportunity (4)

We needed a blood test and a urinalysis…but these seemed

nearly impossible…by working closely with them (carers) it

gets them to understand how we work and how things can be

achieved (1)

Time as a therapeutic tool

The participants experienced understanding and managing

time as means to achieve long- and short-term goals. Their

therapeutic use of time related to having a long-term

perspective and commitment to long-term goals, timing,

consistency, setting a slower pace during visits and to

complete tasks, or allowing the person to set the pace. The

participants understood that tasks would take longer than

with general populations, even if the person had good

verbal skills. It was the judicious use of time, sometimes in

combination with other skills, which is key rather than just

having more time per se, which could lead to overdepen-

dence.

CLDN’s therapeutic role 5

ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities

Page 6: An exploration of community learning disability nurses’ therapeutic role

I feel that the biggest thing is just allowing him to take his

time……….he needs to be able to do it in his own time, I need

to allow him to dictate the pace which he wants to know

things and controls what it is he wants to know really (7)

I wouldn’t really want to increase the amount of time that I

spend with him except when he needs it to be (5)

The participants experienced using time therapeutically

through flexibility, responsiveness and knowing when to

stop.

It’s kind of keeping in touch with him and allowing him to be

independent but when the warning signs occur being able to

get in there and respond very quickly …….the key thing is

you won’t need to be in there forever (5)

To be available in a way that actually is available for her,

not saying here’s a clinic, you can come, but actually

saying ‘I’ll come and find you, I’ll ring you wherever you

are, it doesn’t matter, you tell me where you are and I’ll

come’ (6)

The participants experienced consistency as key. Out-

comes were limited where this was not achieved.

He has had continuous support from one person amongst a

multi-disciplinary team with some staff turnover, someone

who can compare the what was with the what is now in a

lived way rather than a paper based way (2)

I thought it’s wrong someone has to wait for the nurse when

everyone else with diabetes would self-inject and get on with

their lives…so he couldn’t have any breakfast until they

came, his quality of life became very poor (4)

Maximising support networks

The participants experienced a sense of team through

working with others towards the same goals, where the

person was as much a member of the team as the supporters.

The participants enabled others to take up their roles more

fully, even though they may have separate objectives to the

participant, thus strengthening existing support.

together as a team we just help to keep him stable…….I’m

just one part of the circle (5)

Maximising support networks also involved liaison work.

The participants proactively found ways of improving

working relationships. This also was experienced as work-

ing through others. E.G building on existing relationships,

liking and familiarity, and having insight into the limita-

tions and realities of their own and others’ roles.

I suppose every body contributed their own knowledge and

skills really…support workers are sometimes our ears and

eyes (1)

Providing advice and guidance, challenging unfair

practice and enabling others to see their practice from a

Learning Disability perspective were experienced.

I’ve had a couple of incidents where I’ve been asked to go to

one of the gender clinics to support a client, advise the team

on how to work with this person (3)

Creative communication

The participants experienced creative communication

means with the person or other caregivers to achieve the

therapeutic goals set. Techniques were based on nonreliance

on verbal skills and included the use of social stories,

exploring equipment and explaining, role-play, adapting

existing materials, using pictures, and asking to be shown,

which requires physical presence in context, which may not

be possible for services with less flexibility such as clinics.

Nobody else… had ever done anything other than write her a

letter….when you asked her in a way if she could describe

things and actually physically show you, she was doing it,

she was more than willing to do all of those things (6)

The emphasis was on understanding the importance of

communication, being able to assess the person’s commu-

nication needs and developing a personalised strategy to

make communication as easy and effective as possible,

linking with pace and flexibility.

Give her space, find our priority and just concentrate on one

thing (6)

Understanding Learning Disability

Participants experienced this as assessing the persons

understanding of their needs, resulting in reducing risk of

diagnostic overshadowing.

I: so what do you think was the pivotal factor in establishing

that communication?

R: knowing his level of understanding (4)

I came away with the impression not that she was avoiding

services or avoiding sharing information, it was just that she

didn’t absolutely have any of the skills to do it…….. Look,

sometimes it is about her Learning Disability (6)

Where services provided showed little understanding of

Learning Disability, effectiveness was reduced.

She got referred through to our team because everybody

suspected she had a learning disability, everybody had

written that on her notes, but nobody had ever tailored their

interventions or communication to recognise it within their

own practice (6)

6 M. Marsham

ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities

Page 7: An exploration of community learning disability nurses’ therapeutic role

This category related to assessing someone’s understand-

ing and to interventions to develop the person’s insight and

help them make sense of their experiences. Where this

happened, the aim was to reduce risks, maximise capacity

for decision-making, make consequences visible and to

articulate needs.

I think whilst there are no measurable improvements in his

health, he’s someone where I do feel I’m making a significant

difference to his quality of life, to his comprehension of his

current state, and of his future state (2)

I think without us going in, we wouldn’t have made the

headway we’ve got, where actually she’s recognising that

she’s in danger, she’s actually trying to make choices (6)

Initiating learning

This category arose from the participants’ experience of

educating the person, other caregivers or service providers

in general, rather than regarding a specific case. This

educator element covered medically directed intervention

and wider health promotion that connected general medical

advice and its implementation by the person in the context

of their own life.

So it wasn’t just done from ‘an injection was given and

nobody was the wiser’, it was allowing him to be as educated

as possible, so he was given time on that (4)

Participants described their own learning experiences as

integral to their therapeutic role. Learning opportunities

were not restricted to formal training and included joint

work and liaison with other patient groups.

I did feel that would help me understand the condition better,

by speaking to someone like him (specialist consultant), so I

could help him more effectively (7)

Conceptual model

The participants referred to their experiences of therapeutic

role as a combination of more than one of the phenomena

described, and in analysis, the emerging categories were not

distinctly separate. ‘Therapeutic relationships’ and ‘time as

a therapeutic tool’ were the strongest emergent themes;

though, other categories interconnected, with ‘maximising

support networks’ threading through all categories. Had

‘therapeutic relationship’ not been deductive, it would have

emerged as an inductive category, highlighting confirm-

ability with literature (Fig. 1 ).

Discussion

Despite attempts to maintain trustworthiness through

researcher reflexivity and bracketing, my Community

Learning Disability Nursing experience, developing inter-

view credibility over time and the influence of creative

thinking about emergent themes on subsequent interviews

are potential sources of bias and acknowledged as limita-

tions of the study.

Participants sometimes assumed common knowledge

based on shared professional role/identity. This may have

acted as a genuine bond, enhancing trust and disclosure, or

as a bonding ploy if participants felt under pressure to

provide ‘acceptable’ responses, leading to bias based on

their assumption about what I, as a senior Community

Learning Disability Nurse researching the topic, wanted to

hear (Schwalbe & Wolkomir 2003).

There is also the possibility that only Community Learn-

ing Disability Nurses who were self-aware of therapeutic

role volunteered. If the sample was exceptional, findings

can only be transferable to Community Learning Disability

Nurses with similar characteristics. Generalisability in

qualitative research relates to describing variables rather

Maximisingsupport networks

Use of time as

therapeutictool

Creativecom-

-munication

Understandinglearningdisability

Initiatinglearning

Therapeuticoptimism

CLDN

Therapeutic

role

Therapeutic

relationship

Person withlearningdisability

Figure 1 Conceptual model of Community Learn-

ing Disability Nursing Therapeutic role with adults.

CLDN’s therapeutic role 7

ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities

Page 8: An exploration of community learning disability nurses’ therapeutic role

than statistical rules for a specific population. Therefore,

there is no intention of the findings being transferable to all

Community Learning Disability Nurses, but they are gen-

eralisable descriptions of what any Community Learning

Disability Nurse can do, given they have the same interac-

tional competencies as the sample (Gobo 2004). Member

checking would strengthen confirmability but would not

necessarily enhance transferability.

With therapeutic role and working towards medically

directed goals not always clearly demarcated in the lived

experiences described, therapeutic role remains a nebulous

concept, reflecting the difficulty nurses have with its

articulation (Shatell 2004). However, credibility was pro-

tected by consciously returning to the operational definition.

This also impacted on method as focus groups and

observation were discounted partly because of risks of lack

of focus. With a clearer concept of therapeutic role, these

may become appropriate methods for future research e.g.

data triangulation from multiple perspectives (Green &

Thoroughgood 2004), if able to overcome the practical and

ethical issues. Having the perspective of service-users and

carers would be valuable, and redress the limit of this study

being only from the Community Learning Disability Nurs-

ing perspective.

This study supports the argument that therapeutic rela-

tionship/role with people with learning disability is possi-

ble and has positive outcomes, though is not an exclusively

interaction-based experience. Although the presence of

therapeutic relationship was key, it was the combination

of phenomena that constituted therapeutic role. There was a

strong consistent message from the data regarding the

importance of time. The assumption of reciprocity was not

experienced as key in these findings. There is acknowledg-

ment of mutuality, partnership approaches and positive

outcomes for Community Learning Disability Nurses.

However, there was no assumption of reciprocation. The

therapeutic optimism and creative communication seemed

to allow for ‘give and take’ to be less equal than described in

other settings although engagement in the relationship was

expected at some level and however the person could

demonstrate, even if through a proxy. Possibly this more

subtle participation and reduced ability to reciprocate either

through lack of experience or capability has led to the belief

that therapeutic relationships are not possible with the

cognitively impaired and that the limitations of the rela-

tionship lay with the ability of the patient rather than nurse.

The implications of this for health inequalities are not

known.

Conclusion

The findings indicate that Community Learning Disability

Nurses experience a multicomponent therapeutic role in

which therapeutic relationship is key, which they value in

terms of positive consequences. This should be reflected and

enabled in the roles in which they are employed. Service

provision systems and organisational culture need to

support Community Learning Disability Nurses’ therapeu-

tic role, creating an emphasis on time, flexibility and

consistency, and acknowledging the central role of thera-

peutic relationships, which may have positive outcomes

that are not easily observed or measured.

Relevant new knowledge that can be specifically applied

to Community Learning Disability Nursing practice has

been generated, and links with current trends for healthcare

access and care coordination roles (RCN 2011), which may

initially appear to deny Community Learning Disability

Nurses’ therapeutic role.

Further research could consider the support required for

Community Learning Disability Nurses to assert therapeu-

tic role, evidence outcomes and explore alternative perspec-

tives and categories in depth. The conceptual model may

have value as an educational or reflective practice/super-

vision tool, and connections with specialist/advanced

practice models could be explored.

Acknowledgements

Research undertaken whilst studying MSc Advanced Nur-

sing Practice, Florence Nightingale School of Nursing, Kings

College London.

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