an exploration of community learning disability nurses’ therapeutic role
TRANSCRIPT
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
& 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
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(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
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
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ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities
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.
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ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities
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)
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ª 2011 Blackwell Publishing Ltd, British Journal of Learning Disabilities
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
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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