interprofessional training—learning disability as a case study

JOURNAL OF INTERPROFESSIONAL CARE, VOL. 6, NO. 3, 1992 23 1

Interprofessional training-learning disability as a case study

PETER MATHIAS & TONY THOMPSON* Lead Manager of the Joint Awarding Bodies, London and *Senior Lecturer, Department of Nursing, University of Nottingham and Co-ordinator, Mid Trent College of Nursing and Midwifery

Summary This paper describes the background to the joint validation and shared training movement within the field of learning disabilities as it developed during the 1980s. The authors, with other committed colleagues, are concerned to e m r e that the impact of the movement towards joint validation and interprofssional training does not lessen during policy changes in health and social care in the 1990s. The work of the 1980s sought to shift the attitudes of some professionals and those who are the gatekeepers of these professions, away from organizational frameworks inherited bum more stable times, barneworks which placed undue emphasis on the role of services, with consumer need taking second place. The task of relating the purposes of professional training more closely to the needs of service users and the functions of practitioners continues to be undertaken within the field of learning disability in the context of the new Diploma in Social Work and Project 2000 programmes for the preparation of nurses. In general terms there are similarities between the situation which existed in 1979 and that which exists now. In 1979 the Conservatives were returned to Government and the need to respond to the Jay Report (1979) was pressing. The climate to initiate change existed. The nursing and social work statuio y bodies responsible for training and education perceived similarities in their work, encouraged by the Jay Report, and a situation was created for those in learning disability to start to work out the way in which interprofessional training might respond to changing services. The Conservatives have now been re-elected for a further term of office. The professions are far from stable and the need to implement the N H S and Community Care Act 1990 will be high on the agenda as will be the need to examine the possibilities of interprofssional training, albeit in a dzfferent context to that of 1979. I t could be that the previously marginalized group of workers in disability will have the interprofessional background to encompass areas outslde their immediate speciality. We suggest that no other group has tried harder in the past ten years to show how education and training can help create an integrated workforce.

Key words: Interprofessional training; joint and shared training; learning disability; standards and competence.

Correspondence: Dr Peter Mathias, Joint Awarding Bodies, c/o City and Guilds of London Institute, 46 Britannia Street, London WClX 9RE

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232 PETER MATHIAS & TONY THOMPSON

The origins of shared training policy

A benchmark in shared training was created in 1988 when the English National Board for Nursing and Kdwifery (ENB) and the Central Council for Education and Training in Social Work (CCETSW) validated two joint quahfying training courses designed for students with an interest in learning disability. What has been described as “a remarkable achievement” (Walton, 1989) had the most tentative of starts.

The move towards shared training commenced in the early 1980s when Patrick Jenkin, who was then Secretary of State for Social Services, responded to a parliamentary question (1980) about the implementation of the Jay Report (1979), stating that ‘ ‘ h s is not, in our view, the time to abandon a well tried form of training for nurses . . .”. At the same time, the Government announced that the then statutory bodies for nursing, the General Nursing Councils and CCETSW had been invited to convene a working group. The remit of this group was to consider introducing common elements into training. Of course, the debate went back further than 1979. The real shift in thinking about the role of mental handicap nurses emerged with the publication of the Briggs Report (1972). One of the Report’s 75 Recommendations regardug nurse education was that mental handicap nursing should evolve into a “separate caring profession”. During the rest of the 1970s this statement was to have a major impact on any debates regarding nursing which was, and to this day still is, the largest specialist trained workforce for people with learning disabilities. The call for a “new caring profession” provided a neat slogan devoid of content. It was still unclear abut the unique contribution of the nurse in residential care when compared to other professional groups, (Brown, 1992). However, page two of the Briggs Report did identlfy three basic contributions of the mental handicap nurse, which remain important to analysis of this role and function when considering contemporary shared training :

ti) a therapeutic tool for physical illness or disability of psychiatric disorder; ;ii) developing educational, occupational and social training; !iii) providmg ‘home’ (or ‘parental’) care.

The relevance of these points is that they are not dependent upon hospitals,

The Jay Committee

After the policy direction offered by Briggs (op. cit) it was in 1975 that Mrs Barbara Castle, then Secretary of State for Social Services, established a committee chaired by Mrs Peggy Jay. This committee worked to the following terms of reference:

to consider recommendation 74 of the Briggs Committee, in particular to enquire into the nursing and care of the mentally handcapped in the light of developing policies, to examine the roles and aims of the residential care staff required by the health and personal social services for the care of mentally handicapped adults and children, the inter-relationship between them and other health and personal social services staff; how existing staff can best fulfil these roles and aims; in the interest of making the best use of available skills and experience, the possibilities of the career movement of staff from one sector or category to another; the implications for recruitment and training, and to make recommendations. (p. 1)

The model of care adopted by the Jay Committee was based on normative principles and stressed human rights. Areas of practice expertise were identifed which were based on social residential care principles. No guidance or mandate was given by the Committee on how these areas were to be reflected in detded syllabi-this was placed back with the training bodies. The Committee’s recommendation begged the question regarding which training body or bodies were best equipped to be responsible for delivering their model of care?

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INTERPROFESSIONAL TRAINING 233

The uncertainty regarding mental handicap nursing losing its specialist ethos within the broader church of general nursing, together with the need to develop a new model of care, led the Jay Committee to consider four training options:

(i) shared responsibility between the GNC and CCETSW; ($ overall responsibility to the GNC; (E) creation of a new residential care training body; (iv) overall responsibility to CCETSW.

The first three options were dismissed for reasons of coherence of training, the danger of marginalizing mental handicap services and the fact that the nursing profession was still anticipating a less specialist training under the Briggs proposals. The preferred option was that of responsibility for training to come under the authority of CCETSW. Further, the Committee recommended that the Certificate in Social Service (CSS), rather than the Certificate of Qualification in Social Work (CQSW), was likely to be the appropriate qualification to replace the RNMH. The rationale for the decision was based on the content of CSS being likely to impart knowledge and slulls more closely associated with a speciahzed course. This proved to be a rather ndive way of introducing the CSS to the nursing profession.

Effective and influential criticism of Jay’s recommendations was to follow, much of it based on the perceived devaluing of professional status of nursing as in the eyes of some nurses, the CQSW was seen to be the preferred route to hgher status field work whilst CSS was seen to be more concerned with what some saw as the lower status basic occupational skills of residential work. It is interesting to compare this reaction, which missed the point of relevance of functional content, with that of the profession today when responding to the levels of National Council for Vocational Qualifications, whch are described later in this paper.

Between Briggs and Jay the mental handicap nurse had tolerated nearly a decade of professional uncertainty. Whilst some nurses responded emotionally and angrily to the Jay recommendations, many organized responses were well considered. Amongst these was that of the trade union, the Confederation of Health Service Employees. Whilst rejecting the Report’s main recommendations the union suggested a fresh and detailed syllabus for training in 1980 (COHSE, 1980).

Although CCETSW itself was willing to undertake the training it did express doubts that Jay had not fully recognized the contribution of the professional social worker (CCETSW, 1979). This was the background which preceded the publication of the two reports of a Joint Worlung Group appointed by the GNCs and CCETSW. The first amounted to a review of quahfying courses for training the staff working in learning disability health and social services (GNCKCETSW, 1982). The need for shared training was recognized primarily because of the Group’s awareness of the commonality between nurse training and the Certificate in Social Service, reinforced by the need to acknowledge the shift from residential to community care.

The second report from the working group in 1983 (GNCKCETSW, 1983) addressed the in-service and post basic element of training. This report benefited the shared training movement by shifting the debate away from the RNMH-CSS focus. This focus was to be blurred by the introduction of an exciting and far reaching syllabus of mental handicap nursing in 1982.

A new impetus

Whilst the in-service training report proposed that Joint Training Steering Groups could facilitate the sharing of training, the details were not implemented. Antipathy between nursing and social work still existed. It was not until the latter part of 1986 that new moves and pressures emerged. The authors of this paper were part of a working group of the ENB and CCETSW which from its inception aimed to co-operate fully within the spirit of the policy c h a t e and move the debate

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on joint training further. T h s resulted in the publication of a report in 1986 (ENBKCETSW, 1986). This report was well received by nurses and social workers, despite the fact that it used some hard- hitting statements that would have created furore during the Jay debates including:

when the ideological rhetoric is separated from the practical reahty of service delivery, nurses and social workers are finding considerable overlap in their interests, function and competence. (p. 4)

During the first six months of the Working Group’s life 2 1 organizations contacted them to provide evidence of a range of possibilities of co-operating in both qualifying and post q u w i n g training. It was the positive feedback and encouragement we gained from committed individuals and organizations which led us to write in 1987 “if nursing and social work fail to show convincingly that they are wdling and able to meet the challenge of providing new services co-operatively, then they WIU forfeit an involvement in an exciting phase of social policy and will remain on the sidelines as consumers find others more willing to respond to their needs.” (Thompson & Mathias, 1987). There were casualties of innovation as well as successes. In East Sussex, for example, the complex CSS scheme with its small but well supported mental handicap option, has been working jointly with District Health Authorities on training over a five year period, before formally discontinuing the initiative in 1988. The factors which contributed to the demise of the East Sussex initiative have been described by Walton (op. cit). The two schemes which succeeded in attaining validation were:

ti) The Kent Scheme: This was conceived in the early 1980s and the Tunbridge Wells Health Authority took the lead having gained strong support from Maidstone, Medway and Bromley District Health Authorities. The Joint Management Committee of the South East (Bromley) CSS which had a membership of 20 statutory voluntary agencies firmly supported the proposal.

(ii; The Essex Scheme: Like the former course this one evolved by mutual interest and contact between Health Service and College. One District Health Authority (Basildon and Thurrock) and The Havering Technical College which was the base of a 65 place North East London CSS scheme (Walton, 1989).

These schemes were paralleled by events in Wales since the publication of the All Wales Strategy in 1983 Welsh Office, 1983). Most important was the setting up in 1987 of the Welsh National Board for Nursing (WNB) and CCETSW which subsequently sponsored a number of projects which furthered practical opportunities for shared learning. The strength of shared training appears to be particularly associated with the outcome of practice and it has been in the 1990s that further options emerge regarding training outcomes for competent practice.

Implications for the 1990s

The development of co-operation and shared training between nursing and social work in the 1980s took place within a context in which the relevance and future of nursing to learning disability was held in question. Briggs argued for a separate caring profession, and Jay that CCETSW should assume responsibility for training. Meanwhde the services were changing towards a community focus and away from hospitals. Interprofessional co-operation took place in a climate in which the role of one of the panners was subject to change. It was not possible to make any progress on the basis of a comparison of role. Nor was it possible to say, for example, that the role of a nurse is X, that of a social services worker is Y, and that the area of overlap and therefore shared training is Z. It remains to be seen whether the concepts of health care and social care used by the NHS and Community Care Act, but still awaiting clear definition, will alter this situation. The Cullen report (DOH, 1991) is the frst to attempt to look at the role of nursing within the new pattern of services. It envisages a continuing role for the nurse within the health rather than social care domain.

However, in the mid-eighties real progress was made between the nursing boards and CCETSW

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when arguments and uncertainty about role were set aside and the basis of the co-operation set in terms of an understandmg of the hopes, aspirations and requirements of service users and the potential contribution which each of the partners could offer, defined in terms of respective training requirements, at registratiodquahfying and post-registratiodquahfjing levels. Hence, joint post- q u w i n g schemes (always the easiest to organize) and joint CSS-RNMH programmes (much scarcer and more difficult). Now in the 1990s the training rules have changed again. Nursing and social work training have both been reformed with the introduction of Project 2000 and the Diploma in Social Work respectively.

The respective abilities and competence expected of nurses and social workers who have undertaken either the learning disability (mental handicap) branch of Project 2000 nurse training or the Diploma in Social Work are shown below:

Table 1.

Nursing Mental Handicap Branch Programme Social work

1.

2.

3.

4.

5 .

6.

7.

8.

9.

10.

11.

12.

Identify factors that may lead to disability and associated mental handicap in the context of the life continuum of the individual paying regard to hisiher family unit, friends, community and society.

Examine and evaluate the factors which contribute to adverse physical, social and mental experiences. Initiate and co-ordinate actions to create positive growth- enhancing experiences for people. To play an active part in the development of a facilitative environment.

Use existing knowledge base to inform nursing practice.

Evaluate the influence of social and cultural factors in relation to the personal service system. Be pro-active in the process of change to benefit the individual.

Understand the requirements of legislation relevant to practice.

The therapeutic use of self in the network of care systems.

Acquire and utilize skills and knowledge to maximize own health and that of others.

Identify and utilize principles that guide nursing practices in services for people with a mental handicap.

Understand and interpret contemporary philosophies of care by demonstrating professional and interpersonal skills within the context of multi-agency provision and life-planning.

Develop a partnership with people to enhance each other’s quality of life via approaches that are planned, rational and lead to shared interventions that pay positive regard to individuality and differences.

Function effectively in a team and participate in a multiprofessional approach. Use the full resources available within an individual’s local community to most effectively meet that person’s needs.

Develop and utilize the skills and knowledge required to supervise, teach anti monitor others.

Assess needs, strengths, situations, risks.

Plan appropriate action.

Intervene to provide an initial response.

Implement action within the relevant legal and organizational structure.

Transfer their knowledge and slulls to new situations.

Take responsibility for the professional practice.

Evaluate their work.

Adapted from. THOMPSON & MATHIAS (1992) Standards and Mental Handicap-Key to competence (Bailliere Tmdall)

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Level II Core

0 Promote equality for all individuals

Z1 Contribute to the protection of individuals from abuse

-~

W2 Contribute to the ongoing support of clients and others significant to them

W3 Support clients in transition due to their care requirements

U4 Contribute to the health, safely and security of individuals and their environment

U5 Obtain, transmit and store information relating to the delivery of a care service

-~

Endorsements Developmental Care 25 Enable clients to move within their

environment 29 Enable clients to maintain their personal

hygiene and appearance 213 Enable clients to participate in recreation

and leisure activities Y1 Enable clients to manage their domestic

and personal resources X1 Contribute to the support of clients during

development programmes and activities

Direct Care 26 Enable clients to maintain and improve

their mobility 27 Contribute to the movement and treatment

of d i n t s to maximise their physical comfort

Z9 Enable clients to maintain their personal hygiene and appearance

210 Enable clients to eat and drink 21 1 Enable clients to access and use toilet

219 Enable clients to achieve physical comfort facilities

Domlclllary Support Z7 Contribute to the movement and treatment

of clients to maximise their physical comfort

Y1 Enable clients to manage their domestic and personal resources

W8 Enable clients to maintain contacts in potentially isolating siruations

U1 Contribute to the maintenance and management of domestic resources

Residentlal/hospltal support 27 Contribute to the movement and treatment

of clients to maximise their physical comfort

21 0 Enable clients to eat and drink 21 1 Enable clients to access and use toilet

facilities U1 Contribute to the maintenance and

management of domestic resoures U2 Maintain and con(r0l stcck. equipment and

materials

210 Enable clients to eat and drink 21 1 Enable clients to access and use toilet

216 Care for a baby in the first ten days of life

W6 Reinforce professional advce through

facilities

when the mother is unable

supporting and encouraging the mother in active parenting in the first ten days of the baby s life

U1 Contribute to the maintenance and management of domestic resoures

1 Others to be developed --_-j ~ _ _ _

, ~ _ _ _ _ _ _ _ _ _ ~ _

Fig. 2. National Vocational Qualifications in Care at Level 2.

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Level 111 Core


Z1 Contribute lo the protection of individuals from abuse

23 Contribute to the management of aggressive and abusive behaviour

24 Promote wmrnuncation wdh clients where there are communication ddfcukies

28 Supporl clients when they are distressed

YP Enable clients to make use of available services and information

V1 Contribute lo lhe planning and rnondortng of service delivery

U4 Contribute to the health. safely and sewrdy of individuals and their environment

U5 Oblain transmit and store information relating to the delivery of a care Service

P~thalndopsndencs Y3 Enable dmc4sto admirrster theirIinancmlatfaIrs Y3 Awstdmntsb move from a supportive toan

W Prepare andprowdeagreedindivchal development acbwtmslwcllents

W5 Support dmnts mlh difficult or potentially difhwlt relatanships

V2 Determine the ways in which the service can support clients

Independentliwngenvlrment

~ _ _ _ _ _ _ -

22 Conbibute to the provision of advocacy lor dents Y3 Emkk cllents to adninister their financial aHars X 2 Prepare and provde agreed individual

development activities IM clients W1 Support dients in developng their ldenbty and

V2 Determine the ways in which the sewice can i personal relabonships

support clients

- ' supporting indapendence

I__

218 Support indivduals d e r e abuse has been

development ac~ivitles for clients

Supported living

disclosed X 2 Prepare and provde agreed indimdual

A W1 Support dmnts in devdopng their ldenbty and

-

1 persomi rehaonships W5 Support dmnts mth difficult or potentially difficult

relatianships V2 Determine the ways in which the S~NICS can

wpport clients ~

RehaMlltatlve care Y4 Su~rtcllentsandcarersinurdertabng health care

for the client X2 Prepareandprondeagred indivldualdevelopment

acbwbeslor cllents - X16 Prepare and impremen1 agreed therapeubc group

acbwbes W I Support dients in developng their ldenbty and

personal relabonship W5 Support dients mth difficult or potentially diffiwlt

relationshiDs

Contlnulng Care 212 Contribute to the management of client continence X2 Prepare and provide agreed individual

development activities for clients X I 3 Prepare and undertake agreed clinical activibes

mth clients whose health is staMe in non acute care semngs

X I 6 Prepare and impiement agreed therapuhc group acbnbes

U3 Prepare and restore environments lor clinical treatments ard investigabons ~ _ _ ~ _ ~~ ~- ___ ~- -- ~~

Supportive long-term care 212 Contribute to the management of client continence X10 Support polessiomls by assisbq mth ard

carrying out agreed physotheraw movement programmes

X i 2 Suppart pofessionals mtf clinical activiUes X I 3 Prepare and undertake agreed clinical activities

mtf clients whose health is stable in mn acute care settlngs

treatments a d invesbgations u3 Prepareardrestoreenvironmentslordinical

~~ ~ ~-

Fig. 3. A\urional Vocaiional Qualificariom in Care ar L e d 3

S m o n a l Standards F o r Care ' are avallable from T h e Publications Dept; Local Government M a n a g e m e n t Board, A r n d a i e House, A r n d a l e Centre, Luton LUl 2TS

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Level 111 core


21 Contribute lo the protection of individuals from abuse

23 Contribute lo the management of aggressive and abusive behaviour

24 Promote communication with clients where there are communication difficulties

28 Support clients when they are distressed

Y2 Enable clients to make use of available sewices and information

V1 Contribute to the planning and monitoring of service delivery

_ _ _ ~ -

U4 Contribute to the health, safety and security of individuals and their environment

U5 Obtain, transmit and stora informatim relating to the delivery of a care service

. _~

Communication To be developed in early 1992 t _ _ 1-

pyt Care To be developed in early 1932

- 1 _ _ _ [ Others To be developed r

Twmlnrl Cm 26 EMble dents to mainrain and inpmve their mobday 214 S q p x t d ~ d ~ a t t i d b a s 215 W r b l e (0 the care d a decessed p" ,

X 13 Prepare and undmlake agreed d;nicd adintws with dents whose heaw is stable m m n - w e care settings

U3 Prepare and restore envirmnenk la dnical treatments and investgations

k U t 0 &N 212 ContMe to the managemen( d dient mtinenca X12 SuppOR prolessioMk with d m i d adivitws., X19 Prepare and undectake agreed d i i i adintws with

dents in acue cae sott&s U3 Prepare and restore enviramentsfor dinical treatments

and investinations

220 Care lor-and &mole the devebpment d babies X12 sypoc( p r d e d wdh d m d Sdlvlles XI9 Repare and undectaba agreed dwd adintms mth

dens in a d e care settmgs W7 Sypar and enawrage parens and dhers to care la

b&es dunng the Irst year d h r lves U3 Prepare and restore env imrMs 'or dnral treatments

and investgalions

Clink 8nd outp8tlat ew X12 SuppOR prole- w*h d n d a w e s X I 9 Prepare and undectake agreed d r d adivclie5 mth

dents in aare care senmgs V4 Support dmls and carers M uderwunp heakh care la

the dmnt U2 Manlain and conlrd stock. equpnen( and materials U3 Prepare and restom e n n m n l s lor dnral treatments

- _ -

- - _ . -. _- - __ . . - .- Subolan- u n 217 Suworl dmnts who are stkstanoe users 218 supporl irdnduak where abuse has bean dsdcsed Y4 SuppOR dmts and carers in vdertalung heakh care la

the dent X2 Prepare and p r o d agreed indlvdual development

adivles la dents Wt Support dents n devdopng the^ dent ly and p e m a l

rehtiomhps - -

Support and pmtoctlon 22 Cmtnbtre to the ~VKIOII d advocacy lor dients 218 Scqwii i d v d u a k where abuse has bean dsdosed Y4 S q m l d m t s and carers in vdertak~ng heahh care IQ

the dmnt X2 Prepare and p r o d agreed indiwdwl development

adivIms lor dents W5 Support dmts mth dfiicuil ~ p d e n t ~ l C dfiwuii

rehtlooshm

Self and mvlronmental management sklIIs 214 Suw dents and others at tmed bas X14 SJpport the dmt and prdessonal dumg ooapatimal

therapy X15 Assist ocarpatwnal therapsts n supprling dents to

develap sew and eTrvIrmntal management skills X16 Prepare and im@ment agreed therapeuot group

adivaes W4 Assist ocarpdtanal therapists n the provean d support

and equipment to dmts and cam n the ammunay

Mental h r l th w e X2 Prepare and pro& aoreed indiwdwl developnent

adivI(es la dmenrs X12 Sqqmtl prdessmak wnh dnical adivtIes X16 Prepare and implement agreed therapetrot group

adivtms W1 Suwrt dients n developng the^ dentry and permal

re htamhlps U3 Prepare and restore environments lor chnml treatments

and investgatims

Moblllty md movement X8 Prepare and restore the dent and the environment prior

to and f&wng phpaherajy pogrammes X9 S q m l p r d e s r d s by assisting mth and carrying out

agreed physldbrapy programmes X10 SqpM protessmals by asslsting mth and carrying out

agreed phpdhetapy mwemeenr programmes U2 Maintain and contrd stodr eqlnpment and matends

Fig. 3. Continued.

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There are obvious similarities and overlaps between the two sets of statements shown in Table 1 and Figure 1 at a broad and general level. These similarities become more pronounced when the statements are applied to work with people experiencing a learning dsability.

Figure 1 is an amalgam of the competence statements published by CCETSW and the UKCC. Its top row is drawn from the Diploma in Social Work and its second row from the mental handicap branch programme. Rows three and four are drawn from the finer details of each programme. Nursing and social work competence may each be weighted towards certain separate clusters within Figure 1, but the essence of our experience in the eighties is that, whilst patterns of competence may vary, they are all part of the one domain underpinned by the same knowledge and understanding of the client group. It is possible to hold commonality and diversity within a single framework across caring and remedial professions.

Excitingly &us possibility has also been demonstrated across a much broader range of settings and client groups in health and social care by the Care Sector Consortium. A description of the work of the Consortium can be found elsewhere in this issue where Hevey (see page 215) analyses its work in relation to Child Care and Education. In relation to health and social care the first fruits of the Consortium’s work, in 1990, were two separate sets of Health and Social Care awards and standards of competence. These have now been brought together into a single set of standards and awards which again recognize the commonality and diversity of activity within the care sector. Figures 2 and 3 show this in more detail and list the units of competence which will form qualifications at levels 2 and 3 of the framework provided by the National Council for Vocational Quahfkations

The competence required of nurses and social workers is not included in Figures 2 and 3 which instead deal with the competence required of staff who support professionals such as physiotherapists, occupational therapists and nurses or staff who find themselves working in jobs for which existing professional quahfkations are not required.

The professions (of nursing and social work) have not yet entered into the NCVQ framework. When and d they do, it might be predicted that a similar pattern of commonality and diversity will be apparent. A pattern given greater clarity by using the language of competence, and expressed in qualifications at levels 4 and 5 of the NCVQ framework. Figure 1 brings together nursing and social work whilst Figures 2 and 3 bring together the competence required of other workers in the health and social services.

The real opportunity of the 1990s is to use the language of competence to produce qualifications, relevant across professions, which can be related to the standards of the services and to do this in a way which allows for innovation and imagination. One rule from the 1980s for the development of interprofessional training is to concentrate on purpose, function and competence and to avoid protracted arguments and debates about the role, unless the situation is one in which professional roles are stable or subject to agreed or negotiated change.

(NCVQ).

References

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CCE TSW 1979 Comments 071 thc Rcpon of ihe Conimitree of Enquir)] into Menral Handicap h‘untng and Can, August,

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interprofessional training—learning disability as a case study

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