Chapter 9: The role of the student nurse in effecting change

Case study: John

You are a student nurse working under supervision on an acute orthopaedic ward. One of your patients is John, a 30-year-old man who has a learning disability. During handover, you are given the information that John has Attention Deficit Hyperactivity Disorder (ADHD), and Autistic traits. He has difficulty with social communication, social interaction and social imagination. He lives with his family. His mother is his main carer. John has had minor surgery earlier on in the day to correct a Hallux Valgus (bunion). The nurse handing over John’s care reports that since his return from theatre, John has been settled and pain free. As yet he had not wanted to eat or mobilise.

During the handover period, John’s mother arrived on the ward. She has sought you and your mentor out immediately after handover to complain about the care given to John. She is visibly distressed and reports that John is distressed and in acute pain. Your mentor explains that the nurse handing over John’s care had communicated that John has been pain free since return to the ward.

She demands to know how the nursing staff have assessed his pain. Your mentor shows John’s mother the pain assessment tool that has been used. John’s mother responds that the tool is totally inadequate to assess John’s individual response to pain due to his communication problems and requests for a more appropriate tool suitable to John’s needs to be used. You explain that this is the only pain assessment tool used on the ward. John’s mother becomes agitated and complains that the ward staff are not competent to provide the care that John needs.

  1. What do you think could be the main issues/problems regarding John’s care and experience?

  2. What immediate actions could you take to improve the quality of John’s care and experience?

  3. What actions could you take to influence innovative change using a bottom up approach?

› Solution

1. What do you think could be the main issues/problems regarding John’s care and experience?

   The main issue is that John and his mother have not had a positive experience of care. There are a number of factors that will, potentially, have impacted on their experience of the treatment and care they received. Within this scenario, there appears to be little evidence of the availability or application of any national regional or local standards or policies to provide a framework for the development of good practice by staff for the delivery of quality services to people with a learning disability in the acute setting.

   Barriers to good practice, concerning John’s care, could have been influenced by discriminatory attitudes, values and beliefs of staff regarding people with a learning disability. Alternatively, staff may have had little education or training regarding caring for people with a learning disability or people with challenging behaviour and communication problems. In addition, although a pain assessment tool has been used it has been an ineffective tool in assessing John’s pain due to his difficulty with social communication, social interaction and social imagination. The impact of not recognising and managing John’s pain has not enhanced John’s recovery from his surgery.

2. What immediate actions could you take to improve the quality of John’s care and experience?

    Your first action should be using good communication skills. By listening to John’s mother you will be able to understand not only what went wrong with the quality of John’s care but what interventions you could put in place immediately to improve his care.

   In order to enhance John’s care and recovery you will need to pay attention to addressing his pain assessment and management. This should involve working in partnership with John’s mother to adapt the current pain assessment tool to take into account John’s difficulty with social communication, social interaction and social imagination. This short-term reactive approach to change would demonstrate compassion about the care that John has received by developing a relationship based on empathy and respect.

3. What actions could you take to influence innovative change using a bottom up approach?

 You could research national, regional and local best practice guidelines based on best evidence that address the need for reducing inequalities and monitoring safe, effective, patient-centred, timely, efficient and equitable quality care for adults with a learning disability, communication difficulties and challenging behaviour. These policy drivers could provide you with a vehicle to communicate the need for change to your mentor. They would also help you to communicate what could be changed, how it could be changed and who would be best placed to implement the change. You could also investigate whether there is a currently a named acute learning disability liaison nurse or a Learning Disabilities nurse co-ordinator role employed by the trust to provide support for ward staff to develop service improvement change. By researching the drivers for change you could suggest strategies for improving the care and experience of adults with a learning disability, communication difficulties and challenging behaviour. Your strategies would need to consider include using appropriate service improvement tools to:

  • Develop patient forums for developing and evaluation of services
  • Develop care pathways which includes the pre-admission and discharge planning, a risk assessment and use of a patient passport
  • Develop the provision of education or training/resource packs and address potential values, attitudes and beliefs of staff
  • Develop and implement appropriate evidence-based pain assessment tools
  • Develop appropriate qualitative and quantitative feedback measurements to assess the impact of change and to drive forward sustainable improvements.

 This approach to change management would demonstrate that you have developed some effective leadership competencies and behaviours which could impact on motivation and energy to plan, implement, evaluate and sustain change which will impact positively on the care and experience of people with learning disabilities or people with challenging behaviour and communication problem.