Nursing offenders with learning disabilities in environments of varying security

1
Nursing offenders with learning disabilities in
environments of varying security

• What are the key differences?
• Andy Lovell, Reader, University of Chester
• Anne Kingdon, Consultant Nurse, Cheshire Wirral
  Partnership Trust

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Background

• Closure of long stay hospitals and development of
  care in the community (Better Services for the
  Mentally Handicapped 1971, The Jay Report 1979,
  NHS Community Care Act 1990).
• Development of small, short stay, well staffed
  RSUs (2000 beds) (Butler Report 1975)
• Mentally Disordered Offenders needing care and
  treatment should receive it from health and
  social services. 1,500 RSU beds needed including
  for minority groups (Reed Report 1993/4)
• Mansell Reports (1993, 2007) failure to develop
  services locally will give rise to out of area
  placements and result in re-institutionalisation
  through emergency admissions and diversion from
  prisons (1993). reactive models of service
  provision and commissioning has meant that the
  development of adequate local expertise and
  infrastructure has not come to fruition (2007).
• No One Knows Prison Reform Trust report suggest
  that 20-30 of prisoners have learning
  difficulties or disabilities (7 approx have
  intellectual disabilities) that interfere with
  their ability to cope within the criminal justice
  system.

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Contextual factors

• Changing ideas around how people with learning
  disabilities offending behaviour should be
  cared for.
• Re-negotiating the boundaries between secure
  environments prison, high, medium low secure.
• Prison reports about learning disabled population
  (2007).
• Emerging debate around the relationship between
  learning disability and secure settings,
  particularly individuals requiring long-term
  support and care.
• Increasing acceptance that community packages can
  be provided for people with complex needs and
  risks including offending behaviour.

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The Study

• Question What are the skills, knowledge
  attitudes required by qualified learning
  disability nurses working in differing areas of
  security (high, medium low) and community
  settings?
• Definition of competence profession?

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Methodology

• Qualitative approach designed to elicit the views
  of those engaged in working directly with
  offenders with learning disabilities.
• Qualitative research is concerned with
  constructions of reality its own constructions
  and in particular those constructions it meets in
  the field or in the people it studies (Flick,
  1998 11).
• Sources of data collection 6 focus groups 24
  subsequent individual interviews with nurses
  currently working with those whove offended or
  are considered at risk of offending.
• Sample purposively selected from different
  environments.
• Access facilitated locally.

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Ethics

• University of Chester Research Ethics Committee.
• IRAS (Integrated Research Application System,
  formerly NRES).
• Local Clinical Governance procedures applied and
  were variable.

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Key ethical issues

• Satisfaction of ethics committees
• Access to varying levels of security
• Consent
• Anonymity / Confidentiality
• Level of rigour the higher the level of
  security, the greater the level of protectiveness

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Sample population
Registered Nurses working with people with
learning disabilities and forensic needs

• Community community nurses in learning
  disability services, including liaison workers,
  those designated with forensic role nurses
  working with offenders.
• 4 x Low Secure Services including 2 x NHS and 2 x
  Independent sector services.
• 1 x NHS Medium Secure.
• High secure Rampton.

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Completed outstanding data

• Community 2 focus groups 10 interviews
  complete / 3 interviews outstanding.
• Low secure 2 focus groups 8 interviews
  complete / 2 interviews outstanding.
• Medium 1 focus group 5 interviews complete.
• High secure 1 focus group 4-6 individual
  interviews outstanding.

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Data analysis Thematic analysis (following Braun
Clarke, 2006)
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Thematic analysis
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Thematic analysis
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Emerging themes

• Role confusion and/or articulation problems
• Born not made (personality traits
  characteristics)
• Professional expertise language
• Discrete cultures within different spheres of
  care
• Institutional legacy
• Service users are changing
• Working with others
• Tensions

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Theme 1 role confusion / articulation

• feel slightly more dissociated from (the) role
  and (have) started to get confused about the
  whole process C
• we stay away fromthe idea that everybody with a
  forensic background should be looked after by a
  forensic nurse, because with some of our
  clientsthe forensic behaviour wasnt the most
  pressing need C
• Oh God, Im rubbish at articulating stuff like
  that C
• its not cut and dried, its a really difficult
  thing to define L

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Theme 2 born not made

• Im not sure how much formal knowledge is
  thereI know this isnt something thats talked
  about very oftenand is certainly frowned upon in
  nursing, but a lot of it comes down to your
  intuition as well C
• Statements not everyone can do this job its
  not for everyone secure unit?

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Theme 3 the language of expertise

• they (staff working in other levels of
  security) couldnt work in this field because of
  the offences some of our clients have committed
  M
• I think some people also feel quite out of their
  depththeyre just so afraid, how do we manage
  them? M
• some of them feel they havent got the skills
  to manage them, or the knowledge M

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Theme 4 discrete cultures according to level of
security

• The other thing thats quite common in high
  secure servicesis that you can become
  desensitised to the offending behaviour, so
  behaviour that you would normally see as not
  being normal almost becomes normal C
• (In community nursing) its a totally different
  way of looking at things, theres a professional
  culpability there in terms of if anything goes
  wrong it falls down to me reallyI do a lot more
  around defensible practice than I did in secure
  services C
• I think the ward staff must get naffed off quite
  frankly with the community staff, I mean all bar
  two here have been seconded to do a degree C

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Theme 5 the institutional legacy

• (High secure in early90s) was so draconian in
  every wayit was just hideous C
• I wanted to prevent people getting there, that
  was my next thing, that there should be more
  being done within the community to prevent people
  ending up in this (HS) environment C
• youre talking about a place where if staff
  didnt like you they undid the wheel nuts on your
  car C

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Theme 6 the service users are changing

• there is an awful lot of our client group that
  are involved with alcohol and drugsit makes
  things a little more chaoticvulnerable to
  exploitation by people in the community.
• Other quotes that reflect this.

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Theme 7 working with others

• I think its about understanding that youre
  working with a bunch of professions you have no
  understanding about C
• Sometimes they talk a completely different
  language C
• you have to be able to use the appropriate
  language and also to help other people translate
  the language C

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Some initial thoughts characteristics of varying
forensic environments
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Initial thoughts (cont.)
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Key References

• Braun.V Clarke.V (2006) Using thematic analysis
  in psychology. Qualitative Research in
  Psychology. 3 77-101
• Flick.U (1998) An Introduction to Qualitative
  Research. London Sage