Staff perceptions of community learning disability nurses' role.

Method: A total of 40 staff completed a questionnaire to identify the role and rate the effectiveness of community learning disability nurses. Inter-rater reliability was assessed and themes were identified.

Findings: Staff see community learning disability nurses as having service development, liaison and consultancy roles. However, respondents also continued to emphasise nurses' direct clinical role, with over 40 per cent identifying assessment and treatment. The perceived effectiveness of the community learning disability nurse was 4.09, SD=0.71, indicating that staff generally perceived the service to be effective.

Conclusion: Community learning disability nurses are viewed by their multidisciplinary colleagues as having a broad and varied role, which is consistent with the role, identified by nurses themselves. They may need to consider how to further develop their services in relation to clients' physical health. Overall, all participants rated the nursing service as effective.

It has been argued that learning disability nursing, as a profession, is vulnerable to the influences of philosophical, theoretical, and policy changes. As a result it has greater difficulty in developing a clear professional, empirical or philosophical basis for practice and intervention (Bollard and Jukes, 1999).

Nurses traditionally had a key role in learning disability services. With the adoption of community care policies and normalisation principles (Nirje, 1969) the model underpinning nursing practice shifted from a medical model delivered in hospitals to a social-educational model delivered in the community (Bollard and Jukes, 1999).

The role of the nurse has therefore had to adapt to political and philosophical changes, which have influenced the way services have been delivered to people with learning disabilities since the early 1960s (Greig and Peck, 1998). This appears to have contributed to a lack of clarity about the role of the learning disability nurse (Pennington, 2000) and in recent years the profession has had to defend its existence (Parrish and Sines, 1997).

This defence is not, however, helped by difficulties in demonstrating the effectiveness of nursing interventions. Parrish and Sines (1997) argue that this is because the role of the learning disability nurse is diverse and complex and that much of the work is preventative. Other authors, however, argue that it is essential that the profession develops a research base and that practice is constantly evaluated (Tait and Turner, 2001; Beacock, 2000).

Another difficulty in establishing the role of community learning disability is the lack of consensus within the profession (Seal, 1998). With increasing recognition that the health care needs of people with a learning disability often go unrecognised and unmet (Paxton and Taylor, 1998) has come a focus on the nurse's role in health promotion, surveillance, and monitoring. Many authors identify these as key areas where the skills of learning disability nurses are required (Coyle and Northway, 1999; Mansell and Harris, 1998). The government report Continuing the Commitment (1995) also emphasised the need to focus on health surveillance and monitoring.

Despite general support, some authors warn that this role does not need to be carried out by a learning disability nurse. Glasby (2000) argues that health care could be provided by trained practitioners who are not necessarily specialist learning disability nurses. Mathews (1996) reported learning disability nurses' concerns at undertaking such roles. He warns that nurses' failure to undertake roles where their skills appear to clearly lie may contribute to the downfall of the profession.

The debate surrounding the nurse's role is not confined to health promotion. Increasingly nurses have developed specialist roles, providing services to a discrete client group (Pennington, 2000). Cox (1993) argues such specialisation will reduce the range of experience, skills and knowledge of individual staff, ultimately undermining the quality of care. The role of learning disability nursing in social care settings has also been debated. Martel (1999) argues that it has been strengthened by changes in care delivery. One reason for this is the ability to work effectively with social services. Other authors argue that the emphasis on service coordination and management within social care settings may lead to a reduction in the clinical skills of the nurse (Messent and Caan, 2000).

Despite the apparent confusion, most newly qualified learning disability nurses wish to stay in the profession (Tingle, 2001). There also appears to be a growing consensus about nurses' key skills. These include health education, promotion, assessment and surveillance; advocacy and promoting client competence; clinical skills; service coordination, development and evaluation (Tait and Turner, 2001; Coyle and Northway, 1999; Rose and Kay, 1995).

The debate about this changing role has generated a number of models of service provision. There has been only limited input from the professionals and care staff who receive a service from the profession, even though nurses often work in multidisciplinary teams in social care settings. This study aimed to examine the perceptions of health and social care staff in relation to the role.

Method
A total of 40 staff participated - 15 qualified health staff within a community learning disability team or health service assessment and treatment unit, and 25 residential staff, day care staff and social workers who worked with people with a learning disability. Fourteen were male (35 per cent) and 26 female (65 per cent), with a mean 13.7 (SD=8) years' experience in learning disability services. All participants completed a questionnaire, which asked the following:

1. Name three things that a community learning disability nurse does as part of their job.

2. Would you like to change anything about the way the community learning disability nurses work?

3. If yes, describe what you would change.

Participants were asked to rate nurses' effectiveness on a five-point scale where 1 = 'completely ineffective' to 5 = 'highly effective'. They were also asked to note their gender, professional background and number of years of experience of working within learning disability services.

Results
Responses were coded to give a measured inter-rater reliability. All categories had Kappa values of 0.4 or more and significance levels of 0.05 or less, indicating significant agreement between raters on all categories.

The role of community learning disability nurses

The responses to questions one and three were categorised. Table 1 shows examples for each category for 'Name three things that a community learning disability nurse does as part of their job' (question 1) and Table 2 responses to 'What would you change about the way community learning disability nurses work?' (question 3).

Table 3 illustrates the number and percentage of participants identifying three things community learning disability nurses do (question 1). Many gave more than three responses. A Pearson's chi square test found that health staff were significantly more likely to cite assessment (X2=4.88, df=1, p<0.05) and training (X2=5.46, df=1, p<0.05) as a role than were social care staff.

Twenty-five participants (62.5 per cent) said they would change the community learning disability nurse's role in some way, while 10 (25 per cent) would not. An unrelated t-test found no significant differences between those who would or would not change the nurse's role.

Table 4 illustrates the number and percentage of participants identifying each category in response to the question 'What would you change about the way the community learning disability nurse works?' (question 3).

Perceived effectiveness

The mean rating of effectiveness by staff was 4.09, SD=0.71, indicating staff perceived the service to be effective. An independent t-test found no significant differences in the perception of effectiveness in relation to gender, professional group, or whether the participant wished to change the nurse's role. No significant relationship was found between ratings of effectiveness and experience of working in learning disability services.

Discussion
This study examined the perception of staff in learning disability services about the role of the community learning disability nurse. The area most commonly identified related to liaison, service development and coordination, which was categorised as consultancy work.

This role has been identified as crucial by previous authors. Beacock (2000) notes that government policy has increasingly focused on removing professional boundaries and the need for collaboration and coordination between services. He identifies a key nursing role as creating sense out of chaos and sees the role of nurse consultants as central to service development (Beacock, 2002).

The results from the present study suggest that colleagues generally see the community learning disability nurse as undertaking this service development, liaison, and consultancy role. However, participants continued to emphasise nurses' clinical role, with over 40 per cent identifying assessment and treatment as a role. It was perhaps surprising that only 21 per cent of responses related to health promotion, particularly as this is increasingly identified as central to the nursing role (Coyle and Northway, 1999; Mansell and Harris, 1998). This may be because respondents had health issues in mind when discussing the role of nursing in assessment and treatment but did not explicitly refer to it.

Alternatively, the study may reflect the fact that staff working in learning disability services perceive nurses to be less involved. This interpretation is supported by the fact that 26 per cent of those who wished to see changes in the role of the nurse identified health promotion and links with primary care as needing further development.

Few people identified research as a role for community nursing. This may relate to the fact that nursing practice in learning disabilities is often perceived as being driven by philosophical and political changes rather than having an empirical basis (Bollard and Jukes, 1999). Authors increasingly stress the need for nurses to undertake interventions underpinned by research and to evaluate their practice (Tait and Turner, 2001; Beacock, 2000). The results of this study suggest others do not yet perceive this area as a core component of the nursing role.

Over 70 per cent of participants said that they would change the role of the nurse in some way. A large percentage of this group (72 per cent) expressed this positively in terms of wishing for more nursing resources. The remaining responses related to the way the role was carried out or the way the service was organised.

There were a number of requests for improved communication between nursing and other health care staff. In addition, as noted above, there were specific requests for an increased emphasis on the nurse's role in promoting health and working more closely with primary care. Bollard and Jukes (1999) identify two models within which learning disability nurses focus more heavily on health issues. In the first they argue that the nurse could function as a resource and link between the community learning disability team, while in the second the nurse is based within the primary health care team and liaises with the community learning disability team. The authors note a number of advantages and disadvantages with each model.

Limitations
The study has some limitations. The results relate to only one particular area and one particular nursing service. It may be that staff working in other areas hold different views about the role of the learning disability nurse. Likewise the participant sample, while reasonably large at 40, only obtained the views of a limited number of people. It may be that the views of those who did not respond may have been inconsistent with those who did.

Conclusion
Although the general perception of their role is positive, this study suggests learning disability nurses may need to consider how to further develop the services they provide in relation to clients' physical health.

Overall, all participants rated the nursing service as effective. There were no differences in rating between the different professional groups, and those who wished to see some changes in the role of the nurse rated the service as just as effective as those who did not want changes. Similarly there was no relationship between rating of effectiveness and experience of working in learning disability services, suggesting staff who are new to the service and more experienced staff see it as being equally effective.

Changes to the service were largely seen in terms of having more resources, although there was a focus on the need for improved communication and a greater emphasis on clients' health needs. Finally, the service was seen as effective. The study suggests that, as Beacock (2002) hinted, community learning disability nurses may be succeeding in creating order out of chaos.

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