Actividades

Each decade post Jay Report has brought with it challenges to the status and the role of the learning disability nurse in response to changing patterns of service delivery. The closure of NHS-funded hospitals and philosophies of normalisation led to opinion leaders and policymakers of the time recommending that the health care needs of people with learning disabilities should be met by generic rather than specialist services (Kings Fund, 1980; DH, 1989; DH, 2001). As such, the 1990s brought a change in emphasis around the role of the learning disability nurse, with many long-stay learning disability hospitals having either closed or being in the process of closing. Later, the Cullen Report (Cullen, 1991) supported the continuation of learning disability nursing as a distinct part of the nursing register and placed emphasis on an aspect of the nurse’s role that would refocus on health. Almost 30 years after the Jay report, in 2001 the Government produced its White Paper Valuing People First (Department of Health, 2001). Although there is little mention of specific services, the notion of inclusion and the use of generic services are clear and forms part of the paper’s guiding principles of ‘Rights Independence, Choice and Inclusion’. However, this long-awaited policy document, specifically aimed at learning disability, paid little attention to learning disability nursing. Greig (2015) suggests that the policy intention was towards social change, rather than a change in health and social care practices, in that Valuing People represents a ‘fundamental paradigm shift’ in focusing on changing societal attitudes towards people with learning disabilities as he states that: 'It changed the context of national English policy from being about how services cared for people with an intellectual disability to one of how services supported people to live a full life as equal citizens'. (P.64).

These changes in public policy and societal attitudes since the Jay report in 1979 have been the backdrop for the working lives of learning disability nurses over this period. As the only White Paper published specifically focusing on service for people with learning disabilities since the Jay Report, Valuing People is important in relation to my research study as it forms a key part of the legislative and policy history around the services in which these nurses worked.

In a historical context, learning disability nursing has a different narrative to that of ‘general’ nursing, and, whilst there is a large body of historical research around nursing, Sweeney and Mitchell (2009) suggest that the history of learning disability nursing ‘remains largely invisible’. For a number of years since the Briggs and Jay reports, the identity of the learning disability nurse has been under scrutiny with questions as to whether it even fits into the family of nursing. Inclusion in society is now the key aim in care for people with learning disabilities and there is a wide range of service provider agencies; thus leaving some doubt over the future role of the learning disability nurse. The impact of this debate is not only upon service provision, but also on the future education of learning disability nurses.

This challenge to the status and value of the learning disability nurse arguably predated the 1919 Nurses Registration Act and continued through to the Jay report in 1979. Mitchell (2000) argues that, although the 1913 Mental Deficiency Act gave clarity to the differences between mental health and learning disability, the position of the learning disability nurse has been debated as far back as 1895. In his extensive work examining the position of learning disability nursing from the early 20th _century

through to the 1970s, Mitchell highlights how such debates constitute a precursor for many of the attitudes and beliefs around the role and purpose of the learning disability nurse, many of which still continue today (2001; 2002a and b; 2003; 2004a and b).

In the 30 years that this study has covered, the role of the learning disability nurse has changed dramatically. It is acknowledged that, for some time, learning disability nurses have been working in a range of diverse environments, with potential NHS career opportunities in the early 1980s focused on either hospital-based care or on community nursing teams. However, specialist roles within the NHS do still exist,

particularly in health facilitation inpatient services and other specialist roles (DH, 2007; UK Chief Nursing Officers, 2012; Gates & Mafuba 2015). Much of the literature examining this period has focused on roles and the development of new positions, such as nurse specialists, the acute liaison nurse and nurse consultants, whilst less work exists considering roles outside the NHS (Birchenall et al, 1993; Mason & Phipps 2010; Brown et al., 2012; Moulster et al, 2012). In addition, Mafuba & Gates (2013) have discussed the public health role of the learning disability nurse, suggesting that there has been role ambiguity around this aspect of a learning disability nurse’s work: 'The contribution of community learning disability nurses in meeting the public health needs of people with learning disabilities has evolved differently across the UK, resulting in conflicting understanding of this role' (Mafuba & Gates 2013, p.43).

Developments in policy and service delivery models have also changed the locations in which people with learning disabilities require support. The long-stay hospital is no longer the main provider of health services for people with learning disabilities as a more mixed economy of health and social care providers, including the private and voluntary sectors, have taken over. While a range of studies have documented nurses’ roles and service change, none has focused on the narrative of these nurses as a collective in order to try to understand the impact of these changes upon identity. However, whilst there is a dearth of literature on the identity of the learning disability nurse specifically, there has been a great deal of commentary about the future of learning disability nursing (Mitchell, 2004; RCN, 2007; DH, 2001; 2007; Gates, 2007; 2010; UK Chief Nursing Officers, 2012; Jukes, 2014; Gates et al., 2015). Such work has emphasised the place of learning disability nursing within nursing more broadly, reinforcing the nursing role, and Gates has examined the impact of a reduction in the number of learning disability nurses. (Gates, 2007; 2010).

More recent publications post data collection have also discussed the future role of the learning disability nurse and provided a framework for research, leadership and management (UK Chief Nursing Officers, 2012; Jukes, 2013; Gates et al., 2015). Further to this, the UK Chief Nursing Officers also produced a report aiming to provide direction for the profession. Building from the UK Modernising Learning

Disabilities Nursing Review: Strengthening the Commitment (2012) highlighted four

key areas of development around this area of nursing; ‘strengthening capacity’, ‘strengthening capability,’ ‘strengthening quality’ and ‘strengthening the profession’. The report acts as a backdrop to contemporary learning disability nursing, clarifying the Department of Health position, whilst also acknowledging a decrease in the numbers of learning disability nurses and the difficulty in locating those who work outside the NHS. This report was published after the collection of the empirical data for this study, but, like previous reports (DH, 2001; DH, 2007), it may serve to reinforce the perceived role of the learning disability nurse from within the profession. The literature reviewed thus far illustrates change, but also highlights uncertainty and doubt over the future of learning disability nursing. This, in turn, raises questions around why people choose to pursue a career in which their identity is often scrutinised and the value of their role challenged. Where nursing has historically been seen as ministering to or caring for the sick, learning disability nursing has its historical basis in the removal from society and containment of people with learning disabilities. The places where learning disability nurses were employed may be seen as a reflection of societal attitudes towards the care of people with learning disabilities at specific points in time, but they were also part of shaping the identity of learning disability nurses today and where they see themselves in the ‘family’ of nursing. Within my study, this is important as it forms a key part of understanding the context of the narratives of the participants.

In mapping the literature around the place of people with a learning disability in society and the history of learning disability nursing, the focus has been on the developing role of the nurse (Mitchell, 2002; Stewart and Todd, 2001), the practices within service settings such as institutions (Potts and Fido, 1991; Wright and Digby, 1996; Atkinson et al., 1997;) and policy change (Malin, Race & Burton, 2004; Malin & Race, 2010; 2011). Whilst very few studies have focused on the narratives of learning disability nurses, the studies suggest a collective identity and a historical timeline important to my study as a ‘backdrop’ to the narratives of the 20 learning disability nurses who took part.

As has been established, the development of learning disability nursing is inherently situated within a historical context shaped by societal attitudes, policy change and institutional practices. Mitchell’s extensive work also reveals that the scrutiny of the history of learning disability nursing reveals an earlier questioning of the place of learning disability nursing within the family of nursing; ‘learning disability nursing has been under constant question from the 1920s until the 1970s when the Briggs Report suggested that a new profession should emerge and, as a result, the Jay Committee was set up’ (Mitchell, 2002, p.19).

This part of the literature has also revealed a changing service provision for people with learning disabilities as large NHS hospital provision closed and more services were provided in communities, bringing with it a further challenge to learning disability nursing and its place within non-NHS services. In order to further understand learning disability nurses and nursing it is important to first examine literature around why people choose nursing, and more specifically learning disability nursing, as a career.