Do you know that feeling when something you see or read in one context niggles at you and gives you pause for thought about your own context? That was my experience this week. At first glance what I was reading had nothing to do directly with the work of health professionals.
I was researching legal aspects related to the needs of a person with a disability. I got interested in reports about how the criminal justice system dealt with people who have an intellectual disability. There were plenty of reports and surveys covering the rights of people with mental illness and of course the rights of people with disabilities. The World Health Organisation principles are entrenched in Australian legislation and policies governing how these rights are protected. So at first glance this had little to do with nursing.
It was when I was reading about how the criminal justice system actually works with or for a person with a disability, how matters are communicated, the documentation and the procedures that I started to sit up and ponder.
Baldry, Dowse, and Clarence (2012) found that people with mental health disorders and cognitive disability (defined as intellectual disability, borderline intellectual disability and acquired brain injury) are over-represented in the criminal justice system as both offenders and victims.
There is clear evidence that people with intellectual disability are frequently victims. In fact we know that the vulnerable are more likely to be victims; health professionals are often involved in the care and treatment of victims of physical abuse and sexual abuse. Health services are, like the criminal justice system an institution. There are procedures, policies and protocols guiding interactions and interventions. Both systems rely on communication to establish what is going on, what has happened, what steps are to be taken.
In evaluating the criminal justice system procedures in relation to a person with a disability one report was quite scathing about how at every level of contact, inappropriate communication strategies were routinely employed. The limitations of the person with a cognitive impairment to grapple with the speed of delivery, the jargon or concepts that were employed, the complex sentences and ideas were a major problem.
Another report discussed the procedures and staff who were gatekeepers or initial fact finders, those who provided initial information about what would happen, what papers must be signed, when to return for a hearing and such like. My mind leapt to admission procedures, pre discharge information, planning follow-up and future appointments. Routines and protocols, nothing to be anxious about until I remembered how many people failed to adhere to discharge plans, failed to return for follow-up and appointments. Of course not all of those patients were intellectually disabled but when you acknowledge some of the issues that affect the client with a disability it did give me pause for thought.
Among those listed were the possibility that the person with an intellectual disability may be more prone to suggestibility; many may be eager to please a person perceived to be an authority figure thus giving the answers he or she believes are the desired ones rather than the correct ones; people with an intellectual disability may be more likely to respond to questions in a manner they believe is expected of them; many may be prone to ‘cued’ or ‘initiative behaviour’; there may be poor understanding of questions asked, and the implications of the answers given; many people with intellectual disabilities try to hide their disability and may, for example, answer a question to which they do not know the answer, so as not to appear ‘dumb or stupid’ (National Disability Services, 2013).
It was this last proposition that really brought it home to me that there is a risk that we could in our busy, pressured work assume our communication and routine procedures are comprehended and when we gain consent or give instructions these are valid and effective.
Intellectually disabled clients may be victims, they get sick and the shortfalls exposed by all these reports about the criminal justice system might at times be reflected in our approaches and habits of practice in the health system. Although I believe we are better able to identify risk clients and I believe nurses are capable of adapting their communication and approach to clients effectively I was still wondering. What about all the other people in our system? What if the client is hiding their disability? What education is in place for support personnel let alone professionals? These reports condemned the criminal justice system, it occurred to me I would hate to be found so wanting simply because I hadn’t actually given thought to the needs of the client with an intellectual disability.