THE MODEL OF NURSING IN LEARNING DISABILITIES – Part 2.

Fintan Sheerin continues his argument for a new nursing model, with special reference to learning disability services.

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In my previous article (Frontline 37, 24), I examined the historical aspects that have been influential in the development of societal attitudes towards people with learning disabilities, and whilst many of the events recounted occurred in countries other than Ireland, it would, I think, be somewhat naïve to believe that they did not have an influential effect here. Dublin, it must be remembered, was the second city of the British Empire, and was the location of many discoveries during the scientific revolution. Whilst it may be conceded, however, that those events inevitably had some effect on Irish societal attitudes, one must question to what extent they influenced the approach of nursing towards people with learning disabilities. No consideration has yet been given, however, to the way in which, prior to specialisation, nursing itself developed, within the context of the growth of ‘heroic medicine’.

Nursing in the Time of the Scientific Revolution

Prior to the revolution in science and industry that took place during the eighteenth and nineteenth centuries, people who were skilled in various traditional therapies had provided care on an informal basis. Although men had been involved in the provision of such care, often as religious or tribal leaders, caring became largely the ambit of women. This was to change with the regularisation of medicine that developed during the nineteenth century, when scientific men became synonymous with the provision of medical intervention. As caring and traditional approaches, which had been passed down for centuries by word-of-mouth, were denigrated and became marginalised, so also was the fate of their practitioners.

Nursing too suffered, and became an undesirable job for proper women (or men). The nurses of the post-revolution period were typically drawn from the underclass, and often were themselves inmates of the asylums and workhouses in which they resided. They were not nurses as we now understand nurses to be, and, as Dickens has recounted in Martin Chuzzlewit, they provided little in terms of positive intervention for their patients. They were clearly subservient to physicians and addressed caring within the context of the model put forward by the medical profession; due both to their lack of education and their social and professional disempowerment, they were in neither an informed position, nor a situation of any status, to question that approach.

Even when, thanks largely to the ideas of Florence Nightingale, some degree of organisation began to develop within nursing, during the mid-nineteenth century, professionalisation of nursing was seen within the context of ‘faithful obedience’ to the physician. This was, perhaps, a manifestation of the status of women in Victorian society.

As nursing developed further, it was still heavily influenced by medicine, with many of the initial training courses having been devised wholly, or in part, by the medical profession. These courses provided nurses a glimpse of the world of science, by touching on physiological, anatomical and microbiological concepts. This served, not to build up the nursing profession, but rather, to maintain the hierarchical status quo, for it increased the nurses’ awe of a medical profession which was able to use such scientific methods to effect ‘cure’, whereas nursing could only effect ‘care’. Within the field of learning disability, this dependence upon a positivistic medical model of disability, based on an identification of the person as being ‘abnormal’ and ‘different’, was also the context within which early nursing developed there. This was to remain the character of the nursing approach to caring for persons with learning disability right up to, and after, the commencement of specialised nurse training in the late-1950s. There are some who would argue that it is still alive and well within Irish mental handicap nursing, and will remain so until a radical overhaul of the paradigmatic base for such nursing is enacted.

The Model of Nursing

In order to examine the effect that this medical approach has had on nursing, we must first look at the beliefs that underpin that theory of nursing. In order to address this, it is necessary to look at the conceptual model that underpins nursing in that field. Such a model, or representation of the reality that is learning disability nursing, should make explicit the beliefs and values inherent in that discipline of nursing, and should therefore, expound the attitudinal context within which people with learning disabilities are addressed by that group. To do this, we must first delve into the work that has been done in other areas of nursing.

The development of nursing in the United States since the turn of the century has differed greatly from that in Ireland. This is especially so with regard to the education and training system, which has been associated with academic institutes there since the 1920s. In Ireland, such association has only been a reality since the 1980s. It was within the context of nurse education that nurse theorists began to explore the knowledge base upon which nursing practice could be grounded. It quickly became evident, around the 1960s that, not only had nursing not built up such a body of knowledge, it had not even begun to explore what nursing actually was. And so, the next couple of decades were characterised by an extensive debate in the professional literature on what issues were of paramount importance to nursing. One of the authors, Jacqueline Fawcett, who drew on the work of Thomas Kuhn (1970), identified the global term, which, she claimed, identified the phenomena of interest to nursing. This was referred to as the ‘metaparadigm of nursing’ (literally the all-encompassing model of nursing).

Whereas Fawcett (1995) has pointed out that every discipline has a metaparadigm, which acts as a source from which numerous theories emerge, she argued that, within nursing, this global term encompasses four basic components (Fawcett, 1984), which were subsequently suggested by Pearson and Vaughan (1986) to be the essential elements of any nursing theory. These components, more exactly termed the key concepts of nursing, are: Person; Health; Environment & Nursing.

It should be noted that some authors have disagreed on the validity of a four-part metaparadigm, and have included or excluded various concepts. It is, however, generally subscribed to within the professional literature (McKenna, 1997), and may therefore, be considered to be a widely accepted basis for addressing nursing models.

If it is accepted that these key concepts represent the foundation stones for nursing theories (Fitzpatrick and Whall, 1996), one would expect each theorist to outline their beliefs and assumptions regarding the person, to present an identification of the person’s environment, to define their concept of nursing and to discuss views on health. This has been seen to be the case, and is evident from the diverse manner in which individual theorists have conceptualised the four elements, from their differing perspectives. The beliefs and assumptions that are inherent in each theorist’s model represent personal views, and are largely the produce of a socialising process that took place during the development and maturation of that theorist, and so, may be heavily influenced by societal attitudes and stereotypes.

The influence of the medical model on the development of nursing was alluded to in my first article. This has been internalised within a nursing approach, known as the medical model of nursing, and has been at the centre of the profession for many decades. This model can be examined and described by asking questions about how it addresses the four key concepts. During recent lectures to both multidisciplinary and nursing professionals, I asked students to assess the beliefs inherent in the medical model in relation to these concepts, based on their experience of it, either on television, as a recipient of care, as a provider of care or as a co-professional. Some of the responses that were returned are presented in table 2.

Perceptions of the medical model of nursing.

PERSONReduces person to part/disease.
Addresses the disease, not the person.
Person as recipient of, not participant in, care.
Person as patient.
Person as being disempowered.
HEALTHAbsence of physical and mental disease.
Absence of abnormality.
NURSINGCaring for (doing for).
Treating.
Helping.
ENVIRONMENTNot an important factor in medical model.
Environment as having a largely negative influence on health.

Readers may identify with some of the ideas expressed in the above. It is important, however, to state that the medical model of nursing has served us well throughout a period of time, which has seen a general dissemination, and acceptance, of the positivist approach. It was not an intellectually derived model of nursing in the same way as some of the more current ones are, but rather, evolved in relation to medico-nursing practice. As such, it has been in place since the foundation of nursing as a profession, and has developed alongside nursing itself, perhaps moulding it into the profession it is today, and although nursing is in a state of professional flux, and is currently undergoing much change, many, including myself, would argue that it represents the predominant force at work in the profession today – and that is across all disciplines, including learning disabilities.

Despite its contributions, however, the medical model has been strongly criticised in the nursing literature for its dependence on reductive principles which are rooted in the belief that all behavioural phenomena can be conceptualised in terms of physiochemical principles (Engels, 1977). Engels (1977) suggests that this viewpoint pervades society and the socialisation process and fails utterly in accounting for the many social and psychological factors that influence health. The process by which this model categorises signs and symptoms into patterns for diagnostic labeling is argued by Chapman (1985) to be both dehumanising and reductionist. The evidence for its continuation in nursing is clear. Stevens (1979) has alluded to the similarity between the nursing process of care planning and the medical process of treatment planning. Indeed, we are now seeing an international movement towards the development of a taxonomic process of nursing diagnosis, intervention and outcome, with International Council of Nurses and World Health Organisation classifications of disease and disability labels being produced (ICN 1996, WHO 1997).

Whereas it is conceded that the medical model of nursing has served society well in the battle against illness and disease, it is been increasingly considered to be inadequate and inappropriate within learning disability nursing, for, as nurses begin to explore their realm of responsibility, they are beginning to identify the importance and value of the alternative, qualitative, holistic approaches to care that have been inherent in nursing for many years. This is especially true where nurses see other professional groupings addressing issues of learning disability from alternative perspectives, and other countries addressing services from vastly different paradigms.

A New Model of Nursing

As learning disability nurses move away from the institutional settings, there appears to be a concurrent movement towards this alternative paradigm, with calls for a new approach to addressing learning disability issues, from a qualitative perspective, whilst remaining within the context of nursing. It is unfortunate, however, that few serious attempts have been made to conceptualise and share the beliefs inherent in this alternative paradigm. In the absence of such conceptualisations, the medical model may continue to be prevalent.

Some authors have attempted to explore the application of nursing models, from outside learning disabilities, to this area. A search of the Cumulative Index of Nursing and Allied Health Literature and English Nursing Board databases, however, yielded only two such papers. Duff (1997) suggests that the lack of research-based evidence does not support the application of such models in learning disabilities nursing. The failure of learning disability nurses to apply them in practice, as experienced by this writer, affirms this suggestion.

It is my contention that, in keeping with international, and cross-disciplinary trends, there must be a paradigm shift within learning disabilities nursing, away from the problem-orientation of the medical model of nursing towards a developmental model that is focused instead on wellness and on the abilities of the person. Whilst such a move may not sound radical to non-nurses, it does have major implications for this discipline of nursing, because it demands modification of some of the most dearly held tenets in nursing including the problem solving approach to care planning.

The identification of the person – whether client or patient – as a human being who has innate, individual potentials for development also challenges the process by which we label and categorise people, for we are all human beings with potentials for development. With this focus, disability has the potential to move from being the central focus of interest, regarding the learning disabled person, to becoming a secondary issue, in favour of ability. A danger for learning disabilities nursing is, however, that such a shift may further distance it from mainstream nursing, perhaps to an extent such that it will be alienated altogether and may be forced to separate from that mainstream.

The proposed model, based on Sheerin and Sines’ (1999) conceptual approach to personhood, seeks to create a theoretical basis for addressing the application of this alternative paradigm, whilst maintaining, and indeed, affirming the place of learning disabilities nursing within the wider nursing profession. This alternative approach to the person who has a learning disability can be seen in relation to the four key concepts of nursing (table 3).

The Developmental Potential Model of Personhood

PERSONAn integrated human being with individually determined potentials for development.
HEALTHMovement towards the attainment of one’s developmental potentials.
NURSINGA profession that assists the person in the attainment of his/her developmental potentials.
ENVIRONMENTInternal and external aspects that may encourage or impinge upon the ability of the person to attain his/her developmental potentials.

It must be admitted that, similarly to the vast majority of other models of nursing in the professional literature, this has not yet been tested. It may provide a starting point, though, for an explorative process into the changes that are required for nursing in the field of learning disability, as we face the imminent dawn of a new millennium. There needs, however, to be much more work put into this area by such nurses, and, with the inauguration of the new clinical posts, allied to the Registration/Diploma Programmes, I think that the possibility of this happening is better than ever.

In conclusion, it is important to realise that all of these models of learning disability, whether nursing, medical, psychodynamic, social etc. may mean very little to the lived experience of the person with learning disabilities, as a citizen of this country. No amount of paradigm shifting within or across professions will effect change for these people, if there is not a societal shift in paradigm. Currently, we live in a country that, arguably, does not even recognise learning disabled people within its scheme of social stratification. In a society that equates membership with economic productivity, those people who are seen to lack economic productivity potential, cannot hope to achieve a state of normalised life or social role valorisation, unless society starts to see them as people who have possibilities rather than disabilities.

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