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• To understand the importance of the early recognition of health issues in people with learning disabilities
• To enhance your knowledge of the range of communication skills nurses may use to engage service users in a systematic health assessment
• To contribute towards revalidation as part of your 35 hours of CPD (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
An important element of the role of the learning disability nurse is to support service users to maintain their health, particularly in relation to the early detection of health issues and timely access to appropriate treatments. One way of achieving this is by undertaking a systematic health assessment, of which effective communication is a central component in terms of identifying the person’s communication needs and using appropriate communication methods to meet those needs. Effective communication can engage the person in the assessment process as well as identifying their own experience of their health. This article explains the importance of using a systematic approach to health assessment and describes various elements of communication involved in this process. The authors include a fictional case study to outline how a systematic health assessment works in practice and the range of communication skills nurses may use to engage service users in the process.
Learning Disability Practice. doi: 10.7748/ldp.2023.e2197Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated softwareCorrespondence
Fleming S, Burke É, Doyle C et al (2023) Ensuring effective communication when undertaking a systematic health assessment. Learning Disability Practice. doi: 10.7748/ldp.2023.e2197
Published online: 11 May 2023
accessible information - communication - communication difficulties - learning disability - non-verbal communication - patients - patient assessment - patient engagement - professional - therapeutic relationships
The aim of this article is to emphasise the importance of using a systematic approach to undertaking a health assessment and to enhance nurses’ knowledge of the different elements of communication involved in this process. After reading this article and completing the time out activities you should be able to:
• Describe the rationale for using a systematic approach to undertaking a health assessment in a person with learning disabilities.
• Recognise the difference between a comprehensive and a focused systematic health assessment.
• Discuss the importance of effective communication in terms of engaging the person in a systematic health assessment.
• Identify important elements of communication to consider before, during and after undertaking a systematic health assessment.
• Consider how you might incorporate some of the communication methods described in the article when undertaking a systematic health assessment in your practice area.
• Learning disability nurses are in an optimal position to support people with learning disabilities to maintain their health, particularly in relation to early detection of health issues
• Undertaking a systematic health assessment can support the development of a therapeutic relationship between the service user and the nurse
• During a health assessment, it is essential to convey respect for the person, recognise their abilities and treat them with dignity as a valued contributor to their own health and well-being
• Nurses must ensure that they use communication methods that are appropriate to the person’s expressive and receptive abilities
People with learning disabilities experience the same range of health conditions as the general population but, despite this, they have a higher prevalence of chronic health conditions than those without learning disabilities and encounter significant inequities in accessing healthcare, resulting in poorer health and higher mortality rates (Glover et al 2017). In the UK, people with learning disabilities should be offered an annual GP health check, which aims to improve their health through timely identification and management of health issues (NHS England 2019).
Learning disability nurses are in an optimal position to support people with learning disabilities to maintain their health, particularly in relation to early detection of health issues and access to appropriate treatments and services (McCarron et al 2018). This can be achieved through undertaking a systematic health assessment to identify any concerns a person may have about their health or to explore a particular health-related issue. A systematic health assessment requires skilled communication on the part of the nurse to ensure the person understands and can engage with the process and to ensure the nurse is able to attend to, interpret and clarify what the person is expressing – verbally or non-verbally – about their health.
This article describes how the learning disability nurse can use skilled communication to undertake an effective systematic health assessment. The article uses a fictional case study to demonstrate this process in practice.
In your area of practice, and aside from the GP annual health check, how frequently are service users offered a health assessment? What criteria might trigger the need for a health assessment? What are the risks associated with relying only on your knowledge of the service user rather than using a systematic approach to identifying health issues?
A systematic health assessment can be described as comprehensive or focused. A comprehensive health assessment involves gathering information on all aspects of the person’s health history and conducting a full physical examination. It is more appropriate for service users who are new to a service or who may be attending hospital or their GP for a healthcare-related examination or consultation (Rushforth 2009). A focused health assessment is a more selective, problem-based approach to gathering information and forming a differential diagnosis, and is usually undertaken with service users who are already known to the assessor and are returning for routine care or who have a particular health condition, such as a chest infection (Rushforth 2009, Casson et al 2018).
Undertaking a systematic health assessment, whether comprehensive or focused, can support the development of a therapeutic relationship between the service user and the nurse (Ingram 2017), collate important information, such as the person’s lifestyle, social supports and medical history, and help identify health issues or concerns (O’Donovan 2011, Ingram 2017). This information gathering can provide a comprehensive understanding of the person’s needs, health concerns or presenting complaint, enable the nurse to formulate a differential diagnosis before initiating diagnostic testing (O’Donovan 2011, Ingram 2017) and support delivery of quality care (Fawcett and Rhynas 2012).
Nurses can use a framework such as the Calgary-Cambridge model (Kurtz et al 2003) to guide a systematic health assessment. The model has five stages – initiating the session; gathering information; physical examination; explanation and planning; and closing the session – and emphasises the importance of the structure and content of the assessment and of developing a therapeutic relationship with the service user. To focus a systematic health assessment on a specific symptom or health concern, nurses can use the OLDCART mnemonic – which stands for onset, location, duration, character, aggravating/associated factors, relieving factors and treatment/timing – to guide their exploration and develop a comprehensive picture of the service user’s issue (Rushforth 2009).
Undertaking a systematic health assessment can be complex and requires a range of communication skills, which can take time to develop. If you feel you lack experience in this area, can you arrange to shadow a more experienced colleague or spend time with a speech and language therapist to observe an assessment of a service user’s communication abilities?
There are three important and potentially challenging elements of communication involved in undertaking a systematic health assessment: knowing the service user and how they communicate; establishing their expressive and receptive communication abilities; and communicating with them in a way that enables them to understand and engage in the assessment process (García et al 2020).
Before undertaking an assessment, the nurse must familiarise themselves with the person’s past medical history by reviewing their health records and health passport (also called a hospital passport) (The Regulation and Quality Improvement Authority 2018). These records can provide valuable baseline information, providing they are well maintained, and may help the nurse identify which health issues they should focus on or find out more about during the assessment.
The nurse also needs to spend time getting to know or reacquainting themselves with the person to determine how they communicate and identify any reasonable adjustments they may require to enable them to participate in the assessment process. People with learning disabilities should have a communication passport containing detailed information about the most effective ways of interacting and of supporting their understanding and expression (Royal College of Speech and Language Therapists (RCSLT) 2013). If this information is not recorded in a communication passport – which is sometimes incorporated in a health or hospital passport – the nurse should liaise with the person’s family members or carers to gather a complete, dynamic profile of their communication strengths and needs.
Up to 90% of people with learning disabilities have communication issues, while about half have significant difficulties with expressing themselves and understanding what others say (Royal College of Speech and Language Therapists (RCSLT) 2013). The nurse should therefore consider the person’s level of learning disability, the level of their expressive and receptive communication abilities and their methods of communication (The Regulation and Quality Improvement Authority 2018). Understanding the person’s expressive and receptive communication abilities can help to prevent inaccuracies in interpretation and subsequent misreporting of symptoms, which could lead to under or over-diagnosing. The nurse can seek guidance from a speech and language therapist colleague to identify a service user’s receptive and expressive abilities and the supports that may be required to enable them to engage in the health assessment process (Martin et al 2012). These supports may include Alternative and Augmentative Communication – techniques that support or replace spoken communication, including gestures, signing, symbols, word boards or books, as well as voice output communication aids (Communication Matters 2023).
Do all service users in your practice area have a communication passport? If so, what information is included and how often is the information reviewed and/or updated? If not, could you initiate a project to ensure this resource is provided for your service users? The CALL Scotland website contains information on creating communication passports, including ideas for layout and content. Visit www.communicationpassports.org.uk/creating-passports
During a health assessment, it is essential to convey respect for the person, recognise their abilities and treat them with dignity as a valued contributor to their own health and well-being. The nurse should use all opportunities to attune with the person and communicate with them directly during the assessment, rather than with family members or carers for example (Doherty et al 2020).
People with receptive or expressive communication difficulties may find it challenging to understand complex language and/or to express themselves, therefore the nurse should consider the following points (Centre for Developmental Disability Health Victoria 2017):
• Use jargon-free language when asking questions.
• Avoid asking lengthy questions.
• Give the person plenty of time to answer and to ask questions.
• Ensure communication aids and/or devices are working and turned on.
• Clarify how the person communicates ‘yes’ and ‘no’.
• Use visual cues to explain and clarify points.
• Check the person’s understanding throughout the assessment.
• Observe the person’s body language and/or facial expressions throughout the assessment, for example any that might indicate discomfort.
• If the person’s response to a question is unclear, ask them to repeat what they have said or reframe the question using different words and/or pictures.
People with severe learning disabilities may have little or no speech and may communicate mainly through body language, facial expressions and behaviours. In this instance, the nurse may require the support of someone who knows the person well such as a family member or key worker to interpret these expressions and behaviours (Centre for Developmental Disability Health Victoria 2017). Observing and documenting such expressions and their meaning in the person’s communication passport can provide information for future interactions with healthcare professionals.
Table 1 details some points to consider about communication before, during and after undertaking a systematic health assessment.
You have been requested by a key worker to visit a service user with a moderate learning disability who has been experiencing stomach pain and nausea. You have met this service user twice before, but the last time was over a year ago. Thinking about communication, reflect on what you should do to prepare yourself and the service user before undertaking a systematic health assessment. How might you identify or refamiliarise yourself with the person’s communication methods, abilities and support needs? Write down your reflections in a short scenario
This fictional case study – Mary’s story – demonstrates a focused, systematic health assessment in practice, using the Calgary-Cambridge model (Kurtz et al 2003) and the OLDCART mnemonic (Rushforth 2009). The case study shows how using skilled communication enables the learning disability nurse to engage Mary in the assessment process and support her to express her concerns about her health.
Mary is a 59-year-old woman who has Down’s syndrome and a moderate learning disability. She lives in supported living accommodation with three other women. She has recently returned from a month-long holiday at her brother Fred’s house. Mary’s key worker contacts a learning disability nurse who knows Mary well and asks her to undertake a health assessment. The keyworker tells the nurse that since returning Mary is ‘not herself’ and is not keen to go for walks in the park, which she usually likes to do.
The nurse telephones Mary to ask if she is willing to meet her, explain what the meeting will entail and to agree a time and date. Before the meeting, the nurse reviews Mary’s health record and health passport, which contains information about Mary’s preferred communication methods and abilities. Based on this information and her prior knowledge of Mary, the nurse decides to use the Calgary-Cambridge model (Kurtz et al 2003) to structure the assessment and the OLDCART mnemonic (Rushforth 2009) to establish the precise nature of Mary’s symptoms and concerns.
The nurse understands that the OLDCART mnemonic does not have to be followed in sequence and plans to be guided by, and respond to, Mary’s cues, questions and replies. The nurse considers how she might frame exploratory questions and explanations in a way that will ensure Mary understands what is being asked, the possible diagnosis and the treatment plan. She also decides to take a range of communication tools with her when she visits Mary, including a visual pain scale, a body chart and images of medical procedures, which she will use if appropriate or required.
When she arrives at the house, the nurse asks Mary if she can undertake the assessment in her bedroom, which is upstairs. On the way up, the nurse notices that Mary stops halfway, appears breathless, holds the front of her chest and says her arm is aching and that she thinks she ‘still has the flu’. When they arrive at the bedroom, the nurse decides to explore this further. Once Mary’s breathing has settled, the nurse asks her if she is happy to continue with the assessment and tells her that she can stop at any time.
The nurse understands that it is important to gather information in a sensitive, reassuring and conversational way that Mary is familiar with, so she starts by asking her about Mary’s holiday at her brother’s house and the nice things she did there, before turning the conversation to her ‘flu’ symptoms and attending to what is concerning Mary the most. Throughout the process the nurse continues to build trust and rapport with Mary, even though they already know each other, and attends to Mary’s non-verbal and verbal cues, which might express any concerns she has about her health.
Mary says she is ‘achy’ and points to her left arm and chest, says she had a chest infection and was ‘on tablets’ and that ‘I am not myself.’ When the nurse asks what she means by this, Mary rubs her abdomen and says that it makes her feel ‘like getting sick’. The nurse observes that Mary has some shortness of breath while she is talking. Mary also says that she is not going for walks anymore, and when the nurse asks why she says it is because the staff walk too fast, she cannot catch up with them and that it makes her ‘feel dizzy’.
Family members who know a person well can contribute to history taking (Martin et al 2012), so having noted that there was nothing in Mary’s health record to indicate she was unwell during her holiday, the nurse telephones Fred, with Mary’s consent and in her presence, to gather more details about this recent illness. Fred says that Mary was breathless and coughing while she was staying with him and that the local GP had prescribed antibiotics. He adds that Mary was not as keen to do activities as she usually was, but he had just put this down to her getting older and ‘being a bit poorly’.
Table 2 gives examples of the communication methods and questions used by the nurse in Mary’s health assessment.
|History and presenting symptoms based on Mary’s responses and her brother’s report
|Use a timeframe Mary understands
|Ask Mary to point to where pain is on her body and observe whether Mary points directly to a specific location and/or a larger area
|Use a familiar reference, for example past medical issues
|Compare with a familiar ‘painful’ experience using a 1-3 rating scale (1=mild, 2=moderate, 3=severe)
|Aggravating factors/associated factors
|Talk through a typical day to determine when the chest pain and stomach discomfort and nausea are worse and to identify possible triggers
|Based on having talked through a typical day, focus on what improves the pain and nausea
|Based on having talked through a typical day, focus on what eases the pain and nausea
Having gained information about the presenting symptoms, the nurse asks Mary if she is happy to continue with the assessment and explains this will involve taking her blood pressure and listening to her chest but that they can stop at any point. Having again gained Mary’s consent, the nurse continues with the assessment focusing on the presenting symptoms (Table 2) and following Mary’s verbal and non-verbal cues. The nurse takes and records Mary’s temperature, blood pressure, pulse, respiration rate and chest auscultation and weight. All observations are within Mary’s normal range and her chest sounds are clear. Mary’s weight has increased by 3kgs over the last two months.
It is important that the nurse provides the type and amount of information that Mary can understand so that she can share in decision-making. The nurse explains to Mary that it does not appear that she has had a chest infection and asks if she has any questions or further concerns about how she is feeling to check her understanding of this.
The nurse then asks Mary if she is happy for her to arrange a visit with her GP to chat about the ache in her arm and chest, which she agrees to. Using pictures, the nurse explains that before the GP visit, she will arrange for Mary to have blood taken and that, depending on the results, the GP may do an electrocardiograph (ECG). Mary has not had an ECG before, so the nurse arranges to bring some easy read information about the procedure and explains that she will go through this with Mary.
The nurse thanks Mary for meeting with her and says that if she thinks of any questions, she can telephone her. The nurse returns the completed health records to Mary’s key worker and updates the key worker on what has been agreed.
Communicating with Mary in a safe, private space, using communication methods that match her expressive and receptive communication, including images and references specific to Mary’s life and needs, enabled the nurse to engage Mary in a focused systematic health assessment. Talking to Mary’s brother during the assessment revealed additional information which enabled the nurse to form a differential diagnosis (anaemia, strained chest muscle or cardiac-related condition) and management plan (physical examination, blood tests and ECG to confirm diagnosis, followed by treatment specific to that diagnosis).
Considering Mary’s story, think again about the service user in Time out 4. The key worker believes he may be constipated. How might you undertake a focused, systematic health assessment to identify the presenting symptoms and explore the issue further? Reflect on how you might engage the service user in the process and support him to express his experience of his health issue. What questions might you ask and what communication methods might you use to ensure these are understood? Add your reflections to your written scenario
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Learning disability nurses can assist in reducing the health inequities experienced by people with learning disabilities through early detection of health issues and timely referral for treatment and management. Undertaking a systematic health assessment using skilled communication can engage a service user in the process and enable them to express their views and concerns about their health. Nurses must ensure that they adapt their communication techniques and use communication methods that are appropriate to the person’s expressive and receptive abilities. Undertaking a systematic health assessment can be complex, therefore learning disability nurses can work with more experienced staff to enhance their health assessment skills and liaise with speech and language therapist colleagues to enhance their communication skills.
Identify how the use of communication skills when undertaking a systematic health assessment applies to your practice and the requirements of your regulatory body
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