Practice Improvement for Learning Disability Care

Introduction

This dissertation is a practice improvement plan in the form of a research proposal which addresses the negative attitudes supposedly held by health care providers towards people with learning disabilities. The focus will be on adult student nurses and how increasing their knowledge and experiences of working with people with learning disabilities can ultimately improve service user care. The aim will be to introduce a learning opportunity, through a practice placement in a clinical setting, working with people who have learning disabilities alongside learning disability professionals. This practice improvement plan will be presented in a methodical structure with chapters providing a thorough systematic overview of each part of the research process. Mencap (2008) defined a learning disability as “a reduced intellectual ability and difficulty with everyday activities”. Socialising; managing finances and looking after physical health are said to be some of the most significant disadvantages. These problems will affect a person with learning disabilities throughout their entire life (Smith and Forrester-Jones, 2014).

The care provision for people with learning disabilities has changed considerably over the years. From Victorian times where the eugenics era was most prevalent (Atherton, 2011, p.35-53), to segregation in big workhouses (Barber, 2012a) and the present day where legislation requires people with learning disabilities to receive the same rights and treatment as all citizens. (DoH, 2001; 2009; 2012). Although the health care provision for learning disabilities has come a long way, with many people now living in the community accessing generic services, there is still a long way to go in meeting their full health care needs (Barber, 2012b). In spite of mainstream services now being required to make reasonable adjustments for people with learning disabilities, they are still experiencing many barriers to health care provision resulting in poor health outcomes (Mencap, 2004; 2008; 2012). The reasons for this include: lack of confidence and training of health care professionals (Edwards et al., 2007), communication difficulties (Pridding et al., 2007), support to access facilities (Hemmings et al., 2009), no offers of health screening (Gibson, 2006), use of inappropriate assessment tools (Adshead et al., 2015; While and Clark, 2014), diagnostic overshadowing (where symptoms of poor health are attributed to a person’s learning disability)(Gibson, 2006; While and Clark, 2010), physical access due to mobility issues (Swann, 2004), sensory impairments (Wolverson, 2012), lack of knowledge about services available (Bollard, 2009) and most relevant for the purpose of this study – the attitudes of health care providers (Barr and Bracchitta, 2014). There are many reasons for these barriers but attitude appears to be a leading cause for the lack of attention in improving many of these matters (Gibson, 2006; Michael, 2008). Attitude has been described as the cognitive propensity to favour or not favour a particular entity (Smith and Forrester-Jones, 2014, p.111). Attitudes of health care professionals were highlighted as one of the key barriers regarding the physical and emotional wellbeing of people with learning disabilities (Mencap, 2008). Negative attitudes can lead to misunderstanding of the complex health needs of people with learning disabilities and have been described as discrimination in health services (Barber, 2011). Furthermore, this lack of understanding of needs has contributed to poor standards of care and even death in some circumstances (Mencap, 2007; 2012). Mainstream primary and secondary health care providers are often oblivious to the inappropriateness of care they deliver (Gill et al., 2002), with diagnostic overshadowing being a main concern contributing to possible fatalities (DoH, 2001). People with learning disabilities have the right to have their health care needs met in an equitable way (DoH, 2001). This is not only a philosophical and moral right but a right enshrined in the Equality Act 2010 (Equality Act, 2010). The Equality Act states reasonable adjustments must be made to address health inequalities for people with learning disabilities (Mencap, 2008; Walker et al., 2014). These could include for example, physical access, such as wheelchair ramps; easy read leaflets and posters to help understand; better informed professionals (training); regular annual health checks; use of communication tools and provision of learning disability liaison nurses (MacArthur et al., 2015).

The Michael report (2008) describes how lack of consideration to adjust and conform to the needs of people with learning disabilities is attributed to insufficient training and negative attitudes. The report argues that attention to learning disabled service user’s views and needs must be at the forefront of person-centered care. The Nursing and Midwifery Council acknowledge this and requires all students to have some form of training in learning disabilities during their 3 year study programme (NMC, 2010). However, universities have flexibility to design their own curriculums and the amount of training they provide (NMC, 2018, p.5). Current research suggests that the content or amount of training hours is scarce as many studies still report an overwhelming lack of confidence and competence in the area of learning disabilities (Smith et al., 2016). Nurses have been found to view their own level of skills as insufficient to provide the appropriate level of care (Lewis and Stenfert-Kroese, 2010). This is confirmed by several reports (e.g. DoH, 2001; 2009; Mencap, 2007; 2004 etc.) that people with learning disabilities still suffer health disparities due to the delivery of inadequate and ineffective care from mainstream health care providers (Saunder and Knight, 2017). Regardless of specialist area, all qualified nurses should be capable of making reasonable adjustments for people with learning disabilities to ensure an equitable health service responsive to all service user needs. However, to achieve this requires the commitment of education providers and hospital health service leaders. In respect of nurses, a key step to achieving this, is having an understanding of the impact learning disabilities has on the individual (Dawkins, 2010; Doody and Doody, 2012). Gaining experience and learning about the specific needs of people with learning disabilities, could possibly accomplish this and hopefully influence practice and policy for future care (Temple and Mordoch, 2012, p.408).

Background

This chapter describes the impact a change in attitude can have for adult nurses, people with learning disabilities and their families. It will discuss what has previously been studied and what has been found to cause and help improve people’s perspective. It will also suggest why adult student nurses are being targeted and what forms of education they are currently receiving. Assessing the strengths and weaknesses of previous research can assist the focus on relevant areas of practice which need attention. Literature searching can help identify what is known and not known about a subject (Maltby et al., 2010, p.90-92). A worldwide search of literature was conducted on the chosen topic. Worldwide inclusion was used to gain awareness of other countries provisions and practices. This can give greater insight and diversity to the literature search which may show where potential improvements can be made in the UK. Initially research from the previous 10 years was sought to remain up to date (Pautasso, 2013). However, modern research surrounding the chosen topic was lacking, and the time frame would have excluded important legislative papers which changed provision for people with learning disabilities regarding their health and value in society. This prompted the time period to be extended back to 1999. Literature to support the need for this practice improvement plan was accessed through the electronic database Cinahl Plus. Search words: learning disabilities or intellectual disabilities or mental retardation or learning difficulties or special needs, dual diagnosis, mental health, attitudes or perceptions or opinions or thoughts or feelings or beliefs, adult nurses or general nurses, student nurses or nursing students, families and experiences were typed into a Boolean operator. Boolean operators allow the use of AND, OR and NOT between search words to aide connecting topics and reducing unwanted ones (Mit Libraries, 2018). Cinahl plus retrieved results or linked through to Journal websites such as Wiley online library, ProQuest central, Elsevier science, MEDLINE and Internurse. Government papers and relevant books were also introduced to the search to increase the depth of knowledge, evidence and legislation relating to the topic.

Reasons for access

The first theme which emerged from the literature search were the reasons why more people with learning disabilities are accessing general hospital services and the importance of providing equitable care. The life expectancy of people with learning disabilities has significantly increased over the years; from the 1930’s where their average life expectancy was 18.5 years; through the 1960’s where average life expectancy increased to 59 years; to 70 years in 2014 (Walker et al., 2014). Approximately 210,000 people living in the UK are said to have a severe or profound learning disability, with a further 1.2 million people having a mild or moderate learning disability (DoH, 2008). Wolverson (2012) suggests that 2% of the learning disabled population could be accessing general hospital services at any one time. This means for practice, a hospital catering for 2000 patients, approximately 40 people could have some form of learning disability (DoH, 1999) . A study by Kelly et al., (2015) noted that within a 30 day period of discharge from a general hospital service 69% of learning disabled patients were re-admitted with preventable causes. Barr and Gates (2009, p.366) estimated that 26% of the learning disabled population will require general hospital services every year. This is in comparison to 16% a year by the general public. However, when accessing these services people with learning disabilities are experiencing much poorer health care outcomes than their non-learning disabled counter parts (Glasby, 2002). These statistics have naturally increased since the national drive to de-institutionalise and find community settings for people with learning disabilities (DoH, 2001; Bouras et al., 2006, p.99). Evidence suggests that people with learning disabilities show a higher incidence of epilepsy; swallowing difficulties; mental health problems; sensory impairments; infection; metabolic; cardiovascular; musculoskeletal and gastrointestinal disorders; poor diet; smoking and drinking (Barriball and Clark, 2005; Wolverson, 2012). They are also more likely to require acute emergency treatment and long term management in general nursing facilities (RCN, 2014, p.4). This accounts for some of the significantly higher use of general hospital services by this cohort of the population (Smith et al., 2016). Statistics show a need for improvement in health outcomes for people with learning disabilities when admitted to general hospital services. The literature highlights the magnitude of the problem and the necessity to address the level of knowledge and understanding adult nurses have of people with learning disabilities.

Education

The second theme identified was the need for better education and the involvement of people with learning disabilities in delivering increased awareness of their needs. Reports from Michael, 2008; Mencap, 2007; 2004; DoH, 2009; 2012 all indicate a much needed improvement in the structure of education for health care provision for people with learning disabilities. Since the 2001 White paper ‘Valuing People’ and the 2009 ‘Valuing People Now’ was first published the Government have set new standards for all mainstream services to provide more suitable, equitable health care for people with learning disabilities. The aim is to limit the need for specialised services and improve accessibility to mainstream for everyone with a learning disability (DoH, 2001; 2009). This meant non-learning disability specialists would have to manage the healthcare needs of people with learning disabilities. Although both documents reinforce the need for mainstream services to adapt and provide appropriate care, they are silent on the issue of how best to educate service care providers in this task (DoH, 2012).

Universities can vary in the amount of time spent on providing education in respect of learning disabilities to the different fields of student nurses. This can come in the form of placement (differing in duration), class room lectures, or online learning (Barriball and Clark, 2005, p.166). Consequently without a unified structure of education provision shared between all Universities, competence and confidence is variable throughout the UK.

Education is an important tool in the development of learning disability care. Although, there is evidence to suggest that face to face contact is more beneficial to improving negative attitudes (Werner et al., 2012). The UK is increasing its focus on the involvement of service users in the delivery of health care education (NMC, 2018). A reduction in the public’s trust of current health care services for people with learning disabilities has driven the focus on having a service-user perspective. There is also general agreement that this approach provides benefits for everyone involved (Bollard et al., 2012; Speed et al., 2012). These benefits include enhancing professional understanding in the classroom and community (Morgan and Jones, 2009); influencing person-centred practice (Rhodes, 2012); allowing student nurses to witness people with learning disabilities in a different light and seeing and hearing them as experts in their own life and care (Scammell et al., 2015). These benefits counteract negative attitudes and also challenge stereo-types of how learning disabled people are believed to present (Smith et al., 2016, p.112). Bollard et al., (2012) provided face to face contact with learning disabled service users for student nurses in a classroom environment. Students reported that meeting people with learning disabilities in person provided a much deeper level of understanding and evoked greater empathy. For this approach to be successful a wide range of people with learning disabilities would need to be willing to participate and this creates ethical challenges regarding vulnerability, capacity to consent, safeguarding, etc. Perry et al., (2013) conducted a systematic review of 10 studies which explored the use of mental health service users participating in the education of mental health nursing students. They concluded that involvement of mental health sufferers were valued, particularly in providing better communication skills and improving student nurse attitudes. However, some students were concerned with mainly subjective views from some of the service users. This study focused on attitudes of mental health student nurses to service users with mental illness but the findings are relevant to service users with learning disabilities as more exposure to people who receive a similar stigmitisation is likely to improve attitudes and communication (Tew, 2012; Lovell et al., 2011). Werner et al., (2012) believed direct supervised classroom contact for mental health student nurses working with people with learning disabilities could also contribute to the foregoing improvements. Conversely, Birrball and Clark, (2005) suggest the classroom environment can only teach so much and without contact in a clinical practice setting, students will lack confidence to provide competent health care when working on the wards and in the community after they qualify. A virtual experience named Sharville was introduced in one University in Birmingham. Different virtual scenarios where people with learning disabilities needed support were played to students via video in a classroom environment. Students would then choose from a multiple choice questionnaire which course of action best suited the scenario. General consensus from interviewing the students on their experiences showed mainly positive feedback. Students believed the videos helped them better prepare for real life situations in clinical practice (Saunder and Berridge, 2015). Reflection with peers in the class room after watching the videos was highlighted as a positive aspect, but it was noted this would be missing in real life practice as nurses often work on their own. Lecturers who were also interviewed feared that some of the scenarios depicting violence and aggression could strengthen a stigma already attached to people with learning disabilities (Lovell et al., 2011). It was also mentioned that very little was known about the people in the videos. Just a diagnosis with clinical information, as opposed to likes and dislikes, history, service user and family views, etc. All very essential to know in person-centered care, especially to those with learning disabilities (Brown and Kalaitzidis, 2013). The sample size was small for this research project with only 19 participants being interviewed. This is not a statistically significant sample and drawing conclusions from this could be erroneous, even so the research has useful findings. Saunder and Knight, (2017) reinforced the findings of this study with a wider more contextual mixed method approach. Qualitative and quantitative data were analysed through questionnaires of 146 responses from pre-registration students. This was an upgraded virtual reality system named CitySCaPE. Again general consensus was positive, but with minimal knowledge of the service user and not being able to relate to them was a recurring theme. Ecological validity was low in both studies, as although some of the participants had experience working with people with learning disabilities, most did not. A controlled comparison between virtual and actual real life clinical practice would have strengthened the research results (Baumeister and Vohs, 2007). The practice improvement for this study will involve real people with learning disabilities in a clinical setting. This allows participants to get to know and fully understand the person and their social needs as opposed to just a clinical rundown of physical and behavioral issues. Smith and Forrester-Jones (2014) believe there is no substitute for real life practice within the nursing profession.

Service users, their families and nurse perspective

The third theme which showed to be most prominent and perhaps relevant for justification for the practice improvement was the perspective of the service users, their families and the professionals who are providing care. A study by Barksby (2014) suggested that the majority of service users involved believed student nurses provided a satisfactory level of care. The study was based on people with learning disabilities perceptions of student nurses in a care home environment. Some participants did report feeling indifferent, with neither good or bad feelings towards student nurses. This was explained as due to inconsistency of the students’ presence with placements being short and shift pattern changes. This suggests more time spent with people with learning disabilities can contribute to improved levels of care but also better therapeutic relationships improving student attitudes (Iacono and Davis, 2003). However, Smith and Forrester-Jones (2014) identify the relevance of experiential learning and how it is not the frequency of meetings with people with learning disabilities that will improve negative attitudes, but the quality of interaction when the meetings take place. Gill et al., (2002) reinforced this notion with an assessment of General Practitioners attitudes towards people with learning disabilities. They found a strong association between attitude and previous emotional experiences within professional settings with learning disabled service users. Rose et al., (2012) measured carers’ attitudes towards people with both learning disabilities and mental health conditions. Results showed similar findings in regards to the nature of contact, not frequency of contact, being the main contributing factor to a person’s attitude towards those with learning disabilities. In Smith and Forrester-Jones (2014) study, student nurses kept journals of 3 different encounters with the same person with learning disabilities. The research described how their feelings changed from apprehension, fear, pre-conceptions and communication concerns to increased confidence, positive reflections, attitude change and a reluctance to end the study, as they began forming meaningful therapeutic relationships. Barriball and Clark (2005) outlined the development of strategies employed by one particular institute of higher education. Their feedback regarding exposure to people with learning disabilities during training was said to be beneficial but needed to be conducted within a clinical setting rather than care homes, community or schools. This would provide greater clarity regarding the issues students face in their field of practice rather than just the opportunity to gain basic knowledge of caring for people with learning disabilities. Wozencroft et al., (2014) and Carlson and Witschey (2018) believe providing a combination of classroom instruction and direct contact provides a more comprehensive education and encourages a better attitude towards all types of disability. Morin et al., (2018) measured the attitudes of health care professionals against the general public in regards to 4 domains involving people with learning disabilities: knowledge of causes; sensitivity or tenderness; knowledge of capacity and rights and the interaction factor. The results indicated the general public hold more positive attitudes towards people with learning disabilities compared to health care professionals. This was primarily in respect of the interaction factor. This was thought to be attributed to the different types of environments conversations would take place in. Matziou et al., (2009) noticed a difference in negative attitudes between first year nursing students and qualified graduate professionals. This was caused by a higher frequency of negative encounters for the graduates, compared to new students who had little or no encounters of working with people with learning disabilities before. Ballantyne’s (2013) first time experience report of working with a person with learning disabilities suggested that preconceptions and prejudice were already engrained in the subconscious. However, the opportunity to meet and work with this client group had a profound and positive effect on changing previously held views. Clearly, making assumptions can lead to poorer health care provided, which results in health inequalities for people with learning disabilities. Whereas having contact can dilute this impact, but it seems the good effect can be displaced if the nurses face challenges due to the disability e.g. threats and aggression. This may suggest that student nurse training should contain information of why learning disabled service users may present with challenges (e.g. lack of communication skills etc.) or is this just another stereotype of services users?

Challenges reported by nurses when providing care to people with learning disabilities were described as aggressive, emotional, easily distressed, being difficult and less co-operative (Lewis and Stenfert-Kroese 2010). Jackson and Read (2008) discovered close collaboration between learning disability services and general adult health services enabled treatment in a credible affective manner. Temple and Mordoch’s, (2012) study in Canada showed strong agreement amongst adult student nurses that learning disability professionals should always play the main role in the care for people with learning disabilities. Sowney and Barr, (2006) reviewed a case study where admission to a general hospital was required. The lady being admitted lacked the capacity to consent. A strategic care plan was made to enhance her involvement and understanding of the process. General hospital staff reported high anxieties about examining the individual, but with support from learning disability professionals they were able to execute the examination. After the procedure, general nursing staff reported the positive outcome would encourage them to repeat such procedures with more confidence. This study promotes experience as a key factor in developing a new perspective of caring for people with learning disabilities. Although it poses the question, without the availability of experienced staff at every admission, would general health services know how to approach the situation? Walker et al., (2014) recorded the experiences of adults with mild to moderate learning disabilities to determine their perception of general hospital services. The results established positive feedback regarding physical assessments but negative in regards to social support. Specific difficulties mentioned were; no support choosing from the food menu and sporadic information provided to carers’ and service users post-discharge. Some service users had carers’ stay with them for the duration of their admission. This makes findings less clear as the presence of a carer can influence a service user’s experience and lead nurses to depend on their support for communication (Iacono and Davis, 2003). The focus group also stressed the need for general practice professionals to seek their own account of health status and not to rely on the views provided by the carers’ with them who may be ill-informed. Sowney and Barr (2006) stress the lack of experience and pre-registration education will prompt general nurses to rely on the support of carers’ for people with learning disabilities. Lewis and Stenfert-Kroese (2010) found there was a tendency for nurses to spend less time explaining treatment strategies as they believed individuals with learning disabilities would not be able to understand. Sowney and Barr (2007) believed this predicament to be a product of rushed clinical environments which would decrease the likelihood of explaining procedures and gaining consent. A central message in Gates (2011) review indicates families want to be listened to and supported regarding the care for their loved ones with learning disabilities. Family views suggested a strong belief that better education would not only improve standards of care but change some already identified negative attitudes. Some families reported that without the input of a liaison learning disability nurse, General Practitioners have a tendency to mis-communicate and talk down to their loved ones. Although, Robert et al., (2014) reported some families have experienced disappointing treatments in the presence of learning disability nurses with a failure to acknowledge family expertise and contribution to care. McClimens et al., (2017) suggested families of learning disabled individuals value any opportunity for nursing students to see things from their perspective and would enjoy being part of the nurse education process. This was also well received by the students as it gave them more exposure to learning disability care and greater insight into the hardships families of this client group can face.

The literature shows that when health care professionals lack confidence, in the quality of care they provide to people with learning disabilities, it can have strong adverse effects on service users, service providers, families and their perspective of services. Through supervised exposure in the correct environments, adult student nurses can learn to recognise, adapt and grow in confidence when providing care to people with learning disabilities. The research mainly suggests it is the face to face contact which can improve attitudes and have a significant effect on the improvement of health care provision for people with learning disabilities.

Improvement

Rationale

This chapter will discuss the reasons for this intervention and what is intended to occur as a result of practice improvement plan. The literature suggests mainstream health services are inadvertently showing bias against the learning disability population, despite the growing need to adjust due to changes in legislation. Education is being provided in some areas to different nursing professions; but real life exposure for prolonged periods of time; in a clinical environment; supervised by learning disability professionals to gain better experience is missing. Nurses unfamiliar with the complex health and social needs of people with learning disabilities may be confounded by a genuine fear of the unknown (Jackson and Read, 2008, p.6). Care providers have expressed feelings of anxiety and shown signs of inexperience causing the lack of confidence when working with this complex client group (Edwards et al., 2007). This not only has implications on service users but also their families involved (Gates, 2011).

Style of training programme to introduce the staff members to the cohort population:

The primary purpose of this study is to determine if exposure to people with learning disabilities will improve attitudes towards this cohort of the population. The opportunity to meet this complex group in a clinical setting is likely to improve confidence, competence and reduce fear. Adult student nurses will be subjected to a 3 week clinical practice experience with people with learning disabilities. The opportunity will be provided over the duration of a year one of the pre-registration nursing programme. Adult student nurses will be asked to complete a questionnaire pre and post placement. Comparison of any change in statistics will be categorized and analyzed. This will help determine any changes in possible negative attitudes and perhaps provide a mechanism for a way of learning regarding the support people with learning disabilities need for the future. The medical model of learning disabilities has changed over time, practice is now geared to a more social understanding of conditions and treatments (Mathieson, 2008, p.36). Disability is now seen as a problem within the environment as opposed to a problem within the individual (Doody and Doody, 2012). Adult student nurses must experience first-hand the person-centred planning, communication tactics and ethical dilemmas surrounding learning disability care to fully understand the needs of this population. Evidence has shown that a positive attitude towards people with learning disabilities has generally been attributed to more exposure to this client group (Brown and Kalaitzidis, 2013; Chenoweth et al., 2004; Wozencroft et al., 2014). With better awareness and understanding, future adult nurses may no longer shy away from treating such individuals and embrace the challenges many can present with (Cudré-Mauroux, 2010). This has significant implications on current adult nurse practice because it can prevent reliance of assistance from learning disability liaison nurses; promote better engagement with service users rather than carers, possibly avoid the need for longer appointment times to reduce service user anxieties, prevent higher readmission rates and help adult nurses better understand the legal, ethical dilemmas and frameworks surrounding human rights, equality and capacity. Improvement of adult nurse attitudes towards the more vulnerable population will undoubtedly improve the experiences of health care services for those with learning disabilities (Wolverson, 2012). In addition, people with learning disabilities are then more likely to express health concerns and access general health care facilities if they believe the services available are more user friendly (Ploeg Booth, 2011).

Methods

An in depth description of the methods involved in selecting and extracting results from the chosen sample groups will now be provided. This study will select participants from a University in the East Midlands. Selection of this University is based on the premise that no compulsory face to face training or experience with people with learning disabilities is provided to adult student nurses. The adult year one pre-registration cohort will be requested to fill out a pre and post placement questionnaire. Year one has been chosen because it is a formative year, this means none of the assessment marks are used to calculate final degree classification, this reducing risks to the student. Also, previous exposure to people with learning disabilities is less likely. A Likert scale has been chosen to provide the results for this practice improvement plan. Likert scales ask participants to respond to a question or statement on a scale of degrees ranging from two opposite extreme views e.g. ‘strongly agree’ to ‘strongly disagree’ (Lobiondo-Wood and Haber, 2018, p.273). It has been chosen because of its simplicity to answer and provide back to researchers the necessary numerical data. Likert scale questionnaires are ordinal psychometric measurements of belief, opinion and more importantly attitude (QuestionPro, 2018). Advantages of the Likert scale is they are easily understood; quantifiable; quick; efficient; inexpensive; can be sent by mail or internet; used for mathematical analyses via computation and easily coded with single number data (LaMarca, 2011). Disadvantages are limited options for answers, with only a choice from 5 to 7 examples with no room for discrepancies. Also, people avoid the extreme choices as they do not want to be viewed as an extremist, even if they feel the extreme answer would be most accurate (LaMarca, 2011). A 6-point Likert scale will be used ranging from numbers 1-6. Strongly agree being 1 to strongly disagree being 6. This is known as an ordinal scale as it requires a ranking of preferences in number order (Parahoo, 2014, p.354). The neutral option will be excluded from the scale to avoid the middle ‘sit on the fence’ answer. Research frequently suggests participants choose an ambivalent response to scale questionnaires when unsure of how to answer (Boo and Nie, 2017). Removal of the standardised YES or NO answer provides better understanding of the participant’s thoughts and feelings (Bryman, 2008). The style of likert scale being used is known as a unipolar scale, these measure ordinal data; normally present with more accurate answers; are commonly used where there is maximum and minimum amount of attitude being measured and allow focus on the absence or presence of a single item, for example, ‘agree’ or ‘disagree’ (QuestionPro, 2018).Quantitative research has been chosen as the approach to determine the level of practice improvement realised. Quantitative research genuinely requires a statistical analysis of numerical data gathered from the subject under investigation; to maximise accuracy and minimise the likelihood of error; it requires statistically significant quantities of measured data (Clay, 2014; Paltridge and Phakiti, 2015; Wright-St Clair et al., 2014). Quantitative studies normally focus on concepts that are previously well developed with an existing body of evidence (Polit and Beck, 2012, p.73). Choice of the sample should represent the wider population (Offredy and Vickers, 2010, p.174). Consequently the sample group of adult student nurses has been chosen to be typical of the entire population to ensure read across (Hunt and Lathlean, 2015, p.174). Adult student nurses have been selected because of evidence to suggest they score the lowest attitudinal results among all health care professionals (Temple and Mordoch, 2012). Also, pre and post-registration adult nurses are one of the most likely groups to receive exposure to people with learning disabilities in practice (Barr and Gates, 2009). Other pre-registration fields of nursing such as mental health, midwifery and children’s were considered due to a general consensus that negative attitudes are high among different nursing professions, excluding learning disability (Rose et al.,2012; Barber, 2008; Glasper, 2017). However, the scope would have been too large for analysis in the given time frame, i.e. too many students to give a placement opportunity to within the academic year. Also, the more participants involved in a research project, the more time researchers spend collecting and analysing data delaying the desired answer. Parahoo (2014) suggests it is simpler and more beneficial to collect more in depth data from a smaller sample; plus it’s more cost effective (Williamson and Whittaker, 2017, p.125).

A sample size for this study needs to be selected carefully. A balance between statistical and medical considerations must always be attempted (Williamson and Whittaker, 2017, p.111). There will first be a convenience sample targeted of 320 adult student nurses, this is the entire year one cohort. A convenience sample is the most readily available people with the attributes researchers require (Lobiondo-Wood and Harber, 2018, p.217). Lakin (2011, p.196) claims researchers use a sample to represent an entire population because the entire population can rarely be tested due to cost and resources. However, there is always the possibility that for some unforeseen circumstances the sample chosen is completely unrepresentative of the claim (Williamson and Whittaker, 2017, p.125). This is known as sampling bias and refers to the under or over representation of a characteristic linked to the research question (Polit and Beck 2012, p.275). Convenience sampling is more likely to show results of this nature as it entails the use of the most conveniently available group of participants. Polit and Beck (2012) state “those who are available might be atypical of the population with regard to critical variables”. A potential threat to the measure of this group is the response rate. Attrition rates are a common threat to the internal validity in sampling (Lobiondo-Wood and Haber, 2018, p.227). Anticipation of at least a 50% response rate (160 candidates) will be sufficient enough to acquire the necessary raw data. Probability of full participation to finish all questionnaires is unpredictable, age and gender will not be specified. This is known as non-probability sampling (Robson and McCartan, 2011, p.279). Correlation between gender and attitude have not been proven in western society (Benomir et al., 2016; Wozencroft et al., 2014). However, age has shown to make a difference (Beckwith and Matthews, 1995). Age based exclusion of subjects would significantly reduce the sample size, therefore, for the purpose of this practice improvement plan age based filtering has not been applied. Should the scale of the target sample size be significantly increased for further research purposes, age would then be considered. Consideration of age and gender within research is known as probability sampling because participants are known in advance and probability or percentage scores could be configured and predicted before data extraction. For example, hypothetically, out of the 320 participants 160 are male and 160 are female. This gives a 1 in 2 chance or 50% likelihood of a participant being male or female (Parahoo, 2014, p.262) A purposive sample will then be extracted from the answers of the first possible 320 candidates (convenience sample). Possibly, because the willingness of the candidates to participate in the questionnaire cannot be be foreseen until implemented in real life practice. Purposive, because sampling involves the deliberation of who to involve in the research project to ascertain the desired results. A deliberately chosen sample suggests that participants involved are the best available to provide data on the issue being researched (Parhoo, 2014, p.269; Robson and McCartan, 2011, p.281). The purposive sample will be grouped according to the frequency of similar attitudinal results, 40 similar scores will be selected and further divided into 2 groups (group A and group B) 20 in each group. Comparison will only be made from students of a similar baseline, thereby minimizing the possibility of previous experiences influencing attitude scores. If the perspective of the participants is relatively equal before the practice improvement begins the results will hold stronger validity if they change. This is known as blocking and matching of participants during analysis of variance (Robson and McCartan, 2011, p.453) or a cohort Quasi-experimental design (Maltby et al., 2010, p.36-37). Although opinions will be similar due to the initial control of both groups they will not be identical. These are called nonequivalent groups and are a type of Quasi-experimental design because they do not have random assignment and have a pre and post analysis (White and Sabarwal, 2014; Robson and McCartan, 2011). The principles of this selection process should draw out the distinctive qualities necessary to prove if exposure to people with learning disabilities will imminently improve adult student nurses attitudes.

Group A will be the placement group receiving a 3 week placement learning opportunity in an adult respite service for people with learning disabilities. They will be a tight pre-specification group with the aim to actively promote change. This strategy is known as an experimental fixed design (Robson and McCartan, 2011, p.76). Group A will take turns over the duration of the academic year to all receive this opportunity. This cannot be facilitated all at once due to minimal availability of placement opportunity in the same environment. It’s important all students in group A attend the same facility so the level of experience can be somewhat similar (Maltby et al., 2010, p.37). As discussed in the background chapter, different experiences of people with learning disabilities can affect attitude, so it’s important to try and control the level of exposure as much as possible for the purpose of this study. Flaws in this process can be identified as service users and staff changing over the duration of the year providing different experiences for participants. However, the level of experience is better controlled than randomising the type of placement provided. Group B will be the control group and not receive the learning disability placement. In an experimental investigation the control group does not receive any treatment or intervention, also known as a comparison group (Lobiondo-Wood and Haber, 2018, p.509). Group B will proceed with their regular scheduled adult nurse practice placements. This process should strengthen debate whether a learning disability placement makes a difference to a person’s attitude because group B’s attitudinal scores may improve without the planned learning disability experience (see figure 1).

Flow chart of method to extract data:

A hypothesis is the prediction of an outcome between the relationship of two or more variables and through testing the hypothesis results may or may not support the theory (Moule et al., 2017, p.129). The alternate hypothesis is that group A will undergo a significantly different change of attitude compared to group B over the placement period which is applicable to the wider population (Lakin, 2011, p.204). The null hypothesis is that group A and B will show similar results, undergoing no significant change in attitude between the two groups, therefore a learning disability placement will have no impact on a wider population (Lobiondo-Wood and Haber, 2018, p.292). The Community living attitude scale-learning disability (CLAS-LD) will be used to measure the candidates and selected participant’s attitudes towards people with learning disabilities. The CLAS-LD is a widely accepted scale, extensively used in many diverse countries and populations particularly in measuring attitudes towards disability (Kritsotakis et al., 2017; Lam et al., 2010; Palad, et al., 2016). A modified short form version of the CLAS-LD shall be utilised, this includes 16 statements categorised into 4 themes. 4 statements shall be shown in each theme. These are: ‘Empowerment’ (assessment of belief that people with Learning disabilities should be making their own decisions); ‘Exclusion’ (whether people with learning disabilities should be part of the community); ‘Sheltering’ (should people with learning disabilities be protected and supervised due to risk) and ‘Similarity’ (are people with learning disabilities entitled to the same rights and treatment as the non-learning disabled population). A demonstration of the CLAS-LD is shown in (appendix 1). Using a scale questionnaire catergorised into themes can help broaden the level of feedback received and contribute to a better understanding of any certain areas of learning disabilities where attitudes may be more or less commonly negative or positive, as opposed to just a negative or positive attitude toward people with learning disabilities in general (Benomir et al., 2016). All statements will be altered to suggest that from a range of number answers scoring 1-6, those that score from the higher end of the scale will be perceived to have a more morally; positive; ethical attitude towards people with learning disabilities. e.g., statement one; ‘People with learning disabilities should not be able to have children’. An answer of 6 (strongly disagree) will indicate a very positive attitude towards people with learning disabilities. An answer of 1 (strongly agree) will indicate a very negative attitude towards people with learning disabilities.

Implementation

This chapter will detail the nature of how this practice improvement plan will be carried out from start to finish. A Gant chart will be shown in (figure 4) to give a clear indication of the time scale spent for each step of the research process. A Gant chart is a tool for scheduling tasks and tracking progress to meet a desired deadline (Tran, 2015). The first stage of the research proposal is designing the plan to put forward. This will lay the foundations for all necessary measures to take for completing the study. Planning prepares the initial stage of choosing the topic; the method of how to conduct the research; the type of tools to use for collecting and analysing data with how best to disseminate the results (Williamson and Whittaker, 2017, p.49). The second stage will be contacting the University for approval to use their students and linked placement. Approval from the appropriate University ethics committee is required because it is using student nurses as participants (RCN, 2009, p.3). Contact will be made through phone call to establish which exact department and person the research study needs clarification from. This will most likely be the placement facilitator as they will liaise with the appropriate service to provide the necessary placement. The third stage is obtaining ethical approval. Due to the nature of this practice improve plan we can establish that it is in the form of research. This informs researchers which organisations they will need approval from (NHS, 2017). As this study is a clinical trial which may affect people involved, approval will be required from the Health Research Authority. The Health Research Authority brings together the assessment of legal compliance with the involvement of the local Independent Research Ethics Committee to ensure no unethical acts are occurring (IRAS, 2019). An application form will be filled out via the Integrated Research Application System website with all the relevant information about the research proposals intentions attached. Once ethical approval has been obtained recruitment will begin. Contact will be made again with the University placement facilitator via phone call, to establish a suitable placement. Once a placement has been chosen, preliminary questionnaires will be sent out to the appropriate candidates via email with a deadline of 3 weeks to complete. A return of questionnaire completed will give indication of consent to participate. No information about the research proposal will be provided at this stage. Completion of the questionnaire will be requested on the basis of finding out a general consensus of how adult student nurses feel about people with learning disabilities through survey (see Appendix 2). This is to protect the internal validity of the research proposal and prevent selection bias (Lobiondo-Wood and Haber, 2018, p.156). This may appear unethical but it will prevent participants discussing amongst themselves about the research proposal. This is known as demand characteristics which refer to clues in an experiment which may lead participants to believe they know what the researchers are looking for (McLeod, 2015). Although information shared builds trust, motivation and value in participation of the improvement plan (Barnes et al., 2008), full disclosure isn’t necessary at this point of the research because candidates haven’t been chosen for participation yet. Minor unethical approaches are sometimes used in circumstances where doing harm in the short term can provide greater benefits for the future. However, some form of support must always be available in these circumstances (Williamson and Whittaker, 2017, p.60). Questionnaire returns will then be analysed and correlated to provide 40 chosen participants. The 40 participants will then be divided into a placement group (group A) and a control group (group B). Contact will then be made with group A via email, requesting participation in the research proposal. This email will inform group A that they have been selected to take part in a 3 week clinical learning disability placement throughout year one and by partaking in this opportunity their perspective of people with learning disabilities will be measured and analysed, possibly contributing to the development of adult nurse education about people with learning disabilities. The terms measuring of attitude will be avoided as it may cause potential participants to be offended and decline the invitation. Consent for participation will be confirmed by a return email to the researcher declaring they wish to take part (see Appendix 3). Group B will not be informed about group A’s placement opportunity at this stage and will continue with their scheduled adult nurse placements. Once every participant has received the learning disability placement the same questionnaire will be reissued via email to group A and group B. Group B will at this time be informed the same as group A and be fully acquainted with being a comparison group. They will be notified that by filling in the same questionnaire and returning to sender they are consenting and contributing to a practice improvement plan which is assessing adult nurse perspective of people with learning disabilities (see Appendix 4). A deadline of 3 weeks to complete and return the questionnaires will again be expected. Once all questionnaires have been returned to the researcher, a data analysis of results will be conducted. This will then be presented in chart and graph form along with a written explanation of findings. Dissemination will be explained in the final chapter.

Ethical issues

Ethics in research has been defined as a method, procedure or perspective for deciding how to act in order to avoid harm to others (Resnik, 2015). Research has ethical implications at every stage of the process; from choosing a topic right through to dissemination people can be affected (Parahoo, 2014, p.101). Understanding of these issues is vital to the protection of all those involved (Pahroo, 2014 p.106). Consideration of the researcher’s conduct in relation to their own behavior and how this affects others involved is paramount to ethical research standards (RCN, 2009). Health related approaches to research ethics are often decided on the basis of outcomes and consequences of research participation or on the basis of 4 key principles known as Autonomy, Beneficence, Non-maleficence and Justice (Robson and McCartan, 2016, p.208)

Autonomy

Autonomy in research is providing information in a form that is understandable and respectful to the person’s needs and rights to make a voluntary decision (Athar, 2012). Informed consent is a legal principle which protects a person’s right to autonomy and is one of the main ethical considerations in research proposals (Lobiondo-Wood and Haber, 2018, p.238). Informed consent is described as a person knowingly and willingly giving approval in a clear and manifest way to a proposal with understanding of the consequences of the decision (Sherwin, 2015). Consent must be sought after throughout the research process and not just at the beginning. Information must be presented in a format which is understandable and free from coercion (Fouka and Mantzorou, 2011, p.11). Researchers must be mindful of jargon and terminologies which they are fully acquainted with as participants may not be (Maltby et al., 2010, p.348; Parahoo, 2014, p.107). Plenty of consideration time should be provided for participants involved in the research process, this involves any questions they may have about ramifications and the process with which they are involved. This is because participants may not become fully aware of the implications of the study until deeper involved (Parahoo, 2014, p.106). Information on how to withdraw with respect to participants having the right to do so must take precedence over the need for researchers to complete their project. Withdrawal from the research process should be done so without penalty, coercion cannot be used to collect data, this being an infringement on a person’s autonomy (Greaney et al, 2012). Confidentiality and privacy should always be maintained during this process (Maltby et al., 2010, p.348). There must be a clear understanding of the use of data achieved to participants, this would involve who will have access, where it will be stored and the level of security in place at all times (Moule et al., 2017, p.110). For the purpose of this study informed consent will be gained by a return of questionnaire via email for the convenience sample (320 candidates). For the purposive sample (group A and group B) a request for consent to partake in the research study will be sent with the relevant research information attached. Only the names of the candidates will be needed throughout the research proposal. This is to enable selection of the 40 possible participants. Polit and Beck (2012, p.156) state: “Researchers should ensure that their research is no more intrusive than it needs to be“.

Beneficence

Beneficence is the aim to benefit participants in research and hopefully contribute to the wellbeing of society as a whole (Beauchamp & Childress, 2012). This means researchers need to be proactive in promoting and benefiting the welfare of all participants involved (Doody and Noonan, 2016). An evaluation should be carried out to assess whether the potential benefits of the study outweigh the risks to the participants and greater society. It is considered unethical to carry out any form of research which doesn’t benefit participants or society as a whole (Maltby et al., 2010, p.348). Beauchamp & Childress (2012) suggest the benefits to research proposals should always be greater that the cost endured. Potential risks to research studies can include negative implications on a persons and or societies financial, psychological, physical or social wellbeing (Greaney et al., 2012). Potential benefits can be access or intervention which otherwise would have never been possible; increased knowledge; law or policy change; information may help others; monetary or material gain; escape form routine and being part of something etc. (Polit and Beck, 2012, p.153). As previously discussed in the background chapter, negative attitudes are having an impact on service user care for people with learning disabilities. However, more exposure to such individuals has been shown to improve quality of care and care provider attitudes. Participants involved in this study may provide more evidence to reinforce already well-established research. If significant enough, this research may obligate education providers to pay attention to the differences they could make to people with learning disabilities and their families lives.

Non-Maleficence

Non Maleficence in research is closely linked to beneficence as it refers to the obligation to minimize, avoid and prevent harm to people involved (Maltby et al., 2010, p.349). Reasonable steps must be taken to protect participants from foreseeable harm with support in place when this is unavoidable (Williamson and Whittaker, 2017, p.60). Participation must be fundamental to achieving societally and scientifically important objectives that otherwise would never have been realised without investigation (Polit and Beck 2012, p.152). Possible risks of harm in this study are the disruption to a person with learning disabilities life. The introduction of new faces for short periods of time may cause confusion and anxieties resulting in behaviour change. This then has implications on the type of perception students may form on how people with learning disabilities present, ultimately feeding a possible negative attitude. Conversely, some service users may form meaningful relationships with the adult student nurses only to have it cut short by a 3 week only placement. Polit and Beck (2012, p.153) believe the protection of physical harm to participants is relatively straightforward, but psychological implications on participants and who they encounter are more subtle and harder to control, requiring sensitivity and close attention. The potential to cause physical harm in this study should show to be minimal. However, Psychological consequences may be less easily contained (Parahoo, 2014, p.102; Maltby et al., 2010, p.349). Each adult student nurse who receives the placement opportunity will be supervised by an experienced learning disability nurse mentor. This should help diffuse any possible episodes of distress on the service user and students behalf.

Justice

Justice in research refers to the right to fair equal treatment and privacy (Sherwin, 2015). Researchers must treat participants in an equitable way throughout the research process ensuring anonymity (Beauchamp & Childress, 2012). The participant’s needs should always come before the need to continue or complete the research study (Parahoo, 2014, p.103). The principles of justice require an obligation to protect all those who are at particular risk of being exploited. For example, people with learning disabilities (Polit and Beck, 2012, p.155). For the purpose of this study participants are not considered a vulnerable population and informed consent to participate will be in the greater good for their own perspective; professional development and improvement of education provision. The principles of fair treatment refers to treating participants who withdraw from the study in a non-prejudicial manner without victimisation and providing all necessary agreements that were arranged before the practice improvement plan started. Researchers must also demonstrate respect for people from different cultures or backgrounds; give participants the opportunity to investigate their researchers and provide tactful courteous treatment at all times (Polit and Beck, 2012, p.156). Information on how to withdraw will be shared in the email without penalty or repercussion for doing so. The email will make participants fully aware what will happen involving time commitments; expected involvement; what will happen with their information and who will have access to their details. Withholding such information can be seen as deception and is unethical without good reason (Lobiondo-Wood and Haber, 2018, p.235).

Data Analysis

This chapter discusses how results will be measured, analysed, presented and critiqued to assess the relevance of findings. Data analysis is the process of turning raw data into meaningful conclusions about the extent of success of a study (Offredy and Vickers, 2010). Data can be collected in numerous ways, however, the type of raw data achieved should give indication of which approach is most appropriate to use (Williamson and Whittaker, 2017, p.127; Lobiondo-Wood and Haber, 2018, p.282). For example, some variable types of data; ratio and interval, a mean average can be scored during analysis. This is because the distance between variables has a value. For example, interval scores can fall below 0 and have meaning, such as -3 when measuring temperature. Ratio variables stop at 0 but can be measured in height and weight giving meaning from 10 stone to 10.2 stone and 6ft to 6.2 ft. Mean average scores for likert scale ordinal data can be accomplished but are not feasible to this study, the distance between ‘agree’ and ‘strongly agree’ cannot be measured and would have no meaning (Clay, 2014). This issue disqualifies well established data analysis tests such as the T-test, Z-test, F-test etc. because they all commonly rely on a mean average score to divulge further information about raw data (Polit and Beck, 2012; Lakin, 2011). Therefore the raw data produced by the likert scale will be transferred into frequency tables with percentage scores and bar graphs to form comparison between group A and group B. Frequency tables present incidence of responses and the percentage score enables the proportions of responses to be seen clearer making data easier to interpret (Williamson and Whittaker, 2017, p.121). Transformation into graphs can give better insight into the range of change in results (Schneider et al., 2013). Discussion and conclusion of these findings once transformed into chart and graph are known as descriptive statistics and can show a rank order. However, as mentioned; relative sizes between variables are not achievable. For example, a participant who chooses ‘strongly agree’ holds an opinion more strongly than a participant who chooses ‘partly agree’, placing them higher in rank order. But, it cannot differentiate whether that participant feels three or four times more strongly than the other participant (Williamson and Whittaker, 2017, p.120). Visual inspection of results looking at comparison of scores and graphical differences (sometimes called charting) can often be all that is required to providing an adequate convincing demonstration of change or effect taking or not taking place (Robson and McCartan, 2011, p.454). Readers of this research proposal must be convinced that the results of the study obtained are precise, valid and true to what the researchers want to measure (Lobiondo-Wood and Haber, 2018, p.155). Quantitative analysis looks at whether research findings are made by chance or as a result of an intervention involving some real life mechanisms (Maltby et al., 2010, p.244). To detect small changes in quantitative analysis large sample sizes are normally required (Williamson and Whittaker, 2017, p.112). The sample sizes for this research proposal is relatively small so external validity or ecological validity of results is more difficult to obtain (Maltby et al., 2010, p.245). This is where generalization of results can be related to other populations (Lobiondo-Wood and Haber, 2018, p.159). Important research proposals do not normally participate in probability sampling. This is due to lack of time and money; level of knowledge in the field; policy and procedure of institutions and inaccessibility of subjects (Lobiondo-Wood and Haber, 2018, p.228). As this method of sampling is non-probability, it has been known to yield more accurate meaningful results that can contribute to a nursing scientific body of knowledge (Lobiondo-Wood and Haber, 2018, p.228). For the purpose of this study, a 20% improvement in group A’s pre and post questionnaire results will be predicted and should be sufficient enough proof of a statistical significant difference. A statistically significant difference is referred to as findings being more than by random chance and would draw out similar results if the same intervention was carried out on new and more participants (Sinden, 2015). Should findings fall below a 20% improvement, research consumers may question the statistical validity of the results. However, they should not question the clinical significance if just a small percentage change takes place. This is because a small change can still make a difference to a person with learning disabilities life. (Lobiondo-Wood and Haber, 2018 p.294; Robson and McCartan, 2016, p.454). Clinical significance refers to the real life practical benefits or importance of research findings. This is considered most important because, after all, the conclusive goal of nursing research is to generate results that are of real life clinical value to practice and theory (El-Masri, 2016).

The following fictive results in chart and graph form give representation of the hypothetical change which would be expected to occur should the practice improvement plan be carried out with live participants.

Table 1 shows the pre intervention questionnaire responses, these results have been graphed in figures one to five. Inspection of these results shows similar scores for control group B and the placement group A in all themes. The average intergroup difference is approximately 0.3%. This is clearly shown in graphs one to five where the responses for the 2 groups are almost identical. Table 2’s post questionnaire response shows a slight change for the better for the control group B, however, there is now a significant change in attitudinal results for the placement group A. There has been a 23.44% swing from strongly agree to strongly disagree. Once again this is clearly shown in graphs six to ten where the change in attitude of the placement group A is clearly visible. Therefore, the alternate hypothesis would be proven for the sample group chosen. Students who receive a learning disability placement are more likely to significantly improve their attitudes towards people with learning disabilities.

Dissemination

This chapter of the practice improvement plan will explain how the research findings will be communicated to others. Dissemination is the planned process of informing selected audiences of research results which may enable change to the target population (Wilson et al., 2010). Dissemination can involve a range of formats, e.g. publication; presentation (oral, electronic, poster); via classroom or conference; consultation; provision of online materials; podcast etc. (Parahoo, 2014, p.407; Moule et al., 2017, p.392; Lobiondo-Wood and Haber, 2018, p.384). Researchers must disseminate information found in an honest, ethical manner with anonymity and confidentiality always protected (Moule et al., 2017, p.384-385). The purpose of dissemination is not just to raise general awareness but hopefully influence evidence based practice (Lobiondo-Wood and Haber, 2018, p.383). Evidence based practice now being an expected standard demonstrated by regulated nursing bodies and policies (Wilson et al., 2010). It’s important to emphasise the level of change the practice improvement plan may bring about. One of the most effective ways to do this is by contrasting the cost of action versus the cost of no action (WHO, 2014) Research findings do not always realise the desired service user outcome (Lobiondo-Wood and Haber, 2018, p.383), therefore a presentation of findings will be provided as feedback to the University where the research took place. This will be an invitation to all nursing University educationalists and curriculum designers. This has advantages such as face to face discussion (Cronin et al., 2015, p.171) and informs the people who are considered most likely to listen and influence change because the evidence relates to their area of expertise (Hickson, 2008, p.150). A change in the approach to teaching adult student nurses about learning disabilities is assumed to be the best starting point to improve learning disability provision in mainstream services. Students today will be the nurses of the future and they can not only improve services for years to come, but also the present day by speaking out against poor practice when witnessed (Podmore, 2012). According to the World Medical Association (2013) there is an ethical expectation to inform participants and the public about research findings. Even if the research displays negative findings there is still an obligation to disseminate results (Ellis, 2016, p.21). For the purpose of informing the public the researcher would also attempt publication in an appropriate journal. When results of a similar nature are found in different articles, relevant professionals who have the power to make change are more likely to take note and impose improvements on care services (Williamson and Whittaker, 2017, p.57). Combined with publication in a journal a project report is required (Williamson and Whittaker, 2017, p.57). A report of findings will be sent out to all 40 participants and the professionals involved at the learning disability respite service. This will be sent via email with a full report attached and acknowledgements of the researcher’s appreciation for contributing to the research. This is a normal expectation by research ethics committees to show gratitude to participants and everyone involved (Offredy and Vickers, 2010, p.212). Further dissemination would be accomplished by presenting the information at different conferences in different areas of the country, particularly aimed at nursing University lecturers and other health care professionals. Presenting at conference can speed up the process of informing others, compared to publication which can take long periods of time to spread new findings in research (Gerrish and Lacey, 2010, p.475).

A Gannt chart reflecting the implementation stage:

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