Patients With Complex Needs

A learning disability (LD) is a combination of a significantly reduced ability to understand new or complex information and the inability to cope independently (Department of Health, 2001). The assessment of the severity of LD is open to interpretation as there are no distinct differences between the classifications of LD (Royal College of Nursing, 2009). The level of disability is determined by the patients IQ score (Swanson et al., 2005). This means that a patient who is deemed to have a moderate LD cannot be assumed to perform routine procedures in a predetermined manner. There is a possibility they could perform anywhere within a range of coping very well or not be able to participate. Therefore there is no standardised procedure or protocol when testing or providing care for these patients, though many departments have devised their own care plan based around Valuing People (2009).

Ms P has recently been recognised to have potential hearing problems. This was noticed as she has been mishearing a lot of what is said to her during a project to set up a charity shop and cafe in a day service she attends on a weekly basis. When seen by a clinical nurse specialist she was observed to be lip reading whilst communicating.

Efforts were made by the clinical nurse specialist to establish Ms P’s hearing thresholds; however they were unsuccessful as she was inappropriately responding for both conventional and modified response methods.

I shall use this case study to suggest suitable management options and care plan for Ms P with a major consideration to her mental health issues in relation to what should be proposed and how it should be carried out.

It is important to acquire Ms P’s audiometric thresholds through a correctly performed hearing test, by a trained Audiologist. Modifications may need to be made to the test, such as alternative response methods to accommodate her LD’s to achieve reliable results. Testing will allow identification as to whether the patient is struggling due to hearing problems or as a consequence of her LD. There is also a strong possibility of the problem being a combination of both.

Acquisition of subjective hearing thresholds from a LD patient can be difficult as there are concentration and understanding factors to consider when selecting and performing a test. Time needs to be taken to perform an extensive history in order to establish what testing is best suited for the patient. This can improve time efficiency by understanding the patient’s capabilities so that the actions taken are more specific and suited to them. History taking is also a good opportunity to create a good rapport with the patient which can ease interaction and communication throughout the rest of the patients’ pathway. Mansell (1992) found that it is common for learning difficulty patients to have problems when communicating. Therefore actions must be taken to encourage a good patient-clinician interaction and confidence as early as possible as they can improve relations for the long term.

Another major factor which will improve the working relationship between patient and clinician is the presence of the patient’s sister. She will be able to provide important information during history taking and, simply by attending the appointments with the patient, can give her more confidence. Efforts should be made for relatives and carers to attend with the patient during earlier appointments until a decent rapport has been established (Rance et al., 2009).

Once hearing thresholds are obtained, they must be verified, as conventional patient responses to sound stimuli are susceptible to the patients understanding of the test. This could mean that the patient may be responding at sensation level rather than threshold level. If this is the case and the results obtained are unverified it could lead to an intervention method, such as provision for amplification, being implemented at a level which could potentially cause more damage to the patient than benefit.

The verification method would be best suited if it didn’t require a response from the patient to confirm the actual hearing level as this would allow a more objective measure of the patients hearing ability i.e. Cortical Evoked Response Audiometry, Auditory Brainstem Response or Otoacoustic Emissions. This can then allow comparison between actual objective hearing thresholds and subjective patient response thresholds. This would also identify the need for the patient to be referred into other services, should there be no hearing disorder identified.

Management options for this patient could be a combination of provision for amplification, assistive listening devices (ALD), lip reading classes and hearing therapy. Each of these options have advantages and disadvantages which I shall now discuss.

Provision for amplification would enable speech and other environmental sounds to be amplified to a level that is within her residual hearing ability (Dillon, 2001). Hence enabling her to detect and discriminate more of the speech sounds she seems to be missing currently. This should improve her understanding and allow her to function better within the charity shop and cafe she is trying to set up. Disadvantages of using this method are her understanding and maintenance of the device issued to her. She may not be able to look after, insert or operate the device. This could be avoided by educating her sister or employees at the day service to assist her. But this doesn’t promote independence for the patient. It is also worth considering whether her older sister would understand how to assist Ms P with a hearing aid. The benefits of this management option are measurable through aided thresholds. An improvement should also be seen by the people who surround her too, should it be used properly.

The success of a hearing aid could be questionable as she is mainly struggling in a noisy environment where competing sounds could discourage her from use or prevent her from adapting to it. This could be a detrimental effect to applying the method as she may find it more of a hindrance than assistance. She would also benefit from a binaural fitting in a noisy cafe environment as the ability to localise would improve her speech intelligibility. Even though it seems amplification would be the best option in relation to her problems consideration needs to be taken regarding the patient’s preferences and consent to the measure in the first place. Reasoning for having amplification could be explained specific to her interests and problems, which can allow goal setting.

Should she not give consent for amplification, ALD’s or lip-reading classes could be used. ALD’s would benefit her in her problematic situations specifically as they are made solely for a set environment, which is also a disadvantage as she will have problems in environments other than this one. Instructions on use and maintenance will need to be taught in order to gain full benefit, which would lead to similar disadvantages as the amplification management option.

Lip or speech reading classes are a taught skill set which would enforce her current ability to lip read. It would also provide a manageable option which does not have the disadvantage of having to be maintained. However, it would require her to attend classes and learn the skills needed for this option in order to create maximum benefit. This would require a re-analysis of her concentration and learning abilities prior to implementation, as it may not be a suitable option should she not have the patience or understanding of why she is doing it. Even though this is a good option, as it promotes independence, amplification would still be of benefit alongside it to improve speech perception, as some phonemes appear to be similar when lip reading (Denes & Pinson, 1993).

Another service which she could gain access to help her with her difficulties in the café and charity shop is Access to Work. They would be able to provide funding for equipment and services to improve her situation in her working environment. This should be done regardless of any other management option being enforced.

Prior to devising a care plan consideration has to be made regarding the extent of Ms P’s LD on the potential success of the plan, her understanding of her hearing loss and how a management option will improve things for her. She may not think that she has a hearing loss at all. The patient’s personal goals should also be identified as this could provide leverage for encouragement of the management option. Her treatment could be centred on the progress of her day service initiative to improve her understanding of the treatment she is being offered. Goal setting should be encouraged in relation to her interests to ease the patient into her management options. Regular reviews should be enforced as they help maintain the rapport initially established from the testing appointment and enables the clinician organisation over the patients’ progress.

The success of the management plan used will rely heavily on the clinicians understanding and management of the patients’ mental health issues, capacity and capability. This will provide the clinical reasoning behind the management options used and what goal setting should be enforced. It is better for clinicians to encourage the patient to make their own decisions, rather than make a decision based on the patients’ best interests, should they have the capacity to do so, as outlined in the Mental Capacity Act (2005) (, 2005). There has to be sufficient clinical reasoning behind the choices made and their relevance to the patient and her needs, which have been given strong consideration for in this instance.

The care plan most suitable for Ms P is initially to trial amplification with ALD’s, i.e. a loop system. Should these primary interventions not be of any assistance then it is worthwhile trialling the lip reading classes alongside them and as a last resort hearing therapy.