The proposed project management plan aims to support women with learning disabilities living in the community who may be experiencing domestic violence

Proposed project produced as part of the Imagination and Innovation module. October 2020. Contributed by Elizabeth Maushe, Learning Disability Nurse who studied Learning Disability Nursing in the University of Hertfordshire 2017 cohort

Abstract

Background: People with learning disabilities have the same goals and aspirations as those within the general population. One of these goals is having healthy and happy relationships. However, some people with learning disabilities find that their vulnerabilities are exploited and can be subject to relationships whereby they experience domestic violence.

In addition, due to public perceptions women with learning disabilities may be less likely to share their experiences of domestic violence due to fear of judgement. Furthermore, as domestic violence comes in different formats and can be hard to identify, some women with learning disabilities find it difficult to identify the signs and communicate their experiences. This therefore makes it difficult for professionals to provide advice and support.

Aim: The aim of this article is to evaluate and contextualize how a specific proposed project management plan may further enhance the quality of care within learning disability nursing. The proposed project management plan aims to support women with learning disabilities who are living in the community that may be experiencing domestic violence. This will be achieved using team members, providing support groups for women and supporting them to identifying the different signs of domestic violence.

Literature Review

For the section of the project a literature review that was conducted will be examined to evaluate the relevance of four articles to the aim and objectives of the proposed project.

Before the articles were selected an in-depth literature review was completed.

The above flow diagram illustrates the searches that were made in order to select the articles. Despite multiple databases being used, the process of finding the literature was quite challenging as there was very limited research available, and as more detailed searches were made, the more limited the research was and ultimately no research could be found that completely related to the proposed project. This further solidifies the statement given by (McCarthy, et al 2017) that there appears to be inadequate research available that related to the domestic violence experienced by women with learning disabilities. This therefore further emphasises the rationale and importance of this proposed project.

In addition to a flow diagram, a critical analysis of the four articles selected was completed in order to evaluate the way in which the authors completed their studies and the results they obtained. This analysis can be found in the appendix.

The first article (Pestka and Wendt, 2014) aims to highlight the lived experiences of women with learning disabilities who have been in relationships whereby domestic violence took place. This study is relevant to the project as it focuses on the impact domestic violence has had on women with learning disabilities by considering their lived experiences. Pestka and Wendt, (2014) utilised qualitative research to their study. Creswell and Poth (2018) suggests that qualitative research aims to empower the participants to share their stories and provides an opportunity for their voices to be heard. This can be particularly important for women with learning disabilities as evidence suggests that there is little research into their lived experiences of domestic violence (McCarthy, et al, 2015). In order to obtain the lived experiences of these women semi-structured interviews were utilised as a form of data collection.

Pestka and Wendt, (2014) also considered some ethical considerations. They highlighted how consent was obtained. Before the interviews were carried out consent forms were explained in detail to the women and signed. Obtaining informed consent is important in research, Nijhuawan et al,(2013) highlights that it is an ethical and legal requirement that allows participants to gain an understanding of their role and all aspects of the research before the participant can voluntarily confirm his or hers willingness to participate. When obtaining consent (Pestka and Wendt, 2014) should have considered the women’s learning disability and how this may hinder their ability to give informed consent. The term “explaining” to describe the way in which consent was obtained does not specify how the information was provided. This could be highlighted as a limitation of the study as if the women did not entirely understand what the study was about and what their role would be they could not give informed consent. For the project this limitation will be overcome by ensuring that reasonable adjustments are put into place to ensure the women involved can give informed consent. Examples of reasonable adjustments include easy read documents, braille, audio or video. By doing this, the aim is to allow the women to feel empowered and valued.

The three key findings that emerged from the study were: not belonging, wanting to belong and domestic violence. The women who participated in the interviews all expressed that they felt marginalised, unwanted and devalued within society. Despite great changes being put into place to move people with learning disabilities from hospitals to the community such as Transforming Care, (2012), many people with learning disabilities still face negative attitudes in society. Denny et al, (2017) highlights that although people with learning disabilities strive to have meaningful social inclusion and integration, they face barriers achieving this, due to attitudes and perceptions in society that form the catalyst in disenabling them from genuine social integration. Pestka and Wendt, (2014) highlighted that these feelings may have been embedded in these women since childhood where they were in institutionalised care, foster care or specialized support. O’Malley et al, (2019) supports this, highlighting that many women with learning disabilities who have been in institutional care were more likely to experience sexual abuse that has an impact on their ability to form and identify healthy intimate relationships subsequently, further justifying the rationale for the project as evidence suggests that women who have been in the same type of care in childhood are more likely to be in abusive intimate relationships. In addition, as the project aims to start sessions to help women who are in domestic violence relationships, evidence suggests that it may be beneficial to identify the women who have been in institutional, foster or specialist care (Pestka and Wendt, 2014) as they may be more likely to experience such abuse in their intimate relationships.

The second article that was analysed (McCarthy et al, 2019) aims to examine the actions and views of health professionals, social workers and police when supporting women with learning disabilities who have experienced domestic violence. The article is relevant to the project as it is aimed at the community learning disability team and how professionals can work cohesively to meet the needs of women with learning disabilities who are victims of domestic violence. The research study utilised a quantitative methodological design and data was obtained through a cross-sectional survey questionnaire. The utilisation of surveys can present with many advantages and disadvantages for the researcher. McCarthy et al, (2019) did not provide the rationale for choosing surveys to collect data. However, (Kumar, R. 2014) highlights that surveys can be a less expensive way to gather information as resources and time can be significantly saved in comparison to interviews. Also, the participants involved in the survey are all professionals and subsequently, due to busy schedules or commitments, conducting interviews may have been inconvenient to the participants (Gaganpreet, S. 2017).

McCarthy et al, 2019) ensured confidentiality was maintained by categorising the participants by their profession; their names or where they worked was not included in the research. Kumar, R. (2014) suggests that surveys offer greater anonymity for participants as no face-to-face interaction is necessary. For the study, (McCarthy et al, 2019) asked the participants to complete an online survey and the survey was emailed to them by senior managers. The use of an online survey can offer greater anonymity as emails can be encrypted, protected and have passcodes. The General Data and Protection regulation (GDPR, 2018) sets out the lawful obligations of organisations in ensuring information used to create and share research is conducted in a manner that provides security and privacy. This can be advantageous for the researchers as the participants may be more forthcoming and honest with their answers. Despite the anonymity that comes with surveys (Kumar, R. 2014) argues that as there is no need for face-to-face interaction participants may not have the opportunity to ask questions and seek clarification. In comparison to interviews whereby (Galletta and Cross 2013) argue they provide an opportunity for questions to be rephrased and prompt the participant which can be helpful for women with learning disabilities who may have difficulty understanding the questions asked (Goldsmith and Skirton 2015).

Furthermore, the way in which the sample size was selected may have influenced the findings. Gaganpreet, S. 2(017) argued that if participants are not chosen randomly human judgment could affect the selection process. For the study, the surveys were distributed by the managers through email. McCarthy et al, (2019) were able to recognise that that it would be difficult to establish a response rate as the amount of surveys that were passed on by the managers could not be controlled. Also, as incentives were not used participants may not view completing the survey as a necessity especially due to busy schedules (Gaganpreet, S. 2017). This therefore could suggest self-selecting bias from the managers (Gaganpreet, S. 2017). As the managers had the control in distributing the surveys, the managers may have forwarded them to participants who they may have their own attitudes, preferences and motivations towards and therefore the findings may not represent the total population (Kumar, R. 2014).

Interestingly, the results from the study revealed that the majority of the participants who completed the survey were female equating to 84.8%. For the police that were involved in the study 62.2% were female. The rationale for this was not provided however (Kumar, R. 2014) argues that participants who have a particular interest, motivation or connection to the research topic may be more willing to participate. This finding also reflects on the typically gender specific statistics whereby one in four women will experience domestic violence in their lifetime (Home Office, 2013). Although it was not known if the women who completed the survey had experienced domestic violence the statistics highlight that women are more likely to be victims of it, therefore the participants may have been victims or known others who have been victims. These findings relate to the project as the stakeholders who will be involved are nurses from the community learning disability team and other professionals. Subsequently, these individuals may be more inclined to participate in the project if they have a particular interest, motivation or connection to the topic as (Kumar, R. 2014) highlighted which may result in more women than men participating. Despite this, McCarthy et al, (2019) argues that having women may be more advantageous as participants may be more willing to participate as they may allow the participants to feel more comfortable having someone of the same gender. However, as the project aims to be person-centred the women involved would be able to choose if they would like to speak one-to-one with a male or female.

The next article, (Brice et al, 2012) aims to explore the experiences of domestic violence from women with learning disabilities in the context of intimate partner violence. The study utilised a qualitative design and data was collected through interviews. The sample size used for the study were five participants.

For the article an ethical consideration to be analysed is the race of the participants. Brice et al, (2012) also revealed that all the participants were white. The rationale for why all the participants were white was not provided; the reasoning may be due to the study taking place in an area where the majority of the population are white. Despite this, the Office for National Statistics (2018) highlights that women who identified with a mixed or multiple ethnic group constituted to 10.1% of domestic violence experienced by women in comparison to white women who constituted to 6.5%. Therefore, although white women in the United Kingdom (U.K.) do experience domestic violence they do not represent the majority and therefore the findings from the research cannot be generalized to represent all women. In addition, the Office for National Statistics, (ONS,2018) highlights that culture, religion and upbringing can have an impact on how domestic violence is perceived in different ethnic groups so therefore having a participant group that is only one race cannot be used to represent all women as the culture, upbringing and beliefs of women of other groups have not been explored in the study.

The participants for the study were recruited using purposive sampling. Palinkas et al, (2015) defined purposive sampling as the method in which researchers deliberately target a group of individuals who they perceive to be knowledgeable about or have experienced the phenomenon of interest. This is highlighted by (Brice et al, 2012) that reveals the participants were recruited by contacting women’s group and asking the facilitator to recruit women they felt would be able to participant and understand their role in the research.

Purposive sampling can be an advantageous method of sampling. (Arrey et al, 2019) highlights that as many people with learning disabilities often have difficulties in communicating, purposive sampling could be the most suitable method as the women are being recruited by people they may trust and have built therapeutic relationships with. The relationship the participants had with the facilitator was illustrated in the study whereby the participants were asked if they would like somebody present the majority chose to have the group facilitators present.

In contrast, (Etikan et al, 2016) argues that the use of purposive sampling may elicit bias as participants are chosen specifically that are thought to provide the necessary information to answer the research question. Also, (Goldsmith and Skirton, 2015) further argues that the facilitators may have different agendas to the researchers and therefore choose women they felt would respond in a way they preferred which subsequently would deny other women the opportunity to share their stories. In order to reduce the influence, the facilitators may have had on the women, once the interviews were completed the researchers spent some time with the participants in order to ascertain how they found the experience and whether they needed additional support.

Project Management Plan

The overall aim of this project is to establish an effective way to support women with learning disabilities living in the community who may be experiencing domestic abuse.

In order to ensure the aim and objectives of the project are met a thorough analysis of the project must be evaluated and examined. The introduction of the proposed project indicates a need for change. Change within healthcare is an ongoing and complex phenomenon (Byers, V. 2017). Al-Abri, (2007) states that change is welcome in practice if it improves quality, safety and saves money. Change is constant subsequently (Grol et al, 2013) argues that as the needs of the population increases the need for optimal patient knowledge also increase. A prime example of how this need could be met is through education. In the United Kingdom student nurses are required to undergo three years of training in order to build and enhance their skills before they can register as qualified nurses. Grol et al, (2013) also highlights that with change comes the need for increased scientific and medical advancements, demographic changes and inter-organisational coordination.

Within learning disability services major changes have been made and continue to be made. Most notably, the passing of the NHS and Community Care Act, (1990) that encouraged the move of people with learning disabilities from large-scale institutional provisions to small-scale community settings (Lloyd and Pollard, 2018). High profile scandals such as the Winterbourne View report in 2011 accentuated the need for moving people with learning disabilities to the community to the public and enforced the need for change with actions such as Transforming Care, (2012).

To relate back to the project, it focuses on the way in which the community learning disability team can elicit change in order to improve the support that is provided for women with learning disabilities who may be experiencing domestic violence. The project will evaluate the pre, intra and post-operative actions. In order to support this Lewin’s change theory will be utilised as a guidance tool. Lewin’s change theory consists of three stages: unfreezing, freezing and refreezing.

The first stage, unfreezing looks at how the changing agent recognises an issue, the need for change and mobilising others to also see that there is a need for change (Shirey, M.R. 2013).

For the project the changing agent will be the team leader of the community learning disability nursing team. Their role would be to encourage change by using the evidence-based practice as the rationale to encourage team members to be involved in the change. Pre-operatively the team leader may face various challenges when attempting to implement change, which is commonly faced in the first stage of Lewin Theory (Shirey, M. 2013)

Tappen et al, (2017) highlights six major barriers to change: complexity and magnitude of the change, instability of leadership, competing demands, stakeholder resistance, scarce resources and technical problems. All these barriers will have to be taken into consideration by the team leader and suitable ways to overcome the barriers must be made. As highlighted by (Tappen et al 2017) a challenge that the team leader may face is resistance to change. Shirey, M.R (2013) highlights that resistance to change is common and suggests that in order to overcome this teams must successfully identify reasons for and against the change. The way in which staff members will respond to change cannot be predicted. Braithwaite, J. (2018) highlights that the sheer unpredictability of their response can make it hard to impose order. In order for all team members to feel empowered the team leader must ensure they are involved in the decision-making process. Braithwaite, J. (2018) argues that failure to do so can make team members feel that change is being imposed on them and can subsequently lead to resistance. In order to overcome this (Vermeir et al, 2015) argues that effective communication is fundamental. Jones and Van de ven, (2016) argue that the changing agent (team leader) must communicate and address resistance as, if left unchecked, it can fester and over time can cause relationship breakdown and inflict harm.

In order to overcome this the team leader must establish therapeutic relationships with team members even before the commencement of the proposed project. Jones and Van de ven (2016) argues that these relationships are key and supportive leadership can be increasingly impactful in reducing resistance to change. One of the objectives of the project was to provide adequate training to team members. Garzonis et al, (2015) suggests that training is important as it helps team members build and enhance their skills, it could improve staff productivity, keep them motivated and make them feel empowered. Arguably training can be costly and time-consuming; however the Office for National Statistics (ONS, 2019) highlights that on average two women are murdered each week due to domestic violence. This therefore emphasises the rationale for providing adequate training in order to ensure team members are well equipped to support and protect victims.

Furthermore, for successful change the key stakeholders should be identified. (NHS improvement, 2018) highlight that stakeholders can consist of a wide range of people including clinicians, carers and relatives, administrative staff, patients, employers, pharmaceutical firms and government who will help deliver the proposed project for change. Roeder (2013) suggests that these stakeholders will be involved in the following five stages:

Initiating, planning, executing, monitoring and controlling, and closing.

NHS improvement, (2018) argues that before stakeholders become involved in the project the team leader should carry out a stakeholder analysis in order to avoid conflict or potential delays that may arise by inadvertently failing to do so. In order to successfully execute this the team leader should be a strong communicator, an effective leader and have the ability to astutely observe the interactions and behaviours of all stakeholders in order to further avoid conflict and delays (Roeder, 2013).

The proposed change must be effectively communicated and shared and in an efficient way to do so may be in meetings. Meetings are an effective way to allow team members to voice their opinions and share ideas in an environment that is safe. Dongen et al, (2017) suggests that meetings are beneficial as they allow team members to communicate and address any complex and challenging needs of the service users. This is particularly important as the project is aimed to support victims of domestic violence which is a very personal experience. In addition, the project focusses on women with learning disabilities. Therefore, the team must ensure that they take into consideration the challenges the women may face on a day-to-day basis and what they can do to best support their needs. Dongen et al (2017), suggests that that team meetings allow team members to have their voices heard which subsequently makes them feel valued and empowered. This is crucial as it may allow team members to feel more empowered to execute their roles and support the women who are vulnerable.

Once the team have collaboratively come to an agreement the proposed project will enter the stage of intra-operative action. It is important to highlight that before any action takes place the proposed project will be presented to an ethics committee. Ventura, M. (2018) states that ethics committees are a group of individuals formed to protect the interests of service users and address any moral dilemmas within the healthcare sector. Therefore, an ethics committee will have to review the project to ensure it meets the legal ethical guidelines before it is implemented (Morales, P.J 2018).

Furthermore, relating back to Lewin’s theory the next stage is freezing (Shirey, M.R. 2013) highlights that stage two entails looking at change as a process which involves consolidating a detailed action plan. Shirey, M.R. (2013) highlights that, as with stage one, freezing can cause various challenges to arise. The project aims to target women who have been in institutional care and this will be achieved by accessing their records. However, if there is a lack of information and records, this can present as an obstacle. Lodge, et al (2011) highlights that for many people with learning disabilities important information often goes missing, for example medical records, evidence of diagnosis and childhood data. This can become a challenge as, if there is no evidence of who has been in care as a child, these women can be missed and the rationale for the project will be defeated. To overcome this team members could contact the family members of the women and gather that information. In doing so, team members must take into consideration the General Data Protection Regulations, (GDPR, 2018) and ensure that information is passed on through a need-to-know basis. As this could compromise the project if the women involved are truly in an abusive relationship and the abusive partner finds out this could also compromise the safety of the women. Another solution may be contacting the carers or support staff that the women have that may help them with day to day tasks. () suggests that support staff often have built therapeutic relationships with these women and therefore trust is often built and they would be a useful source for gathering the necessary information.

The identification of people with learning disabilities is not a new phenomenon. Lodge et al, (2011) highlights that in the UK General Practitioners (GPs) receive additional income for maintaining registers of people with learning disabilities as part of the Quality Outcomes Framework to ensure annual healthcare checks are provided. Lodge et al, (2011) suggested a coding system to help GPs better identify people with learning disabilities. This can be utilised for the project as a long-term strategy. Women with learning disabilities can be identified by cross-referencing with the register that is maintained at GPs and further analysis can be made to identify if these women have been in institutional care by examining records. The women who have been in institutional care will be screened and a coding system can be utilise to categorise them from women with learning disabilities who have not been in institutional care.

Once the women have been identified members from the team will contact them. In order to ensure their safety is not compromised the women could be invited for an appointment and during this appointment information regarding the support groups can be shared and offered. In order to ensure the women can comprehend the information team members must implement the Equality Act, (2010) and provide reasonable adjustments such as providing the information in an easy read, braille or audio format. The women will have the freedom to choose to whether they would like to join the support groups. However, it is important that the team members effectively communicate the potential benefits of the support groups and emphasise to the women that the environment is safe, and any information disclosed will be kept confidential.

Support groups are an effective way to support women. (Santos, et al 2017) suggests that support groups have been widely used with female victims of intimate partner abuse. Worrall et al, (2018) suggests that support groups are interventions that are facilitated by professionals that aim to provide psychological, emotional, educational and practical support for individuals who are experiencing difficulties. The aim of the support groups is to provide a safe environment for the women to feel free to disclose information. NICE, (2013) suggests that for effective support groups to take place the sessions must be coordinated by trained facilitators. As mentioned, the team leader would need to provide adequate training to team members prior to the implementation of the project to ensure the safety of both the members and women are not compromised. The support groups would operate one a week for an hour, one session in the morning and one session in the evening. NICE (2013) suggests that offering various sessions may allow for more people to participate as people operate on differing schedules.

Evaluation

The final stage of Lewin’s change theory is refreezing. Shirey, M.R. (2013) states that in this stage stabilisation of the change is crucial in order to ensure it is embedded into existing systems including culture, policies and practice. The overarching aim of the project is to ensure that intrinsic systems are put into place to ensure team members are well trained and equipped to protect and support women with learning disabilities who may be experiencing domestic violence. In order to evaluate the successfulness of the project a review will have to be carried out. This can be achieved by using an appropriate evaluation tool. For this project a suitable tool would be a questionnaire. Questionnaires are a good evaluation tool as they provide quantitative data. An example of the layout of a potential questionnaire can be seen in the appendix.

Conclusion

In conclusion, the proposed project has highlighted the issues, challenges and dilemmas that may arise when a changing agent encourages change. Despite the challenges that may be faced, the project has emphasised the importance of change in protecting those who are vulnerable in society and rely on professionals and the services they provide them to protect them and keep them safe and feeling valued. The use of Lewin’s theory as a guidance tool has further highlighted that change is a process rather than an event and requires the collaboration of all team members to ensure all the aims and objectives are met.

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Appendices

Evaluation questionnaire

The purpose of this questionnaire is to:

Ask you how you felt about the support groups
Ask you how you felt about the way the staff supported you
Ask you what you feel could be done to better support you and make the support groups better

(This questionnaire will be anonymous, meaning no-one will be able to know who has completed it unless you choose to provide your name.)

What age group do you belong to (please tick)

18-24

25-40

40-60

60+

Next we would like you to answer the following questions by circling the smiley faces.

The staff who led the support groups were easy to understand

The staff who led the support groups listened to me

The staff who led the support groups made me feel safe

The staff who led the support groups were supportive

Next we would like to answer the following questions

1) Staff communicated well with me

Yes