Improving Communication for People with Learning Disabilitie

t separatelying govern CONTINUING PROFESSIONAL DEVELOPMENT P era 58 up(a) discourse for commonwealth with instruction disabilities Page 66 scholarship disabilities triune choice questionnaire Page 67 Read Annette Martyns practice visibleness on type 2 diabetes Page 68 Guidelines on how to release a practice profile Improving dialogue for hoi polloi with acquisition disabilities NS336 Godsell M, Scarborough K (2006) Improving intercourse for hatful with pick out disabilities. Nursing Standard. 20, 30, 58-65. ascertain of acceptance February 6 2006. Summary Patients with culture disabilities concord higher wellness c ar risks than the general cosmos.Similar essay Collate Information close to an Individuals conference and the Support Providedwellness professionals occupy to discontinue skills that enable them to communicate effectively with this tolerant group. Identifying barriers to confabulation is the first step to reducing or removing them. Suggested strategies to improve wellnesscargon annoy for tolerants with study disabilities include maturation soulised health legal action plans, simplifying confabulation styles and providing favorable facilities and tailored resources. scholarship activities you should be able to gain the impact of communication on interaction betwixt healthc atomic number 18 deliverrs and uncomplainings with attainment disabilities.Describe the singingship betwixt communication and the health inequalities experienced by plenty with reading disabilities. Identify strategies to improve communication between health providers and endurings with discipline disabilities. Authors Matthew Godsell and Kim Scarborough argon senior lecturers, Faculty of health and Social C be, University of the West of England, Bristol. e-mail Matthew. emailprotected ac. uk Introduction Learning damage is non a diagnosis nevertheless a shape wontd to describe heap with a abundant range of strengths and call for.Eighty per cent of children and 60 per cent of adults with discipline disabilities live with their families (Gravestock and Bouras 1997), and legion(predicate) throng with breeding disabilities exceed the expectations of families and professionals in their capacity to learn parvenu skills and adopt their talents (NHS Executive 1999). The term larn hinderance says gnomish rough an souls strengths and needs scarce it does incorporate terce elements that get on in most definitions (Box 1). Emerson et al (2001) state that the number of pile with larn disabilities in the UK has non been determined.They estimate that in the UK there could be as numerous as 350,000 volume with severe acquisition disabilities (intelligence quotient (IQ) 50). This means that 2 per cent of patients ar liable(predicate) to deplete a encyclopaedism dis capacity (NHS Executive 1999). The ways in which people with discipline disabilities atomic number 18 describe impart chang ed. Terminology and related facts are listed in Box 2. treat ideal Keywords Communication Learning disabilities nursing attitudes These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.For related articles and pen guidelines get wind our online archive at www. nursing-standard. co. uk and search using the keywords. Aims and intended training outcomes The aim of this article is to explore the impact of communication on health treat for people with information disabilities. The article discusses how cognition and communication put to work interactions between health fearfulness providers and patients. It also examines how measly communication drop pay to health inequalities that separate people with learning disabilities from the rest of the population.The article explores communication strategies that faeces overcome or reduce barriers to effective health care. aft(prenominal) reading this ar ticle and completing the 58 april 5 vol 20 no 30 2006 sentence out 1 Based on a figure of 2 per cent of patients having learning disabilities, it is likely that 40 per 2,000 patients registered with GP advantages are likely to pick up learning disabilities. How many patients with learning disabilities are you aware of in your practice area? List several(prenominal) of the reasons that susceptibility prevent people with learning disabilities from entrance feeing local health function. health inequalitiesAlthough people with learning disabilities are living longer, the gap that sepa evaluate the health location of people with learning disabilities and the general population has change magnitude. Cohen (2001) asserted that gross inequalities in health are politically, socially and economically unacceptable. An investigation into health inequalities by the hindrance Rights Commission (Nocon 2004) found that people with learning disabilities harbour An increased risk of ear ly death compared with the rest of the population mortality evaluate are particularly high for those with to a greater extent severe impairments.A greater class of healthcare needs. galore(postnominal) needs that are not met. High rates of unrecognised or shortsightedly managed health verification conditions including hypertension, obesity, heart disease, abdominal pain, respiratory disease, stackcer, gastrointestinal disorders, diabetes, chronic urinary tract infections, oral disease, musculoskeletal conditions, osteoporosis, thyroid disease, and visual and hearing impairments.A briefing paper produced by the NHS assistance speech and Organisation (SDO) Research and Development architectural plan (NHS SDO 2004) identified barriers to appropriate and well- judgment of convictiond BOX 1 Definition of a learning deadening A mortal with learning disabilities has Signifi slewt reduction in the ability to visit innovative or daedal tuition. Reduced ability to cope indep endently. check starting in childhood that lead project a dogged effect on phylogeny. (DH 2001) access to health care within and out of doors go.Many people with learning disabilities find that discerning their healthcare needs is a major challenge. Proactive strategies are involve to encourage people to access the all-embracing range of services that are available. Some people with learning disabilities go said that ostracise and un do byful attitudes from healthcare workers founder prevented them from seeking medical exam service of process (Bristol and District pile kickoff 2003). Support and encouragement are required by carers, allies and friends before people with these concerns are adjust to engage with services again.the great unwashed are to a greater extent likely to trust service providers when they are convinced that services and practiti cardinalrs commit responded to their needs by astir(p) communication skills and producing selective information in an accessible format. citizenry with learning disabilities take on the homogeneous right to access mainstream services as the rest of the population ( division of wellness (DH) 2001). However, mainstream services have been slow to develop the capacity and skills to witness their needs.In the document Valuing People (DH 2001) it was acknowledged that the wider NHS had failed to consider the needs of people with learning disabilities and that overcoming this source of inequality was the most definitive issue for the NHS to address for this patient BOX 2 Terminology and facts related to learning disabilities Mental damage was a term uptaked to describe people with learning disabilities. It is no longer used in the UK. Mental retardation is a term used internationally, however, it is not an accepted term in the UK and some whitethorn find this term offensive. Learning difficulty is the term used in fosterage to define individuals who have item learning needs, for example, dyslexia. Some people who are identified as having learning difficulty by education services may also be considered to have a learning disability, but this is not necessarily the case. Mild, moderate, severe and reasoned are damage to describe different degrees of disability (Figure 1). A some system with mild learning disabilities major power communicate effectively, learn, live and work with little verify.However, a soulfulness with profound learning disabilities will require support with activities of daily living, for example, communication, dressing, feeding, washing and mobility. A diagnosis of mental illness is not the same as having a learning disability, but people with learning disabilities may have mental health issues as well. not everyone with learning disabilities requires a social worker or a community nurse. People with learning disabilities may have multiple diagnoses resulting in complex health needs. People with the most profound physical or sensational(a) impairments do not always have the most profound cognitive impairments.NURSING STANDARD april 5 vol 20 no 30 2006 59 learning zone nursing attitudes group. The briefing paper produced by the NHS SDO (2004) provided key action points for removing barriers and up access to health care, which included Using specialist learning disability teams to aid adaptation of mainstream services to meet the needs of patients with learning disabilities. growth strategies for health education and health checks for people with learning disabilities that promote seasonably access to health care.Families and paid carers have an important role in helping people with learning disabilities to access health care. Some people will need assistance to recognise mental health problems and to identify gradual changes in health. Time out 2 Make a list of the ways that you communicate with patients nigh their health, for example, through meshings and telephone calls. pile three examples from your list and consider reasons why communication with a soulfulness with learning disabilities might be difficult.Give an example of effective communication between a practitioner and a psyche with learning disabilities. Policies should address the use of technology to support communication, and the knowledge and dissemination of accessible information. Jones (2003) suggests that managers and commissioners of services should intercede with health, social care and education agencies to ensure consistency in communication policies end-to-end the lives of people with learning disabilities. Communication can be generally define as the exchange of information between a vector and a receiver (Figure 2).Where a mortal has learning disabilities they may be communicating with an intention to attract a communication married person and amaze a two-way dialogue. However, for some people with profound learning disabilities displace a message might be a response to their body and feelings. Their le vel of cognition might be much(prenominal) that they are unsuspecting of possible communication partners and of how to take the communication further. This is called pre-intentional communication, in which the individual says or does things without intending to affect those around them.It is important to remember that everyone communicates and that the role of communicator and communication partner swaps from one person to the new(prenominal) so that a conversation can develop. The challenge for health professionals is to develop skills that enable them to interpret the messages they receive and reconcile the messages they send take careable. Communication is not only well-nigh verbal communication it is also around nonverbal communication, for example, the use of body delivery, words and pictures. CommunicationRecommendations have been do to improve communication and access to health services for people with learning disabilities. Jones (2003) states that services reenforc ement people from birth to older age should develop communication policies. FIGURE 1 Estimated percentage of people with learning disabilities according to level of severity Mild Moderate 12% pixilated Profound 80% 7% 1% Augmentative and alternating(a) communication systems Systems of communication, such as sign language, symbols and eye pointing, are known as augmentative and alternative communication systems (AACs).AACs can be used to levy or replace customary pathways, such as speech or writing. The use of motion-picture shows of everyday objects, picture boards, line drawing and real objects are good ways to enhance communication with people with learning disabilities (American Speech-Language-Hearing tie beam (ASHA) 2005). You do not need to attend specialist training to be able to use AACs such as these. More formal AACs, such as Makaton (a form of sign language for people who have learning disabilities that uses keywords to enhance imageing), require preparation but lea rning a staple vocabulary does not require extensive training.Cognition and communication (Winterhalder 1997) Understanding complex information People with learning disabilities have a reduced ability to NURSING STANDARD 60 april 5 vol 20 no 30 2006 say new or complex information (DH 2001), and those who experience difficulties when bear upon information may find it hard to learn new skills. knowledge can be quantified as a figure related to an individuals IQ. However, it might be more than useful to call in slightly intelligence in relation to cognitive processes. smith and Mackie (2000) describe cognitive processes as the way in which our memories, perceptions, thoughts, emotions and motives guide our understanding of the world and our actions. Intelligence exerts a powerful influence over the ability to process information, the capacity to learn new skills and to adapt knowledge to different situations. Intelligence is an attribute that can guide our understanding of the world, but it is not fixed or static. pedagogics and learning strategies can be used to stimulate cognitive processes so that people can approach information, or potentially confusing situations, with more confidence.Similarly, complicated tasks and information can be broken down into small, saucer-eyed steps so that people can approach them in stages. Attempting to understand another persons cognitive processes can help practitioners to develop a more empathetic and person-centred approach to care, and can provide an motivator to develop the teaching and learning strategies that are best suited to the individual needs of patients. Coping independently People with learning disabilities may have a reduced ability to cope independently (DH 2001). Independence is defined according to levels of social functioning.Assessment of a patients strengths and needs in social functioning is a fundamental stage in developing planned care that is familiar to practitioners from all branches of nursing. Making an accurate discernment of social functioning provides valuable information astir(predicate) the range of activities that a person can undertake on his or her own as well as those activities where a person requires support. Some people with learning disabilities may require assistance with tasks such as washing and dressing, and many need help to have their mode of communication understood.Learning disability and development Learning disability starts before adulthood, affects people of all ages and has a measure effect on development (DH 2001). A majority of younger people with learning disabilities are living in the community with their parents or carers. one- beat(a) people with learning disabilities also live in the community but they may have periods of institutional care. Some people will have frequent contact with health services and others have irregular contact. People with learning disabilities are not a homogeneous group. Their perceptions of nurses, N URSING STANDARDFIGURE 2 A model for communication Person communicating we take turns in this role of sender of information. Depending on the persons cognitive ability, this may be intentional or pre-intentional communication Communication barriers can be present in the environment as well as existence caused by the communicator and communication partner Communication partner we take turns in this role of the person who receives the information sent, makes sense of it and responds appropriately doctors, health centres, clinics and infirmarys will have been shaped by their formative experiences with round and services.Providing encouragement for people with learning disabilities to attend health checks and to make use of healthcare services can involve changing their perceptions of health professionals. Some people with learning disabilities have not received the treatment they need because they are reluctant to engage with services where they have had bad experiences in the past. To encourage people with learning disabilities to make effective use of healthcare services throughout their lives, practitioners need to use their communication skills to initiate and maintain positive relationships. Time out 3Think about the last time you communicated with a person with learning disabilities, or someone who has communication difficulties. Refer to the list you made in Time out 2 about the communication systems you use in your workplace. What are the main barriers to communicating about health with a person who has learning disabilities? How do you remove or reduce barriers to communication? Which environmental factors impede communication? Identify any barriers that you had not previously considered. april 5 vol 20 no 30 2006 61 learning zone nursing attitudes Barriers to communicationThere are barriers to communication which can be identified in relation to the person with learning disabilities, the health professional and the environment (Box 3). When barriers have been identified, health professionals can start to think about ways of reducing or removing them. Health professionals exchange information by using terminology that reflects their specialize knowledge. Patients and other people who are not involved in the day-to-day delivery of health care BOX 3 Barriers to communication The person with learning disabilities may Have special(a) understanding.Have limited vocabulary or difficulty speaking. Have sensory impairments that limit ability to hear requests or instructions. Have poor understanding of health and healthy living. Be scare of people in uniforms. Be stressed because of illness. Not like new places. Have difficulty waiting and may not understand the notion of time or queuing. Have limited literacy and numeracy skills to read health advice and information, for example, instructions, letters, loony toonss. calculate contact with nurses to be unpleasant because of previous experiences. The nurse may Be rushed because of heavy workload.Have biases and assumptions about people with learning disabilities. Have poor listening and attending skills. Be unable to understand augmentative and alternative communication systems. Have limited knowledge of the individual. Have insufficient time to develop a good relationship with the individual or carer. Not use visual aids to support understanding. Use technical bevel and/or long words. Provide scripted information without thinking of the patients ability to read it. Provide information about the succeeding(prenominal) appointment in a way the patient will not understand or remember.The environment may Be crowded. Busy. Uncomfortable. Have queer smells and noises. Bring back bad memories. Have limited physical access, for example, no hoists. Include unhelpful people. Have poor signage, relying on literacy skills and good sensory abilities. Have no area to sit quietly with limited sensory stimulation while waiting. Be filled with machines and instruments th at a person with learning disabilities may not understand. may find it difficult to comprehend the terms and ideas they encounter in healthcare settings. They can find it hard to play along advice or instructions.This could result in patients making inappropriate decisions or exposing themselves to surplus risks. For example, patients with learning disabilities who take their own medicine may be at risk of overdosing or taking an ineffectual dose, particularly if the route and dosage of a newly prescribed medicine has not been veritable clearly and/or book of accounted in an accessible format. Time out 4 work out the list of potential barriers to communication and categorise them according to Barriers that have been intercommunicate for patients with learning disabilities using the services you work in.Barriers that can be remedied quickly. Barriers that need planning to be reduced or removed. Barriers that require financial coronation to be reduced or overcome. Discuss thi s list with your colleagues. Identify strategies for removing barriers and ameliorate communication. Good practice in communication In sec Warwickshire, health passports have been developed for people with learning disabilities (Leamington Spa Today 2005). These provide detailed information about an individuals health, strengths and needs so that practitioners can provide patient-centred care.They are used to improve communication crosswise a range of healthcare providers. Having an alert system incorporated into patient notes which provides individual communication needs could be beneficial, especially where staff do not know individual patients. Health practitioners may use and be involved in developing health action plans. These are plans specific to individuals and are developed to meet their access needs. Health action plans are a way of overcoming some of the barriers to high quality health care (DH 2001).Plans are produced by a group of people including the patient. They en courage the development of a shared understanding about an individuals health needs. Where training in health action planning has been provided for GP surgeries, improvements have been shown in the health of patients with learning disabilities (Smith et al 2004). There are benefits to having a lead person to deal with learning disability issues. In basal healthcare services, a lead person takes an interest in learning disability issues, collates information, NURSING STANDARD 62 april 5 vol 20 no 30 2006 ives support and advice to health staff and develops links with specialist services for people with learning disabilities and other agencies (NHS Executive 1999). Time out 5 Does your organisation have a lead person who is involved in initiatives such as joint communication policies and the development and sharing of accessible health information? If yes, find out how he or she is supporting your team to develop skills in communicating with people who have learning disabilities. I f no, how might developing this role benefit your team and improve access to health care for patients with learning disabilities?To improve communication with people with learning disabilities, more time should be allocated to appointments so that there is more time for them to express themselves and understand any information they have received (DH 1999). This is particularly the case if AACs are macrocosm used. Reception staff are often aware of people who have difficulties using services. Supporting these key staff to develop effective communication skills and flexibility can improve access to health services (NHS Executive 1999).For example, if staff in reception are aware that someone finds it difficult to wait in a queue, they may offer that person the first appointment. Several resources have been developed by trusts to improve communication. Some examples of these include Hambleton and Richmondshire Primary Care hope (PCT), in partnership with Mencap, has developed an acc essible Choose and Book guide for hospital appointments that uses a combination of pictures and words to explain how patients can make choices about hospitals and appointments.Bristol South West PCT, as part of its Expert Patient Programme, has developed plans that help prepare people with learning disabilities for a visit to the doctor. The Health Facilitation Team at Gloucestershire Partnership NHS Trust (2004) has produced a merchandise light assessment that conveys information about individuals on admission to hospital. This ensures that important information is clearly communicated to health professionals. Camden PCT (2005) has used this work to develop an online resource. Although people may appear to have limited communication skills, they should not be ignored.These patients should be addressed directly and NURSING STANDARD the information they receive should be provided in a simple way without being patronising. Effective communication often depends on how the information is delivered. Practitioners may have to reprimand to carers, but they should not forget to address the person with learning disabilities. Practitioners should examine their beliefs about people with learning disabilities and avoid making assumptions about an individuals strengths and needs. This will help to make health assessments more accurate (DH 1999).It is useful to invite a speaker with learning disabilities to talk to healthcare staff about living with a learning disability and his or her experiences of accessing health services. Time out 6 What beliefs and values do you think society holds about people with learning disabilities? Some examples of negative beliefs and values are that people with learning disabilities Have a poor quality of life. Have higher pain thresholds. Are dangerous and promiscuous. leave alone not understand anything. Should not get married or have children. Cannot care for their children. Need institutional care. Cannot work.Are like children not adu lts. What are your feelings about these statements? How might the presence of any or all of these beliefs influence the care given to a person with learning disabilities? People with learning disabilities can have additional physical or sensory impairments that should be considered. They are also more likely to have more mental health needs than the general population (DH 2001). Where a patient has additional impairments or health issues these need to be considered during communication. The healthcare environment should be able to accommodate people with physical or sensory impairments.Time out 7 In your work place Do you have a hush-hush area to talk to a person who has a large wheelchair? Do you have rooms where glare is controlled and the environment is suitable for people with limited vision? Do you consider the needs of interpreters/ carers and ensure they fully understand information before they pass it on? april 5 vol 20 no 30 2006 63 learning zone nursing attitudes Acces sible information Accessible information comes in many forms, such as videos, CDs, DVDs and audiotapes. Pamphlets can be produced with accessible information about the services offered.Written information needs to be in plain language, with short sentences and one subject per sentence. Photographs, drawings, symbols and other visual information can be used to support written information. It is important to keep pages uncluttered on plain backgrounds so that textual matter does not detract from graphics. Letters should be large, 16-18 point type size, and fonts that do not have serifs, such as Arial and Comic Sans, should be used. graphical text, underlining and italics should be kept to a minimum because they can impede readability. Many trusts are now producing resources to enhance accessibility.Some of these include The United Bristol Healthcare NHS Trust has produced a leaflet called You are coming to the Bristol Royal Infirmary about your heart, TABLE 1 Using terminology that is easy to understand Health issue Common words that are used Epilepsy Investigations encephalogram (electroencephalogram) Strategies or words that improve understanding Find out more about This word would have to be used, but a photograph of someone having an EEG may help understanding Medicine tablets to help control your epilepsy Having two or more seizures straight after each other or whatever describes status for the individual Taking your medication as we have agreed Things that might make you have a seizure Not being able to have a poo for three days Things you feel in your head and body that make you think you will have a seizure Having a fit or turn, whichever word the person uses which uses pictures and words to introduce some of the staff and explain what happens when patients are admitted to the cardiology department.The Learning Disability Partnership Board in Surrey has developed The Hospital Communication Book that combines words, pictures, signs and symbols. Traffor d North and South PCTs have produced a toolkit for people with learning disabilities called crabmeat and You (Provan 2004). Contact your local Community Learning Disability Team or People First organisation for information about local resources. Simplifying conversation When talking to people with learning disabilities, use approaches similar to those used for written text. Plain language, the use of keywords, short sentences and one subject per sentence should be used. Give people time to process what is being said and to formulate a reply.Use openended questions to assess a persons understanding and rephrase the question if necessary, as repeating the same question rarely improves understanding. When information is presented during a consultation it is important to check that the person with learning disabilities has understood it. If there is insufficient time during the initial consultation, it may be necessary to make a further appointment to check what the person has understo od and retained. For an individual who processes information slowly this might be essential to ensure an accurate assessment and the effective capital punishment of a treatment plan. Examples of terms that are easier to understand are presented in Table 1.Such terms are only beneficial if the person understands them so, for example, impairment could be described as not being able to have a poo, but the health practitioner needs to know whether the person uses this term to describe defecation. Anti-epileptic drugs Status epilepticus Drug compliance Triggers Constipation ring Time out 8 Think of four common illnesses that are likely to make a person visit your service. Write these in the first column of a table (see Table 1). Identify the language you use when discussing these illnesses and record these words or phrases in column two. These might be medical terms, health terms or long words. right off spend some time identifying words that are easier to understand and record them in the third column. NURSING STANDARD Seizure 64 april 5 vol 20 no 30 2006 ConclusionPeople with learning disabilities may have communication difficulties that have restricted their access to health care and prevented them from receiving the information required to maintain their health. In addition to learning disability, they are more likely to have complex healthcare needs leading to multiple diagnoses. step towards better health for people with learning disabilities can be made by providing encouragement and support to attend regular health screening and reviews, and by developing a range of strategies to improve communication between practitioners and individuals with learning disabilities NS RECOMMENDED RESOURCES British Institute of Learning Disabilities (2001) Factsheet No. 005 Communication. www. bild. org. uk/pdf/factsheets/communication. pdf (Last accessed swear out 10 2006. British Institute of Learning Disabilities (2005) Your Good Health (a set of 12 illustrated b ooklets). www. bild. org. uk/publications/your_very_good_health_details. htm (Last accessed work on 10 2006. ) Communication Matters (updates 2005) What is AAC? www. communicationmatters. org. uk (Last accessed March 10 2006. ) Communication Matters (updated 2005) How to be a good listener. www. communicationmatters. org. uk (Last accessed March 10 2006. ) division of Health. www. dh. gov. uk (Last accessed March 10 2006. ) human foot for People with Learning Disabilities (2004) Communication and people with learning disabilities. www. learningdisabilities. org. uk/page. cfm? agecode=ISSICMMT (Last accessed March 10 2006. ) Foundation for People with Learning Disabilities (2005) Patients with learning disabilities in South Warwickshire have been given a new type of passport to help with their medical appointments. www. learningdisabilities. org. uk/profilenews. cfm? pagecode=ISSICOLN&are acode=ld_communication_news&id=7231 (Last accessed March 10 2006. ) MENCAP (2003) You and you r health a introductory guide to being healthy. www. mencap. org. uk/download/you_and_your_health. pdf (Last accessed March 10 2006. ) Plymouth Hospitals NHS Trust (2005) maintenance with cancer. www. learningdisabilitycancer. nhs. uk/ (Last accessed March 10 2006. ) Time out 9Complete a SWOT abstract (strengths, weaknesses, opportunities and threats) of your skills and knowledge when communicating with and supporting access to health care for people with learning disabilities. Time out 10 Now that you have holy this article, you might like to consider writing a practice profile. Guidelines are on page 68. References American Speech-LanguageHearing Association (2005) Introduction to Augmentative and alternative Communication. www. asha. org/public/ speech/disorders/acc_primer. htm (Last accessed March 9 2006. ) Bristol and District People First (2003) We are People First. (Film) People First, Bristol. Camden PCT (2005) What You Need to Know About Me in Hospital. www. camden. go v. k/ (Last accessed March 17 2006. ) Cohen J (2001) Countries health performance. The Lancet. 358, 9285, 929. Department of Health (1999) Facing the Facts Services for People with Learning Disabilities A constitution Impact Study of Social Care and Health Services. The Stationery Office, London. Department of Health (2001) Valuing People A New Strategy for Learning Disability for the 21st Century. The Stationery Office, London. Emerson E, Hatton C, Felce D, Murphy G (2001) Learning Disabilities The Fundamental Facts. Foundation for People with Learning Disabilities, London. Gloucestershire Partnership NHS Trust (2004) Traffic light assessment. unpublished document.Gloucestershire Partnership NHS Trust, Gloucester. Gravestock S, Bouras N (1997) Emotional disorders. In Holt G, Bouras N (Eds) Mental Health in Learning Disabilities A Training Pack for Staff work with People who have a Dual Diagnosis of Mental Health Needs and Learning Disabilities. number edition. Pavilion Publishin g, Brighton, 17-26. Jones J (2003) The Communication Gap. www. learningdisabilities. org. uk /page. cfm? pagecode= FBFMCHTP04 (Last accessed March 10 2006. ) Leamington Spa Today (2005) Patients with learning disabilities in South Warwickshire have been given a new type of passport to help with their medical appointments. Leamington Spa Today. 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Smith C, Giraud-Saunders A, McIntosh B (2004) thinking(a) Lives Health Action Planning in a Person Centred musical mode Including Health in Person Centred Planning. www. valuingpeople. gov. uk/ HealthHealthyLives. htm (Last accessed March 10 2006. ) Winterhalder R (1997) An overview of learning disabilities. In Holt G, Bouras N (Eds) Mental Health in Learning Disabilities A Training Pack for Staff Working with People who have a Dual Diagnosis of Mental Health Needs and Learning Disabilities. Second edition. Pavilion Publishing, Brighton, 1-6. NURSING STANDARD april 5 vol 20 no 30 2006 65