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The preceding chapters have highlighted national variation in policies, systems and practices to support the care of children with LD in hospital, as well as considerable uncertainty among senior staff about what is in place in their organisation. We have also provided evidence of perceived inequality for children with LD, from the perspective of staff, in relation to multiple aspects of hospital care, including safety. Interviews with senior managers in 22 hospitals across the country have revealed organisational, staff and family factors that facilitate or prevent such inequality. This chapter focuses on staff views and experiences at the individual level, from interviews with 98 staff working in six of these hospitals, including nine ward managers (phase 2). A clear theme running through this chapter is the often complex relationship that staff have with parents, who can be viewed as being massively helpful but also a hindrance.
Identifying children with learning disability
Staff from different professional groups referred to the terminology used around LD and the resulting lack of clarity, especially given that ‘special needs is a huge range’ (ward manager, specialist children’s hospital E) and the lack of education about definitions (staff quotation 1; see Appendix 7). The use of terms such as ‘learning disorder’ or ‘learning difficulty’, ‘developmental delay’ and ‘special needs’, as well as specific diagnoses such as dyslexia or dyscalculia, or the complete lack of any information about LD, was not uncommon. As one allied health professional said:
They say ‘LD’ and that could mean autism. It could mean intellectual disability. It could mean that the child has behaviour needs or mental health needs. You never know what it actually means.
Furthermore, there appeared to be a conflation between LD (or equivalent) and physical disability.
Different staff talked about various methods by which they could identify that a child in their care had LD. These included both formal methods, including the referral letter, pre-admission clinic, patient notes, admission history, hospital passports or equivalent, flagging or alerts, and informal methods, including huddles/handover, indications from diagnosis, intuition, knowing the child and asking parents. An issue raised was that referral letters might or might not have information about a child’s LD.
At one site with ‘strong links with the community paediatricians’ (nurse, specialist children’s hospital), staff said that this helped hugely with communicating about patients in advance of their child’s admission. Pre-assessment clinics were viewed as an opportunity for staff to ‘gain real insight as to how they’re behaving’ (ward manager, specialist children’s hospital F), and to identify specific needs and plan reasonable adjustments. However, it was also recognised that it may be left to the doctor’s secretary to inform the ward about a patients’ needs, or that the information doctors passed to ward nurses did not always contain the detail needed. There was variability in staff views about the usefulness of patient notes, with some seeing them as a good source of information and others highlighting that it ‘depends whether the nursing staff have written it’ (nurse, non-children’s hospital G). It was also noted that it might be easier to find relevant information about those with more complex needs or patient issues, such as safeguarding, than about those with mild LD, as well as other patient issues such as safeguarding. The value of being given information about what a diagnosis of LD meant for an individual child was highlighted, as was having a dedicated section at the front of the child’s notes to highlight any special needs that they may have (staff quotation 2; see Appendix 7).
Many staff, including several ward managers, highlighted that it was not uncommon that they would not know that they would be admitting a child with LD until the child arrived on the ward, and it might not be until a history was taken that a diagnosis of LD was likely to become apparent. For example, one play specialist working in a specialist children’s hospital described inadvertently offering a child who was blind some books to read, while a paediatrician said, ‘actually do we as nurses and doctors always know when a child in front of us has a visual impairment or hearing impairment, I wonder?’ (non-children’s hospital G). There was variation in whether or not parents were asked directly about LD, with a staff member from one non-children’s hospital saying that it was not asked at all during admission, another saying that it was not done routinely, and another saying that they always talked through the child’s activities of daily living with parents, including behaviour and development. Learning on the job by simply asking the child questions, such as their date of birth, and observing their behaviour was another tactic used in practice. Time was seen as a barrier to acquiring the relevant information. The challenges of unplanned admissions, especially those through accident and emergency, were highlighted.
Across all sites there was an awareness of hospital passports and ‘all about me’ documents, but there was uncertainty about the extent to which these were used by staff or families. Ensuring that the passport was easily accessible and available in advance of the child’s admission was a suggestion to improve practice. Broadly, staff felt that it would benefit their practice and the child’s experience if a flag or alert existed for a patient with LD, but the way in which this would be applied and what it could mean was questioned:
Those alerts come from non-formal assessment . . . I don’t feel like it’s a fair way of communicating about a child’s needs.
A ward manager working in a different children’s hospital also recognised that parents may not want their child to be labelled, although this view was based on a single previous experience.
A few staff commented that some diagnoses would suggest that a child might be more likely to have LD, for example ‘severe cerebral palsy’ or ‘maybe Down’s syndrome’, but they did not necessarily clarify this with the parent, which meant that it might not be until later in the admission that a particular LD-related need was identified. In addition to the clues from a diagnosis, several staff said that they used their ‘intuition’ (physiotherapist, non-children’s hospital D; nurse, non-children’s hospital G) to identify whether or not a child had LD. They talked about ‘just being able to tell’ (nurse, non-children’s hospital G) or ‘having a little inkling’ (nurse, specialist children’s hospital G) or the child looking ‘a bit slow’ (nurse, non-children’s hospital G). Some, but not all, did go on to say that they would check their suspicions by asking the family or reading the child’s notes.
Several staff talked about ward huddles and handovers as other potential sources of information about a child’s LD and the need for reasonable adjustments. However, other staff felt that the extent of a child’s disability or specific needs might not be shared during huddles and, therefore, this was ‘hit and miss’ (doctor, specialist children’s hospital F).
Interviewees also reported ‘knowing’ some of the children from previous admissions, which meant that they were aware of the child’s background and could draw on this information when caring for the child or sharing their knowledge with other members of staff. About half of staff cited parents as a reliable source of information about their child’s LD:
It’s all about not relying on one system to give you all the information. It’s about using all the ones available to you. Again, we come back to why family are so useful in those situations because they, at the end of the day, will have the most up-to-date information about the patient and how to manage them best, rather than what might have been written days, weeks or months ago.
Parents were largely reported to be forthcoming with information, particularly if they experienced regular hospital admissions. However, as a few staff noted, parents might also have LD, speak English as a second language or be really tired or disengaged, all of which could have an impact on whether or not information about their child’s LD was shared. Moreover, as the ward manager of a surgical ward said:
It must be easier for parents if they’ve not got to explain everything every time they come in . . . if you go in with that little bit of knowledge and probably a little bit of sensitivity and make sure you’re prepared.
The value of identifying LD in advance of an admission was recognised by a number of ward managers, who talked about the challenges of trying at the last minute to, for example, prepare bed areas or source specialist beds/equipment, which could take days to arrange.
Confidence, knowledge and skills
The degree to which staff felt confident, knowledgeable and skilled in caring for children with LD varied, as did their views on how this compared with caring for children without LD. What was apparent was that their understanding about children without LD was often the ‘yardstick’ with which staff measured their knowledge. They recognised that, for children with LD, there was no blueprint to follow, and a standard patient pathway for a particular condition or admission type did not necessarily fit with the needs of these children:
We’re used to dealing with them [children without LD] . . . to how that disease displays itself . . . We have our set protocols, we have our practice nurses to do education with them, to help lead practice. But with children with LD you can have one condition that can manifest itself in very different ways . . . we aren’t always as prepared . . . it’s responding to the individual child’s needs, whereas your chronic condition we’re more looking at the condition itself.
Many staff recognised that when it came to skills and expertise in relation to children with LD, and particularly those with multiple and complex conditions, there was always room for improvement. However, a lack of training was seen as a particular barrier (see Training), with many describing gaining their knowledge, skills and confidence through experience instead (staff quotation 3; see Appendix 7). Central to this knowledge by experience was being ‘regularly and repeatedly exposed to children with disabilities and the people that care for them in their normal environment’ (nurse, specialist children’s hospital F). Experience was also seen as valuable in terms of building staff’s confidence in being open about the limitations of their own abilities:
The more you look after children with special needs, the easier it becomes. You lose that fear of the unknown and you get to learn how to communicate appropriately . . . watching other people look after children with special needs you can learn quite a lot but it’s also about having the confidence to ask the parents what they expect from you as well . . . not be afraid to say, ‘Look, I don’t know what I’m doing. What do you want me to do?’.
The presence or absence of parents could have an impact on staff. If parents were present, then staff could work with them to find out specific information about the child and combine this with their own knowledge and skills to provide individualised care (staff quotation 4, staff quotation 5; see Appendix 7). If parents were not present, then providing tailored care was more difficult and could have implications for the time spent with the child, the time set aside to complete a task or the timing of care. This was the case even for staff who had a lot of experience, because ‘there’s often a finely tuned balance where if you don’t quite get something right it can throw other things off’ (nurse, specialist children’s hospital F), whereas for children without LD ‘it’s usually pretty clear-cut’ (nurse, specialist children’s hospital F). It was generally recognised that knowing the individual child helped to develop staff’s confidence, which in turn could have an impact on how much time they spent with the child:
If you know a family well, then you would feel more confident to go and talk to that family but if you didn’t really know how a child communicated or how to communicate back . . . it’s the not knowing. You’re maybe not going to go and put yourself in that unfamiliar environment . . . in that uncomfortable situation.
It was recognised that newly qualified staff, who could be scared of the unexpected, may find it particularly challenging to develop their knowledge through experience (staff quotation 6; see Appendix 7).
Training
The amount of undergraduate training that nurses and allied health professionals received in LD varied considerably, with paediatricians reporting more variability than other staff, based on their specialist training. Within the context of a packed curriculum, chronic or long-term conditions appeared to be covered, but only a limited focus was given to LD. Experience of LD largely came from placements, most often in special educational needs schools or other non-hospital settings. Specific LD training, when offered, was highly valued:
I found it brilliant. We had service users coming in, giving us talks and personal accounts and telling us what they would like from nursing staff. We would have parents coming in . . . telling us their experiences . . . and what they would like for the future.
When asked about continued professional development, most staff were not aware of any specific LD training in their hospital, referring instead to mandatory training, such as manual handing and safeguarding, and condition- or treatment-specific training. Skills in and knowledge about LD came from ‘learning on the job’ from patients, parents and colleagues, the success of which varied:
It’s more of the mentorship that I’ve learned . . . I’ve worked with consultants, whose communication with these LD were absolutely fantastic, and you think, ‘Wow, I want be like that’. On the other hand, unfortunately, there are people who haven’t been that brilliant with dealing with children with LD.
A small proportion of staff felt that they had received enough training to care for both children with and children without LD, whereas others reported gaps in their training in relation to LD, autism, Down syndrome and cerebral palsy, communication methods, managing behaviour, and distraction and positioning:
There’s still things that we’re failing to meet . . . it’s more the LD-specific factors that we struggle with.
This staff member went on to say that a big weakness in their service was not having enough staff trained in Makaton and other communication methods, highlighting disparity in staff confidence between communicating with a teenager with cystic fibrosis and communicating with a teenager with cerebral palsy (ward manager, specialist children’s hospital F). That parents could subsequently be relied on by staff who might ‘unravel’ without the parents’ support was a factor that a ward manager from another specialist children’s hospital also raised.
Making reasonable adjustments
It is a legal requirement for public services to ensure that their services are accessible to people with disabilities. The 1995 Disability Discrimination Act92 lays out the legal duties of service providers to make adjustments. A range of factors have an impact on whether or not an adjustment is deemed ‘reasonable’, including whether or not it can actually be done, the cost, and the organisation’s resources and size. The guidance documents from the Equality and Human Rights Commission point out that ‘just because something is difficult does not mean it cannot also be reasonable’.93 Furthermore, the legal requirement is for services to proactively anticipate the need for reasonable adjustments, rather than wait until these adjustments are required.
When staff were asked to explain what the term ‘reasonable adjustments’ meant, about one-third did not have any understanding of the term, with some talking about reasonable adjustments but in another context, such as education or employment. The remaining staff provided some form of description, but with varying degrees of clarity and confidence about what this meant in practice, as shown by the following definitions provided by four ward managers working in two different specialist children’s hospitals:
How we can adjust the environment or how we work, reasonably. So, meeting the needs of the patient, but also not putting needs, or the needs of the services, at risk.
You can alter things that aren’t going to affect us too much.
Putting things in place that are reasonable, so if a patient wants a certain thing and you can give them that without too much trouble, that you’d try your best to do it.
You can do the very best you can for your patient within your own policies, procedures, and health and safety that you could do it for more than one patient. You can’t go above and beyond for the one patient if you weren’t prepared to do it for another patient.
Few staff talked about reasonable adjustments being anticipatory.
The majority of staff felt that they could make (reasonable) adjustments when these were needed, with some less experienced staff feeling that they needed assistance from colleagues or more senior colleagues to put some adjustments in place, something also highlighted by ward managers. Overall, staff believed that they did the best they could to make adjustments to meet the needs of a child whether or not they had LD, but at times an adjustment was more of a ‘best fit’ rather than a ‘perfect fit’.
The majority of (reasonable) adjustments described (see Appendix 8) related to some form of flexible practice, an alternative approach or prioritisation. However, these were not always seen as ‘changing the way things are done for children with LD’.35 Rather, it was implied that these adjustments were sometimes part of standard practice and that in some cases these were made ‘probably without even realising you’re doing it’. Others were more considered; one service at a specialist children’s hospital had the capacity and flexibility to offer assessment at home rather than distressing the child by having them come to hospital. Staff also noted that parents and children sometimes made specific requests for adjustments that were highly individualised, not all of which were met.
The use of resources to assist in the provision of (reasonable) adjustments was described, and these included a range of equipment such as specific mattresses, beds or seating options. However, the availability and accessibility of these in the hospital varied:
We had a child who needed to be in a pit bed on the floor because they’re not safe to be in our normal beds . . . Ringing round for that pit bed at 3:00 in the morning, who has got the pit bed? No one knows where it is, oh it’s in a room where it’s behind a lock code and nobody knows what the code is. In the end we contacted the adult services and they had a pit bed that we used instead. There’s always a solution but sometimes it can be slightly more longwinded than it needs to be.
Some staff reflected on the difficulty of knowing that a patient may need a specific adjustment and not having the resources to implement this or the permission to do so (staff quotation 7; see Appendix 7). Some staff felt that it was not their responsibility or within their power to make reasonable adjustments (staff quotation 8; see Appendix 7), including a band 5 staff nurse at a specialist children’s hospital who felt that a reasonable adjustment she had identified for a patient had been implemented only when a more senior member of staff requested it. Conversely, however, some junior nurses felt that being newly qualified had a positive impact on the implementation of reasonable adjustments because they had received recent training in individualised family-centred care. They said that some senior nurses could have rigid approaches to following rules/policies that prevented reasonable adjustments being made. Certainly, the degree to which staff ‘turned a blind eye’ to these rules differed.
Barriers to the implementation of reasonable adjustments were also described in relation to space, ward staff, bed status, the availability of side rooms and unplanned admissions, as well as information about adjustments not being handed over or recorded in a patient’s notes and an adjustment being needed outside regular working hours. Furthermore, it was recognised that information that was available for children about being in hospital or specific medical conditions was in written form and not adjusted to make it accessible for those with LD.
Safety
Overall, the majority of staff indicated that they believed that they were able to provide safe care to children. However, this depended on staffing levels, which could change day to day, and the ward layout, with one children’s hospital having recently increased the number of side rooms and removed the nurses’ station, which compromised the visibility and observation of children. Similar to that already described in relation to communication, parents were viewed as having a pivotal role in the provision of safe care for their children, which often could not be replicated by ward staff when parents needed to leave the bedside:
[Parent says] ‘I’m just popping for a cup of tea, can you sit with them? I’ve left the door open, will you keep an ear out?’ ‘No.’ [Staff member] . . . You do, you try your best and you say, ‘Yes, we’ll pass him by all the time, but I can’t physically sit in there for the duration it takes for you to go and have a cigarette and a cup of tea and a chat with your mum on the phone’. So, that parent might need to actually, you know, forfeit their cup of tea and their fag, and stay with them, because they wouldn’t be safe, but you can’t force parents to stay there. So, that’s when it becomes unsafe, if you’re taking a staff member off the ward to sit with them, but that half hour is vital, isn’t it? Some time for parents to go and have a breather.
This example highlights particularly well the conflicting views staff can have about supporting parents to have a break in hospital and there appearing to be no choice between that and maintaining the child’s safety. Managing behaviours of concern, in children with and children without LD, was raised as a particular issue that could compromise the safety of children and also staff, who might be hit, punched or kicked as a result (staff quotation 9; see Appendix 7). Staff would try to work with parents when children displayed such behaviours or draw on specialist support, such as the play team, but may not have the resources or strategies in place on the ward, which ‘could be a dangerous place for somebody if they suddenly decide to have this mega blow-out’ (teacher, non-children’s hospital I). As one staff member said:
I’ve looked after children who have been climbing on the lockers and jumping around on the bed, and I suppose that’s not ideal, but I don’t know how you could solve that.
Another example was provided of a child aged 12 years with the intellectual capacity of a 3-year-old who required regular life-saving blood transfusions. The following quotation from a nurse highlights the complexity of managing this situation:
We do have situations where it can become unsafe . . . the child hits you and does quite a lot of damage to staff around him. Managing that is difficult because the cubicle is too small, and he’s at risk of damaging himself. He stands up with the wheelchair on his back and walks around with it. He tries to grab the machine that’s delivering the blood . . . so you need about two to one with him . . . we can’t put him in the playroom because he’s a danger to other children . . . there’s no real space for him . . . he ends up in the corridor, in a very boring end of the unit . . . we can’t sedate him because ethically that’s not right.
Staff across different hospitals recognised that some children need additional support or staff to spend time with them as a result of behaviours of concern or self-harm, but that this may not be provided. However, others did not see that aspects of a child’s safety in hospital were within their remit.
Involving parents
Approximately half of the staff members interviewed talked about parents of children with LD as a reliable source of information and about the importance of working in partnership with parents and listening to their views. Ward managers talked specifically about negotiating roles and responsibilities with parents and that it was important ‘not to jump in and take everything over’ (ward manager, specialist children’s hospital F), as well as recognising that because every family is different ‘you just assess it as they come in’ (ward manager, specialist children’s hospital E). Some staff reflected on the difference between parents of children with LD and parents of children without LD in terms of (1) their willingness to be involved, (2) their expectations and (3) their attitude:
We find that with children with LD, they [parents] are generally more happy to be involved . . . they like to be involved in personal aspects of care, they like to ask questions . . . I think with some of those parents [of children without LD] they tend to take more of a step back.
The parents with children with LD tend to just make do and manage, to the extent that we go, ‘You really shouldn’t be lifting that child. They’re 15, why are you carrying them up the stairs?’. It’s often that the parents of children . . . suddenly in plaster, where they’ve been a normal child up until then, that have higher expectations of what equipment we can provide, what adaptations we can provide.
You tend to find the parents of the children who have got LD are not as nervous for the majority of the procedure, unless they’re having something major. They tend to be more aware of the process, they know the staff. They’re a bit more institutionalised, really . . . so they have more patience . . . Your parents that have got children without disabilities and they’ve never been in before, they’re, kind of, expecting an instant service, they come in, they go to theatre, they’re out, they’re home, then that’s it. That’s just not how it works and there’s 100% a difference between those parents.
What was apparent was that the relationship that parents of children with LD had with staff was often complex, and it was evident that, as well as being viewed as a massive help, parents could be seen as a hindrance:
If the parents feel they need it [one-to-one care], but we don’t think they need it, . . . staff can feel quite anxious . . . because they’re such an expert in their child and they want things done precisely . . . they don’t want to be in a position where they think they’re going to be complained about.
Parents can be brilliant, but they can also be very difficult to deal with, understandably if their child is in a distressing situation . . . that can manifest itself in them either being very helpful and understanding towards the health-care professionals who are trying to help the child, but it can also lead some parents to being difficult to discuss with. They can sometimes be verbally abusive. They can be sometimes aggressive. They can be just sometimes a bit difficult to deal with.
Examples were also provided of parents potentially compromising the safety of their child or other children on the ward by, for example, carrying hot drinks on the ward, continuing practices from home when the hospital wanted to manage things differently or lifting their child manually rather than hoisting them.
Environment
Although the ward environment was seen to create challenges for both children with and children without LD, it was generally perceived to be less conducive to the needs of those with LD. Lack of space was a particular issue, especially for those who used wheelchairs and required the use of hoists. The number of belongings that parents needed to bring into hospital compounded the situation, particularly in bays where the space between the beds was minimal (staff quotation 10; see Appendix 7). At three sites it was also noted that the bathrooms for children with physical impairment or complex needs were inappropriate or lacked appropriate equipment. In one non-children’s hospital, the bathroom for disabled people was used as a storage cupboard, and in one of the children’s hospitals the ceiling tracking hoists in the side rooms reached the toilet but did not reach the shower.
Many staff recognised the benefit to children on the ward of having access to a playroom, sensory room or activity space, but it was felt that these spaces were primarily suitable for children without LD, who also had a greater choice of toys and activities appropriate to their needs. As one staff member pointed out, ‘there isn’t a massive amount for them [children with disabilities] to do’ [nurse, specialist children’s hospital E]. At one children’s hospital, a redesign of the wards had also resulted in a loss of the sensory room, with the other spaces not perceived as suitable for children with LD or spaces they would use:
We’ve got a teen room for teenagers. We’ve got a playroom for kids. We should probably have a Snoezelen somewhere, because we have a lot of children with multiple LD.
The age range of children on the ward created difficulties, not just in relation to accommodating children with and children without LD, but also babies and teenagers and boys and girls, with specific provision varying between sites:
We’ve got lots of things for babies; we’ve got youngish children, nothing for that older child range. Not everybody just wants to go home and play on a DVD or an Xbox [Microsoft Corporation, Redmond, WA, USA]. Whether you’ve got LD or not, there’s nothing in between.
We do have good facilities for teenagers who are in hospital more long term . . . so I think they probably would have better access to facilities that what we would offer our children with LD.
From a sensory perspective, staff recognised that wards could be noisy, with areas near the nurses’ station noted as particularly noisy and busy during the day, and at night noise could come from patients, machines or admissions to the ward. It was recognised that children with LD could be more sensitive to noise than those without LD and that finding access to a quiet space could be difficult. Staff from a number of sites also felt that the wards were often too hot, making the environment uncomfortable for staff and children. Not all sites and/or wards had reliable air conditioning units. Fans might be available, but there might not be enough for everyone wanting one or they might be removed from the ward. By contrast, the wards could be very cold during the winter months.
In terms of equipment, there were variations in what things were available for which patients. A ward manager compared having direct access to most of the equipment needed for the care of children with long-term conditions on the ward with having to source equipment for children with LD through specialist services in the hospital (e.g. occupational therapy and physiotherapy) or from outside the hospital (e.g. in relation to specialist beds). The challenges of accessing such equipment out of hours, ‘which could be a nightmare’, as well as knowing how to use such equipment, were identified as risks that needed to be addressed. Access to sensory equipment was also variable, with some sites feeling that this was largely lacking and others describing having a fibre-optics trolley with music, a LD box containing objects with different textures and noise, a soft-play area in the play room, a disco ball and bubble tubing.
Inequalities
Staff views about perceived inequality in hospital care between children with and children without LD differed. A considerable number of staff members reported that that they did not believe that any inequalities existed, that they had not seen any inequality or discrimination or that nursing staff treated both groups of children equally. Other staff members felt that inequalities did exist, but interestingly that these were in favour of children with LD. There was no acknowledgement that any adjustments in care, such as some form of prioritisation, increased observation or spending more time with the child, were necessary means of achieving equity. On the other hand, some staff felt that children with LD may be less likely to access schooling, playrooms and sensory equipment, and less likely to be communicated with and engaged with by staff, including nurses and play specialists, who may avoid spending time with them. It was also felt that staff may regard children with LD as a lower priority because of their complexity and the time required to care for them, and one staff member perceived it more likely that the parents of children with LD would complain if problems had occurred. As one nurse summed up:
I’m just trying to think whether more parents of children with a LD have talked about problems they’ve had than if they didn’t have a LD I think it would be unfair to say equal. I think there are parents and children that have had complaints when they haven’t had a LD, and those when they have had the LD. Possibly maybe more so when they’ve got a LD.
When asked about inequality, one staff nurse made an interesting observation about the lack of choice that children with LD have about what is going on around them:
I think children with LD are more likely to comply. It’s children without that are more aware of what’s going on, and they don’t want to be sitting still, and sometimes a person’s who’s got LD doesn’t have a choice but to sit still because they can’t move.
There was an overall sense that families who advocate and make requests on behalf of their children are often those who get extra support, whereas those who do not speak up may not, the implication being that some families are getting what they need and others are not.
We have presented a wealth of information about the views of hospital staff with experience of caring for children with and children without LD, including factors seen as preventing and facilitating their receipt of high-quality hospital care (Figures 9–12). The challenges associated with identifying children with LD were highlighted, as was the lack of training in issues related to LD both at an undergraduate level and in clinical practice, which could leave staff lacking the necessary skills and confidence to meet the needs of these children. Particular challenges were described in relation to communicating with those who do not use verbal communication and those who present with behaviours that challenge. Although parents were sometimes seen as a hindrance, on the whole staff valued parents’ input and saw them as integral to maintaining the safety of the child. The environment was a particular challenge for meeting the needs of those with LD, who often required more space and more specialist equipment and resources, which were not always available or accessible. Issues related to the care of teenagers without LD was also seen as area that required significant improvement.
FIGURE 9 Perceived barriers to and facilitators of identifying children with LD in hospital (staff interviews) (RQ1). LDLN, learning disabilities liaison nurse. (Figure not reproduced here; see the original article.)
FIGURE 10 Perceived barriers to and facilitators of meeting the needs of children with LD in hospital (staff interviews) (RQ1). (Figure not reproduced here; see the original article.)
FIGURE 11 Perceived barriers to and facilitators of involving families as partners in their care (staff interviews) (RQ3). (Figure not reproduced here; see the original article.)
FIGURE 12 Perceived barriers to and facilitators of children with LD being safe in hospital (staff interviews) (RQ5). (Figure not reproduced here; see the original article.)