Communication Methods for People with Learning Disabilities

IDENTIFYING HOW TO COMMUNICATE WITH PEOPLE WITH LEARNING DISABILITY

                                                     CHAPTER ONE

1.1 AIM

The aim of this research is to find out the best way or methods of communicating with people with learning disability.

1.2  OBJECTIVES

1 Identifying the best way, method and techniques of communicating with people with learning disability.

2 Using primary research, as well as secondary research to identify methods and techniques of communicating with people with learning disability

3 Carry out a survey by talking directly with people with learning disability, and their families and advocates

4 To recommend the best method /techniques of communicating with people with learning disability

1.3 RATIONALE

Study rationale

The fundamental reason for this study is to understand how people with learning disabilities communicate, their experiences, views and perspectives regarding communication with carers and health care professionals. This study importantly focuses on the numerous health policies forwarded in relation to consumer involvement, particularly with respect to people with learning disabilities and the delivery of health services.  This study will allow the researcher to make sense of the interplay between government policies and Frontline staff regarding how social care professionals‘ practices reflect relevant health policies. Communication, in particular the voice of the service user, forms the backbone of any meaningful involvement. If service users are to have any involvement in the management of their own care as stipulated in the government agenda, one way of implementing this is by actively involving service users as stakeholders through communication. This approach will enable service users to adopt a more consumerist approach regarding the services they receive if they so desire.

1.4  TIME FRAME or BUDGET PLAN: The table below shows the description of the timeline or budget plan for the proposed and the indicative project plan for the  year 2017

Chapter two

                                               Literature review

2.1  Introduction

In United kingdom learning disability people are made of a sizable minority within a population (Cooper et al, 2004). It is being estimated that disabled people are made of about 2% of the population (Cooper et al, 2004). It is a known fact that disabilities, people have problems with communication difficulties (Kerr, 2001) However, communication involving learning people has been has been ill studied,  for example, in terms of service user view and perspectives vary regarding communication  little attention has been given to this area.

Communication has been defined in various ways, however, it is generally referred as a process where information, feeling and meaning are shared through verbal and non-verbal message. (Brook and heath 1993 in: berry, 2007) the communication, the message or content of the communication are taken into account, the process through the message is conveyed, the communication channels and the context through which the interaction occurs. (Hargie and Dickson, 2004). However, this definition the one put  forward by Roger and Kincaid as a way whereby participant create and information shared, feeling and experiences with one another so as to reach a mutual understanding (Roger and Kincaid, 1981) The word communication as been widely used in health care communication. (Dimatto, 2004; Fallowfield and Jenkins, 1999 Weider, et al, 2005). Good communication practice with people with a learning disability is generally attributed as central to good health management. (Berry, 2007) It remains unclear, however, how the effectiveness is determined and more importantly, how this could be maximised (Vander Gaag, 1998). It is being argued that the effectiveness of communication is based upon success of communication put forward in achieving a set goal (Hargie and Dickson 2004). Berry, however,  put forward most communication is based upon the appropriate use of both verbal and nonverbal channels (Berr, 2007). However, with interpersonal communication two participant are involve at least  and the effectiveness of  of the communication is a shared responsibility between those involve in the follow ways; an intention share, the desire to reach a common goal and understanding, active listening by those receiving the message, understanding by all parties involve, the influence of background culture that is the commitment to use the right language and willingness to ensure understanding (Higgs et al., 2005)

In this study, communication takes place between service users; carers and healthcare professional. Therefore, inputs and view of those involve may indicate key determinants to the effectiveness and ineffectiveness  of communication. In order to ensure good communication practice, there is the need to take individual views and perspective regarding communication into account. Communication is a central human process that enable individual and collective adaptation to health risk at many different levels  (Kreps, 2003)  However, communication involving learning disabilities has not been fully studied especially the service users view in terms of communication have not been solicited.

Effective communication may essential to the management of learning disabilities, people, this is because it has the therapeutic effect for the service user (Traveline et al, 2005) promoting health functions which psycho-social benefits (Rimmer 1999). Good communication always brings about beneficial effect, bad communication may bring about a lot of negative outcomes for example, failure to involve with the health service (Berry, 2007). It is being said that learning disabilities, people are more susceptible to unidentified side effect (Hannah and Brodie, 1998) and are also more vulnerable to neurotoxic effects which may result due to antiepillectic medication Alvarez et al., 1998). In all non adherence to treatment is reported to be higher with learning disabilities when compared with the general population and this could as a result, of cognitive and communication impairments (Whitten and Griffiths, 2007).

Good positive health outcomes may be as a result of good effective communication for example, there is the growing interest to promote good health for people with learning disabilities with the ail of reducing secondary condition for example, obesity, hypertension and pressure as well as the promotion of independence in order to enhance the quality of life so as to reduce the environmental factors which serve as a barrier to good health. (Rimmer, 1999).  In this regard effective communication which involve service users, carers and healthcare professional is essentially important in this regard.

Carers play essential role in the supporting and management condition of  individuals with learning disabilities and the need for between service users and carer for good effective communication is essentially important. Good, effective communication may not only improve the quality of life, but may help bring about a  reduction in mortality through better understanding of health promotion.

Several studies have been carried out in communication involving people with learning disabilities (Graves, 2007; McConkey et al., 1999; Ziviani et al, 2004). To a some extent, other studies (McConkey et al, 1999; Purcell et al, 2000) have gone as far as adopting quantitative approaches and even employ an observational method by means of video recording and quantifying the frequencies of social care staff use of verbal and non-verbal means of communication with service users. It is however claimed that quantitative studies are not able to take full account of multiple interaction that do happen in social setting (Cronbach, 1975) however qualitative research tends study and understand social interaction and service users and carers perspective regarding communication, providing views and experiences regarding communication with health care professional (Rowan and Huston, 1997) The views and experience of communication of the service user remain unsolicited despite various research finding which show certain people with learning disability if given the required right support and facilities will be able to communicate and express their views when it come health issues (young and Chesson, 2006, 2007). However, there is the paucity of research involving people with learning disability investigation their their views and experience regarding communication, for instance through the use of qualitative interviews. This study is carried out in order to bridge this gap in communication by offering learning disabilities and carer the opportunity that will enable express their views and experiences with regards to communication so as to give a holistic understanding of communication with regards to consumer perspectives.

Effective communication will enable service user to contribute extensively towards the provision of good care for service users. To have a good effective communication there is the need to take into consideration the view and experiences of service user regarding communication. This may bring about effective ways of speeding up communication so as to enhance good quality life.

Communication can said to be a complex multidisciplinary concept and has been defined in various ways (Kraus and Fussell in: Higgins and Kruglandski, 1996). It is made of a complex verbal and non-verbal behaviours liked together with the so aim of sharing information, messages, ideal and feeling (Arnold and Boggs, 2003;Hourcade et al., 2004; Rogers and Kincaid, 1981). It may take different form, there is the interpersonal involving individual communicating with themselves or interpersonal which involves communicating with others. In health care settings, communication is said to be transitional in nature (Berne, 1961)  communication may involves both the intrapersonal and interpersonal relationships (Donnelly and Neville, 2008) it said that with intra-personal communication can seen as an internal activity which involves a possible sources of action or activities,  however it could also involve external expression such as talking and writing (Berry, 2007). It is argued that interpersonal communication is made up of four types of element. These are the core of self, needs and motivation, cognition and monitoring the reaction of others (Burton and Dimbleby, 1995).

The core of the self relates to the value of the individual, the self image personality of individual differences. Self image do not only depend on how one view him or herself, rather they are seen and categorized by others (Berry, 2007). Self image consist of physical attribute such as body image, social and emotional component and intellectual attributes. It is the collection of these attributes that form the individual self-esteem, which is a major contributing factor in interpersonal communication. (Berry, 2007). Communication may also be based on the needs of the  individual’s and motivation. These give the choice to individual to initiate and decide whether he/she will interact with others or not. In the context of this study, some of the factors may relate to medication or relate to the formation of social relationship. Learning disability people  may have certain needs and motivation which drive the self to interpret or generate communication. More also argument is also put forward that cognition is the internal activity in which sense of the world is made (Burton and Dimbleby, 1995). Five cognitive processes are said to be involved in interpersonal communication. These are decoding information, integration, memory, schemata and encoding the information (Burton and Dimbleby, 1995). The last element of interpersonal communication focuses on monitoring others reaction toward our communication to see what kind of effect our communication may on others. However, it is argued that the  differences between one-way and two-way communication also reflect a degree of ‗power‘ (Berry, 2007).it is however claimed that information or directives  involving one way communication may bring about little opportunity for the receiver in providing feedback

This focus of this communication reflects other model of communication as stated as by Shannon and Weaver (1949) with this model information is selected from a source which is then encoded into a message. This message then moves through a channel such speech to a receiver who then decode the message and acts on it (Shannon and Weaver, 1949) moreover one directional pattern of communication has been criticised as too narrow due to the fact it does not allow transitional nature of communication (Berne 1961) while that of interpersonal communication involve two or more participants whereby all involves are able to contribute to the communication process to reach a mutually understanding. (Rogers and Kincaid, 1981).Interpersonal according Hargie and Dickson (2004) defines interpersonal communication as a means through information, meaning and feeling are shared by people through the exchange of verbal and non-verbal messages.. This process of communication involves the following element 1. Two or more communicators, 2. a message (that is  the content of the communication in the message), 3. The medium or the means through which the message is conveyed for example  voice, body language, photos and technologies 4. The communication channels, for example . The link between the communicators 5. a code or a system of meaning shared by a group, 6. Noise e.g environmental factors, 7. Feedback, 8. The context in which the interaction occurs or takes place (Hargie and Dickson, 2004).

The emphasis on communication reflects the latest model of communication  emphasising on  process and a more approach to communication, e.g Hardie’s model of communication (1997) is made up of three basic assumptions whereby people act purposefully, sensitive to the effect of their action and lastly step taken to amend subsequent actions in the light of information. According to this model it state that due to the nature of communication involve all those that participate are senders and receiver of information at the same time. Six elements of interpersonal communication are identified by the model. These six elements are: the person-situated context, goals, mediating process responses, feedback and perceptions (Hargie, 1997 in: Berry, 2007). According to this author it state that what take place when people engaged in communication involves certain attributes individual bring into the relationship. These attributes include their knowledge, values, emotions, motives, attitudes and expectations as well as age and gender. In addition, these models recognise the impact on the interaction and the tasks placed on participant of an individual involve in the interaction as influenced by culture. Another  important element of this model includes the goal individual, try to achieve and the mediating process  such mediating processes involve  a lot of cognitive process like encoding, storage and retrieval of information, inferential processes and response generation (Hargie, 1997)  more also these processes are claimed to be impaired in certain individual with learning disabilities, particularly people with autism which may lead to communication difficulties.

In cognitive psychology, cognition and communication has been widely researched, particularly in relation to the theory of mind. It is asserted that the mind theory involve the ability of individual to attribute certain mental state like  beliefs, desire, intention and knowledge on the ground these mental state are different from other individual’s (Happe 1993) It is claimed that for some people, for example with autism do suffer from certain impairments (Happ,1993) the ability to represent such state will require metal representation these however not to be present in the autistic person’s processing of a social situation. This means people with autistic do have specific difficulties in their use of language for communication (Happ 1993)

Communication in terms of health care setting is essentially significant to the quality of life of the individual (Van der Gaag, 1998) key determinant of patient satisfaction, compliance and recovery  depends on effective communication (chant et al, 2002). Good communication can be of great to patient in their recovery process as opposed to poor communication which can be distressing to social care professional, patient and health (Hemsley et al, 2001). People with learning disabilities are more likely to encounter communication difficulties when compare with the population in general, irrespective of their level of impairment (Kelly, 2002). According Mc Queen et al about 66% of people with learning disabilities may have some difficulties in communication.

( MC Queen et al, in Van der Gaag, 1998) A survey carried out in educational centre  shows that 81% of people with learning disabilities need support in terms of communication. However, it is further claimed that it is more challenging to communicate with adults with learning disabilities when compared with the general population. (McConkey et al, 1999) these difficulties in communication are usually conceptualized to come from the person with learning disabilities. (Mc Conkey et al, 1999). Due to this researcher are always soliciting the view of carers and health care professional on how to improve these shortcomings in communication (McConkey et al 1999)  however, communication is  referred as a process where information, feeling, experience  and meaning are shared (Hargie and Dickson , 2004). It is being assumed that adult style of communication with learning disabilities is less susceptible to change and therefore any communication modification may be likely driven by able person who are better adapted to meeting the need of individual communication (Chatterton, 1999, McConkey et al,1999) Bartlet and burning, cited in Bartlett (1997) stated that there is the need for staff to recognised and provide changes to meet the communication acts of service users. However, another school of thought is of the view that everyone can communicate that even those with severely impaired communication difficulties when given the right support and facilities are able to communicate effectively (Kovarsky et al 1999 in: Hemsley et al 2001). As stated earlier  communication can seen as a way whereby participant create and information shared, feeling and experiences with one another so as to reach a mutual understanding, this process involve active listening by the receiver, good understanding of all the participants involve, using accessible language and the willingness to ensure the message to the language is understood (Higgs et al, 2005). This focus of communication as two way process has not been shown in the research that investigate communication in terms of people with learning disabilities view of the service user as discussed in the following chapter. However, there is the need to carry out more investigation to look into the views and experience of people  with learning disabilities so as to be able to identify or reduce the difficulty in communication. As stated earlier the management and diagnosis of learning disability is linked with communication difficulties (Whitten and Griffiths,2007) often among the general population  the diagnosis of certain illness remains high and such type type of illness can be very difficult among individual with learning disabilities (Whitten and Griffith, 2007). In that case proper diagnosis is said to be partially dependent on the availability of witness accounts, e.g from carers. (Sander, 2003a; Sander and Shorvon, 1996) furthermore, who need medication to for certain type of illness, for example, illness like seizure need effective communication from carers and health professional with regard to adverse effects of the medication

                                          CHAPTER THREE

3.1 THE STUDY METHODLOGY

3.1.1 INTRODUCTION

This section further will showcase the qualitative research methodology chosen and the philosophical groundwork utilized in the study.and method utilized in this study.

As stated above the virtual merit of qualitative and quantitative paradigms have been debated for long (Patton, 1990). The qualitative research method made use of an approach known as naturalistic approach which to understand phenomena in a specific setting whilst the quantitative adopt methods known as the experimental and quantitative measures to test hypothetical generalisation (Hoepfl, 1997) Each paradigm is fundamentally different and leads to knowledge of different kinds. Qualitative are particularly suggested for research that involves people with learning disabilities as earlier discussed. While quantitative research seeks out for prediction and generalisation of the finding, casual determination, whereas qualitative research seek out for illumination, understanding of similar situations (Hoepfl, 1997). Moreover, those proposing qualitative research claim that is not possible for quantitative study to take full detailed account of the multiple interaction taking place in a social setting (Cronbach, 1975). Thus, it is time to get rid of of the null hypothesis because it did not take important effect (Cronbach, 1975). it is argued that our understanding of the world can be represented in a lot of ways (Eisner, 1991). Qualitative inquiry accepts the dynamic nature and complexity of the social world (Hoepfl, 1997). While no claim has been made concerning the superiority of qualitative above quantitative research, moreover  considering the focus of the study and the participants involved as the sources of primary data, indicates similarity with the view of qualitative research. However, others researcher claimed it is not irrelevant to get into paradigms and methodological debate because both has its role with a different purpose (Patton, 1990, 2002). Thus a paradigm of choice looks out for methodological appropriateness as the main reason for quality methodological judging  is advocated (Patton, 2002) different method are appropriate for different as recognises by paradigm of choice (Patton, 1990). This allow for situational responsiveness which involve designing a study appropriate for the exact inquiry situation (Patton, 1990). Moreover, others researcher also claimed that both qualitative and quantitative approaches can be utilised effectively in the same project research and might lead to finding that  none of any type of analysis could alone provide (Patton, 1990; Strauss and Corbin, 1990). Nevertheless, this study will make use of only the qualitative approach as the choice methodology which seek specific phenomena and this will allow the objective study to be realised. In addition, it has been said that the aim of health research is to provide knowledge that can be reasonably confident and provide findings, which are important to makers of policy and practitioners (Murphy et al., 1998). Hence the decision whether is going to be qualitative or quantitative or the two methodologies should  be identified on which approach is likely to objective of research efficiently and effectively (Murphy et al., 1998). The quintessence of this study is to comprehend the experience and view of adult based community with learning disabilities concerning communication with carers and health and social care professional for instance the doctors and nurses. It explores how learning disabilities, people do communicate carers, health and social care professional concerning related issues like medication and quality of life. It also helps to ask for  carers perception and views concerning communication with the service user, health and social care professionals. The focal point of this project itself lend to a qualitative approach characterised by focusing on participants attached to behaviour (Patton, 1990). As participants who based in the community, qualitative research make use of the environment that is (natural setting) as their data sources (Eisner, 1991; Lincoln and Guba, 1985; Patton, 1990). Qualitative research The ideal of social interaction and understanding of  carers perspectives and service user concerning communication can be made possible due to qualitative research study, with qualitative research study insight into what their views and experience are provided and the reason why they do what they do (Rowan and Huston, 1997). Multiple views as expressed by people with learning disabilities and their carers concerning communications, health professional  are taken into account (Lincoln and Guba, 1985).

3.2 PHILOSOPHY UNDERPINING UTILIZED IN THIS STUDY

The explanation above has shown why the paradigm of choice for this study is the qualitative approach. Various forms of qualitative approach exist. The main common ones are Ethnography, Grounded theory, phenomenological and case study methodologies. Nevertheless, in order the aim and objective study of the stated project as outlined in the first chapter, the naturalistic inquiry paradigm as forwarded by Lincoln and Guba (1985) was considered appropriate for this study.

3.3 DATA COLLECTION

As stated above the sources of data for this study were for two may surcease

1 Semi-structured interviews
2 Carer Communication diaries

1 Semi-structured interviews:Interviewing,  according Dexter 1970 in Lincoln,1985 is a conversation with a purpose. The word unstructured is a term that is misleading because it is not possible to imagine an interview, which does not have structure (Murphy et al., 1998). The semi-structured interview, which make use of interview schedule were regarded as the most suitable for interviewing learning disabilities, people as this allowed the interview to focus on certain issues.

CHAPTER FOUR

4.1 DATA ANALYSIS

The qualitative data analysis is quite challenging and task exciting (Ritchie and Lewis, 2003). Though this chapter is entitled as analysis, the qualitative data analysis is said to be concurrent and cyclical with the process of data collection (Tech, 1990). Analysis of data started as soon as the data were first collected and ended with the finding of the study written up (Ritchie and Lewis, 2003; Tech, 1990). The two of the processes were complementary as they drove each other on or informed each other. (Miles and Huberman, 1994). Furthermore, it has been stated the most difficult situation encounter when using qualitative data is that qualitative data method are not well defined and data analysis have very few guidelines for the protection of against biased audience conclusion (Murphy et al., 1998). However, this trend has changed significantly within the last two decades. We now better documentation concerning  the analysis of qualitative method or approaches with increasing publication exploring the practical and theoretical issues of analysis of the qualitative data (Spencer et al., 2003). However, it is stated more clarity have now been known concerning the management of qualitative data’, there remains little rigour concerning how findings are generated from the collection of data. (Ritchie and Lewis, 2003). With the advent of technology, Computer assisted Qualitative Data Analysis software (CAQDAS) has become a popular tool in the management of qualitative data. Nevertheless, these software packages have their strengths and weaknesses. It is stated that one of the most important functions of the CAQDAS is in the processing large data chunks set. The claim that the use of CAQDAS packages in the support of analysis of data enhances the rigour of the analysis have been criticized. Some of the criticisms may appear to be technical and epistemological in origin. For instance, there has been concerns articulated concerning the hazard of loosing data.through the operator error and the individual software choice and its implementation might lead to difficulties. (Murphy et al., 1998).

The naturalistic paradigm holds the view that the knower and the known are interactive and inseparable. The emphasis of the human as the collection of main data tool use CAQDAS more incongruent with the philosophical underpinning this study. Nevertheless, it is the skills of the researcher that are needed to shift, synthesise, order and interpretation of data and it’s also argued that no software can take the place of these human properties (Ritchie and Lewis, 2003). The length of interview in this study are short generally ranging between 15-30mins for user of the service and 45min for carers. This was managed readily by the researcher.

4.2 ANALYTICAL APPROACH UTILIZED IN THIS STUDY

As earlier stated, this is an exploratory study with the aim of producing descriptive findings that include the view of the participants and experiences concerning communication, with limited comparison. The audiences targeted are health care professionals, carers, academics and makers of policy. The analysis is aimed to provide descriptive answers about social policy concerning communication with carers, health care professional and learning disabilities.

Framework analysis is largely concerned suitable for the applied policy analysis research. (Pope and Mays, 2006). However,  in this study, the analysis will make use of the thematic framework as specified by spencer and colleagues (Spencer et al in: Ritchie and Lewis, 2003). This approach is systematic and designed for transparency that enable interpretations and analytical process to be viewed and assessed by people instead of the researcher (Pope and Mays, 2006). It is often said that analytical process is like thematic analysis, however by prior reason they to be  more explicit and more informed. (Pope and Mays, 2006). This method of approach to qualitative analysis concerned with the systematic process of charting, shifting, and material sorting according to key themes and categories. (Bryman and Burgess, 1994). This framework analysis is categorised into two key stages

• Familiarization
• Identifying a thematic framework

These two stages may appear different, but they are all highly  interconnected (Bryman and Burgess, 1994).

4.2.1 FAMILIARIZATION

Material used for qualitative are said to be invariably voluminous, not structured and unwieldy, there is therefore the need for this material to be processed (Bryman and Burgess, 1994). The process whereby audio-interviews are transcribed and field factored into the schedule of the researcher right away after each collection of each set of data.contrary to the suggestion that selective and partial transcription is enough for the study of qualitative (Burgess in: Bryman and Burgess, 1994) all of the whole interviews were verbatim transcribed. This facilitated familiarisation  with the data and unpacking of the multiple realities expressed by participants within the context of their experience in life. This process of data immersion, which require tape listening, transcript reading and note taking of recurrent themes, continued until it was felt that circumstances and diversity have been unpacked. A range of themes from the interview data emerged, which relate to service user communication with a health care professional and carers for instance non~verbal communication, verbal communication or other type of communication, understanding, listening, time, acquiescence, involvement, pace, medication and information, fear/stigma, impairments (physical and cognitive) workload, social event, domestic chores medical appointment.  These were noted down and identified.

4.2.2 IDENTIFYING A THEMATIC FRAMEWORK

The familiarization stage, was characterised not only by gaining an overview of the depth, richness, and variety of diversities in the data, but also through an abstraction process and the synthesis / conceptualisation which also took place (Bryman and Burgess, 1994). Though it is being argued that selective familiarization possible. (Spencer et al, in: Ritchie and Lewis, 2003), individual transcript was examined thoroughly. This requires analytical reading and re-reading each individual interview transcript again and again, highlighting the  vital statement recording and grouping of the recurrent themes, patterns and ideas as they come into view from the data (Gillham, 2000) in that case themes that are related to the view of the participant and perception concerning communication with health and social care professionals and relating to learning disabilities. After the exhaustion of all the transcript with the recurrent themes and patterns noted, the identifying theme list or group themes wire were used in the development of a conceptual framework which comprises various main theme and sub-themes Though the framework construction appeared mechanical, it required logical and intuitive process (Bryman and Burgess, 1994). The emergence of the thematic framework was based on the emergence of an issue and themes being raised by participants, and incorporation issues earlier identified (Bryman and Burgess, 1994). These issues were informed with the project aim and objective and introduced through a schedule of interviews. The following is an extract of a thematic framework showing main themes and sub-themes categories concerning service user communication with healthcare professional and carers .as shown below

4.3 ANALYSIS OF CARER COMMUNICATION DIARIES

Conveniently sampled four care workers completed the communication diaries for this study (two male and two female). They have a choice to decide a communication activity/event from three categories, each such as domestic chores, health management and routine planning. Equal weighting was given to every activity/event in terms of content and context. Entries for different activities such as shopping, laundry work, tidying up, laundry, health management and laundry work were made. The interview data analysis and the themes emergence guided the communication diaries design. For instance, it informed the example of event given in the communication guidance. The diaries were thematically analysed and reflect four processes of indexing, familiarisation, interpretation and charting

First, the familiarisation process with diary’s content as a whole occurred. For thorough understanding of the whole data and context, this process involved reading the diaries a lot of time (Astedt-Kurki and Isola, 2001, Gillham, 2000) Second, entries for the event were read through again, this time highlighting, statement, recurrent themes (Gillham, 2000). The next involves drawing of the chart for each of the participants and summary of the themes emerging from every event under the four categories such as means of communication, communication strategies with service users, barriers in communication and the experience drawn from the activity  for reference purpose (future recommendation) following the third is the mapping and interpretations this involved looking at every participant’s entry, synthesising and interpretation. Comparison of entries from other participants were done to know the differences and similarities. Finally, as a whole the data were interpreted and finding was sorted into main themes categories and sub themes as summarised below

1 Communication Method

Verbal

Verbal communication and writing skills were used” Diary MW

Nonverbal e.g. pictures, gestures

From the shelves, she is a able to point out gift” Diary MW

Tone of voice and body language is a strong indicator regarding………. well being Diary BM

2  Communication strategies and styles

This is one on one sessions

I have to wait till she and I had time in the in the room and we discussed things that needed to be done” Diary MW

I looked from time to be in privacy with her to discuss” Diary MW

Locate a suitable environment

Local cafe visited to avoid uninterrupted planning time” Diary MW

Planning

She knew it was her turn to make use of the washing machine through the rota” Diary MW

Empowerment

Allow to do much for himself as much as he can” Diary GS

Enough time to do the  job at own pace

“….. Prefers left alone to complete task in her own pace” Diary MW

“……. Do not try to rush him” Diary GS

“Keeping calm and doing shopping at service user pace” Diary AJ

“I may begin earlier to allow her more time” Diary MW

3 Facilitating factors of communication

Reinforcements

“Sometimes the conversation moved on to other affairs, but I ensured she is focused by summarizing before we polish off our chat” Diary MW

Provision of choices to communicate

“………… Brochures and catalogue could be used” Diary MW

Accessible Language

“Using simple, clear words and understood the language” Diary AJ

Reassurance

Checking with….. that she was ok to told on with the job and showing appreciation care Diary BM

Reminding her to occupy her time and think through” Diary GS

4 Communication functions and needs

Guidance relating to health management

Observe…… taking her tablets” Diary AJ

Watch…..using her inhaler and taking the tablets” Diary AJ

Self-management

“…… Keeping her weight under control and observe what she eats” Diary GS

“… Knowing what time to take her medication” Diary AJ

“…… She had a positive position towards her health care and willing for me to set up an engagement at the clinic” Diary MW

“…. She had a pretty good idea of what to purchase for relative and just guidance concerning cost, once she confident with choices was empowered and happy with her choices” Diary MW

Communication barriers

Physical impairment

She some find it difficult to communicate ideas. She Had ideas, but unable to verbalised easily” diary MW

I reminded her several times and am aware I  may be nagging which might make her not to complete her job” Diary MW

She is unable to manage her time properly and easily distracted from her chores Diary MW

Anxiety

She was troubled she may go to the clinic without assistance” “but once she knows she will would be supported  by the staff she will be contented to move ahead Diary MW

4.4 CONCLUSION REGARDING FINDINGS FROM DIARIES

Looking at the interview data carers reported that communication method with service user was mostly done through verbal. A nonverbal  method of communication such gestures, photographs and pictures to a very limited extent were reported.  It however remains unclear much of the non-verbal method of communication were unrecognised or unreported by carers. However a lot of strategies and style of communication were given when dealing with the service users. Carers also looked at the factors that have helped to facilitate event or future activities, when engaging with the service users in communication. In addition, barriers in communication identified mainly alike to what was given in the interviews. Furthermore, activities identified by carers mainly not related to health management, but were largely centred on activities. On the other hand, those carers who reported on activities that is related to health issues did it on a superficial level. However, this is an indication  of limitation of carers and involvement in non health management with service users. In all it was evident that the findings through the communication diaries, mainly  illuminates what comes up from the data during the interview process.

4.5 CONLUSION AND RECOMMENDATION

In this study people with learning disabilities as service user have powerful potential insight concerning how they communicate with health care professionals and carers. Though carers and the service user experience of communication concerning learning disability and other issues which are related are multiple and different, engagement in active communication was largely seen by carers and service users as a predictor of strong communication effectiveness. The findings in this study show that learning disabilities, people as service user are certainly able to express their views and communicate on the issues that matter to them whenever they have the opportunity. It is apparent that carers and service user have the awareness of what make an effective communication and how specific strategy are adopted to improve communication. Furthermore carers and service users in this study reported  a lot of experiences and views  as they impact on their communication with professional health care.

4.6 RECOMMENDATION

To make communication more effective the following recommendation can now be adopted

POLICIES

Looking at this study it is an exploratory study, however, it is uncertain whether there will be an immediate impact on health policies in these findings. from the discussion on these study policy outcomes depend on a number of factors and it might be premature to portray any conclusion concerning health policies being based on the result of this single study. In this study the finding suggests there should be a need for a lot of research in health policy in order to investigate how important health policies reflect clinical practice

CLINICAL PRACTICE

As described in this work, this study suggests that people with learning disabilities with effective communication is similar to reflective model. There is therefore the need to make available training to  provide the required social care professionals and health needs concerning carers and communication concerning people with learning disabilities. In addition, this finding also suggests that the improvement in social capital might enhance communication, thereby helping with improved life quality.

EDUCATION

From this study it shows that it is difficult and challenging to communicate with people with learning disabilities. Therefore, it is important to make communication necessary with people with learning disabilities as content for all pre registration social care and health education

ALTERNATIVE COMMUNICATION

This determination reflects the demand for alternative and augmentative communication technique to minimise any potential communication barriers between  service user and carers. Development in technology has led to the development of various forms devices which aid communication. Communication devices  which are user-friendly have been developed for people with learning disabilities  to include  output voice devices (Beukelman, 1998;Hourcade et al., 2004). The role played by photograph and picture to make possible communication easily has been discussed in the literature review extensively. People with learning disabilities might be having communication and cognitive impairments and using photographs and picture might help spontaneous to elicit and recall information. The finding in this study show when adequate opportunity and effective method are given various people with learning disabilities and communication impairments will be able reliable and informative account of their opinion (Kroese et al., 1998). Visual representation like photographs and pictures make possible communication and acquiescence reduction and the effect of recency (this helps in the recalling of recent words) (Kroese et al, 1998

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