Tuffrey-Wijne Irene, Goulding Lucy, Giatras Nikoletta, Abraham Elisabeth, Gillard Steve, White Sarah, Edwards Christine, Hollins Sheila
Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK.
BMJ Open. 2014 Apr 16;4(4):e004606. doi: 10.1136/bmjopen-2013-004606.
To identify the factors that promote and compromise the implementation of reasonably adjusted healthcare services for patients with intellectual disabilities in acute National Health Service (NHS) hospitals.
A mixed-methods study involving interviews, questionnaires and participant observation (July 2011-March 2013).
Six acute NHS hospital trusts in England.
Reasonable adjustments for people with intellectual disabilities were identified through the literature. Data were collected on implementation and staff understanding of these adjustments.
Data collected included staff questionnaires (n=990), staff interviews (n=68), interviews with adults with intellectual disabilities (n=33), questionnaires (n=88) and interviews (n=37) with carers of patients with intellectual disabilities, and expert panel discussions (n=42). Hospital strategies that supported implementation of reasonable adjustments did not reliably translate into consistent provision of such adjustments. Good practice often depended on the knowledge, understanding and flexibility of individual staff and teams, leading to the delivery of reasonable adjustments being haphazard throughout the organisation. Major barriers included: lack of effective systems for identifying and flagging patients with intellectual disabilities, lack of staff understanding of the reasonable adjustments that may be needed, lack of clear lines of responsibility and accountability for implementing reasonable adjustments, and lack of allocation of additional funding and resources. Key enablers were the Intellectual Disability Liaison Nurse and the ward manager.
The evidence suggests that ward culture, staff attitudes and staff knowledge are crucial in ensuring that hospital services are accessible to vulnerable patients. The authors suggest that flagging the need for specific reasonable adjustments, rather than the vulnerable condition itself, may address some of the barriers. Further research is recommended that describes and quantifies the most frequently needed reasonable adjustments within the hospital pathways of vulnerable patient groups, and the most effective organisational infrastructure required to guarantee their use, together with resource implications.
确定在国家医疗服务体系（NHS）急性病医院中，促进和阻碍为智障患者提供合理调整的医疗服务实施的因素。
一项混合方法研究，包括访谈、问卷调查和参与观察（2011年7月至2013年3月）。
英格兰的六个NHS急性病医院信托机构。
通过文献确定对智障人士的合理调整。收集关于这些调整的实施情况和工作人员理解程度的数据。
收集的数据包括工作人员问卷（n = 990）、工作人员访谈（n = 68）、对成年智障患者的访谈（n = 33）、问卷（n = 88）以及对智障患者护理人员的访谈（n = 37），还有专家小组讨论（n = 42）。支持合理调整实施的医院策略并未可靠地转化为对此类调整的一致提供。良好做法往往取决于个别工作人员和团队的知识、理解和灵活性，导致整个组织中合理调整的提供参差不齐。主要障碍包括：缺乏识别和标记智障患者的有效系统、工作人员对可能需要的合理调整缺乏理解、实施合理调整缺乏明确的责任和问责界限，以及缺乏额外资金和资源的分配。关键促成因素是智障联络护士和病房经理。
证据表明，病房文化、工作人员态度和知识对于确保弱势患者能够获得医院服务至关重要。作者建议，标记特定合理调整的需求，而非弱势状况本身，可能会消除一些障碍。建议进一步开展研究，描述并量化弱势患者群体医院诊疗路径中最常需要的合理调整，以及保证其使用所需的最有效的组织架构，同时考虑资源影响。
