Exploring the use of service-user narratives to improve care
Intended for healthcare professionals
CPD    

Exploring the use of service-user narratives to improve care

Bob Price Independent health services training consultant, Mytchett, Surrey, England

Why you should read this article:
  • To understand the process of using service-user narratives to improve care

  • To recognise the potential benefits and issues associated with the use of service-user narratives

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

A narrative is a constructed story that people use to explain events and their responses to them. Understanding service-user narratives is important for improving their access to healthcare services and for personalising their care. This article offers an overview of narratives, describing the process of exploring service users’ narratives (exploration), defining the challenges they may be facing (challenge clarification) and supporting them to formulate new narratives to manage these challenges (new narrative formulation). The author uses a case study about a person with a learning disability to illustrate and explain these concepts.

Learning Disability Practice. doi: 10.7748/ldp.2022.e2192

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

altanprice@sky.com

Conflict of interest

None declared

Price B (2022) Exploring the use of service-user narratives to improve care. Learning Disability Practice. doi: 10.7748/ldp.2022.e2192

Published online: 25 August 2022

Aims and intended learning outcomes

The aim of this article is to assist readers to explore the role of service-user narratives in supporting people with learning disabilities to access effective healthcare. After reading this article and completing the time out activities you should be able to:

  • Describe what a narrative is and how it can assist nurses to understand the service user’s perspective of a situation.

  • Explain the importance of understanding and sharing narratives in supporting service users to access and benefit from healthcare services.

  • Understand the process of using service-user narratives to improve care, through exploration, challenge clarification and new narrative formulation.

  • Explore some of the issues that can arise from service-user narratives, drawing on your experience and the case study described in this article.

Introduction

Key points

  • A narrative is a story constructed by people to explain events and their responses to these events

  • Understanding narratives is central to developing rapport with service users and supporting them to access healthcare services

  • Nurses can assist people with learning disabilities to narrate their concerns and needs, and this narrative can be used to support them to develop ways of coping with change

  • The use of service-user narratives involves exploring the person’s initial narrative, describing the challenges involved in upcoming changes, and facilitating new narratives that sustain the person throughout these challenges

A person’s learning disability may affect their ability to describe their experience of physical illness, treatment and care, but there are compelling reasons to persevere in attempting to understand what they are expressing. This understanding is important to obtain a person’s informed consent to treatment or acknowledge their cognitive ability when providing medical information (Chinn and Homeyard 2017), and to understand the person’s experience of illness, treatment and care.

Person-centred care relies on the development of trust between the nurse and service user, and that trust is only established when the nurse gains an insight into how the service user interprets what is happening to them (Price 2022a). Understanding narratives – that is, the way in which people recount their experiences or perception of challenges – is central to developing rapport with service users and supporting them to access healthcare services (Guidelines and Audit Implementation Network 2010, Greenfield et al 2014). If the service user is to partner the nurse in care, and develop their confidence in facing upcoming challenges, the nurse needs to work closely with the person’s narratives to understand their perception of the challenges ahead and support them to develop new narratives that empower them to cope with these challenges.

This article is aimed at all nurses and other health and social care professionals who support people with learning disabilities to access effective healthcare. This article is intended as an introductory discussion of narratives and their analysis. Although people with learning disabilities express their experiences and needs in different ways, the article focuses on those who express these verbally. For wider reading on narratives, see the further resources section at the end of the article.

The article provides a summary of narrative exploration, challenge clarification and new narrative formulation based on the author’s insights gained from a case study described in his previous work on person-centred concepts of care (Price 2022a, 2022b). This case study is about John, an autistic man with a moderate learning disability who had been diagnosed with bowel cancer and requires surgical treatment in the form of a left hemicolectomy (bowel resection). It explains how nurses assisted John – a pseudonym – to prepare for a stay in hospital, to undergo surgery and to manage a temporary colostomy (stoma). The author suggests that the principles described in this article apply to a range of healthcare interventions that may be required by people with learning disabilities.

TIME OUT 1

Think about a service user in your area of practice who had to manage a physical illness or undergo a medical procedure. How did they narrate (explain) the situation to themselves and others?

Service-user narratives

A narrative is a story constructed by people to explain events and their responses to these events. Narrating is a recurring human activity, although it may become increasingly prominent when people encounter adversity (Glintborg and de la Mata 2020). People narrate their lives by drawing on their experiences, beliefs, customs and conventions, and they may or may not make use of the medical and scientific ‘evidence’ that is presented to them, which can be important in the context of treatment recommendations.

A pervading role of narratives in people’s lives is to sustain a sense of agency or coping in the face of significant change (Price 2022a). Emotions, such as those associated with a challenging diagnosis, are sometimes better managed when the person narrates hope and resilience in the face of a new threat (Price 2022a).

Table 1 provides examples of the roles of service-user narratives about illness.

Table 1.

Examples of the roles of service-user narratives about illness

Role of service user-narratives about illness Possible interpretation
To explain the origins of illnessThe person might perceive the origins of the illness as signifying something about them, such as their culpability. For example, they might believe that an infection results from their past negligence
To determine the threat of illnessThe person might determine the level of threat based on their observation of other people who have become ill rather than an objective risk analysis
To justify responses (coping)The person may have few strategies for coping with change, which could hinder their ability to adapt to new circumstances. Their narrative may express what they feel is right or possible for them under the circumstances
To anticipate what might happen nextNarratives do not simply refer to what has happened before, they speculate about what comes next and may reveal optimism or pessimism about what is possible
To support life choices and valuesThe narrative might express the person’s perception of their own fortitude and attitudes to change
To express feelings of loss, despair or hopeNarratives often express raw emotions
To manage changes and/or to secure helpResponding to illness often involves preparing for the changes ahead. The narrative might signal what the person believes being a patient involves

Humans are accustomed to expressing and reviewing their narratives with others. Taken together as an expression of how events have unfolded over time, they might represent life stories (Hamilton and Atkinson 2009) – ‘I have arrived at this situation after all these events’. Nurses are well placed to listen to such narratives and connect these to how the person has responded to and coped with change in the past. Learning disability nurses are adept at identifying narratives that suggest the service user is distressed or that they have been confronted with change beyond their coping ability (Marshall et al 2013). This makes them important interpreters of service users’ concerns and needs when they have to engage with a new healthcare service or intervention.

With the assistance of nurses, people with learning disabilities can narrate their concerns and needs (McParland 2015) and this narrative can be used to support them to develop ways of coping with change. For example, Leaning and Addeley (2016) explained how narratives could inform and be used to reconstruct the experience of people with learning disabilities who transitioned from long-stay hospitals to community-based care. Lewis and Rose (2018) explored how the narrative of a service user with a mild learning disability could be used to support her with her mental health issues, while Wilkinson (2018) examined how discussions about operative care could be modified to accommodate the needs of a patient with a learning disability.

TIME OUT 2

Think about the service user you identified in Time out 1. Did they seem to talk more or less when faced with the situation? If less, how did you support them to explore their concerns and needs? Or did they talk about the situation in a new way, for example discussing it frequently?

Brown et al (2012) emphasised that narratives are used by individuals to explore the meaning of illness for them. Illness might be explored in terms of its origins (‘why I got ill’), whether it represents a threat (‘how serious is it?’) and what that might mean in terms of changes to daily living. As the service user describes what has been happening to them and what this signifies, they start to reveal the narrative of what ‘being unwell’ involves. This narrative is not necessarily an accurate representation of medical facts but conveys the service user’s perceptions and beliefs. This is illustrated in Box 1, which summarises John’s opening narratives about a significant change in his health. Box 2 describes how Alice, a learning disability nurse, understood the importance of John’s opening narratives.

Box 1.

John’s opening narratives about a significant change in his health

John is a 60-year-old autistic man with a moderate learning disability who finds sudden changes challenging to manage. John lives in residential care. He has been diagnosed with bowel cancer and a left hemicolectomy (bowel resection) has been recommended as treatment. John will need the formation of a temporary colostomy (stoma) until his bowel heals. John is supported by Alice, a learning disability nurse, and Kieran, the hospital liaison nurse. Alice and Kieran identify three of John’s opening narratives about his situation:

  • Causation of illness – John believes that he developed cancer through something ‘bad’ that he ate. John perceives cancer as originating from a ‘bug’. He has no overt signs or symptoms of illness, something he explains as a ‘bug still growing’. He also states that his ‘guts’ have been damaged and that is why ‘they want to cut them out’

  • Going into hospital – John narrates the hospital as a threat, viewing it as a place where routine is disrupted and where ‘they’ decide how long ‘they gonna keep you’. It is a place of strangers and ‘strange smells’. John is keenly attuned to different smells and sounds, and this is how he assesses environments as secure or threatening

  • Surgery – John knows that ‘they put you to sleep if you have an operation’ but does not understand why that means ‘you need a bag on your belly’ afterwards. He asks: ‘What do they put in that bag anyway?’ For John, toileting is private and something that happens behind and below him. He finds it challenging to understand how long it takes to recover from surgery

(Adapted from Price 2022b)

Box 2.

Understanding the importance of John’s opening narratives

Alice, a learning disability nurse, realised the importance of the three opening narratives detailed in Box 1 by:

  • Observing the frequency with which John returned to them, particularly the narrative about causation of illness. John asked to eat separately from the other residents, fearing they might ‘catch’ his cancer

  • Recognising the way John drew heavily on what had happened to someone else. John’s friend Dorothy had been in hospital but was there for a long time and John feared that his hospital stay might be protracted

  • Noticing John’s increased agitation when he talked about what the doctor said to him after his diagnosis. John had not grasped concepts such as recovery and the need to rest the bowel. John was not clear about what would be different after his surgery

(Adapted from Price 2022b)

TIME OUT 3

Visit the Patient Voices website (www.patientvoices.org.uk), which catalogues people’s experiences (narratives) of illness and change. Review some of the narratives and note how change is viewed in the context of past experiences (life story). If such narratives are dismissed, and service users are ‘told’ what they should focus on by healthcare staff, what might be the effects of this on a person with a learning disability?

Narrative exploration

Service users narrate their experiences, feelings and understanding in individual ways. These ways can all be termed ‘rehearsal’; that is, ‘this is what has happened, this is what that means and this is what might follow’ (Price 2022a). The extent to which a change or event represents a sudden and sometimes permanent shift in daily living patterns can induce considerable anxiety, particularly in autistic people. For autistic people, continuity of experience and preparation for events are particularly important (Beardon 2021).

The initial aim of listening to service-user narratives is to acknowledge and respect their experiences and feelings (Brown et al 2012, Grob et al 2016). This is an essential aspect of developing rapport, so it is important not to make assumptions about the way in which a person relates their experiences (Price 2022a). However, listening to a service user’s narrative can be conducted strategically by focusing on:

  • How they tell their story. For example, they might convey a sense of chaos or describe their concerns in terms of a ‘quest’ to feel safe again.

  • What they are focusing on. For example, in the case study, John believed he had eaten something ‘bad’ and that his cancer originated from a bug.

  • The way different elements of an experience or change fit together. This focus can assist nurses to assess the person’s understanding of cause and effect or the sequence in which change is understood to work. For example, John found it challenging to understand why the bowel needed to be rested before the stoma could be closed.

  • Indications of distress and agitation and what these seem to be linked to. For example, the person might not report distress verbally, but may express it non-verbally, for example by scowling, turning away or breaking eye contact.

The nurse’s enquiries into the experiences expressed by the service user become part of an evolving dialogue of support. As service users build increasingly robust narratives, they may develop greater confidence in facing later challenges (Damsgaard et al 2021). Therefore, nurses should listen first, resist the urge to make presumptions about the service user’s narrative and avoid altering the narrative to fit with their own perception of what investigations, treatment and care might require.

Three important lessons were learned from the case study of John (Price 2022b):

  • That the service user’s opening narratives might not be captured in one conversation and that there was a need for incremental discussions.

  • That it was important not to ‘interrogate’ the service user. Open questions were important but asking multiple questions at once could feel daunting to John. It was also beneficial to have discussions at times when John seemed ruminative.

  • That it could be beneficial to use ‘what if…?’ suggestions that might clarify John’s concerns and offer a different way for him to think about hospital and what happens there. For example, Alice assured John that she was not asking him questions simply to gather information but was helping him to explore what hospital might be like. Then she suggested: ‘What if Kieran arranged for you to take some photographs of the people who will look after you in hospital. How would that seem?’

TIME OUT 4

When listening to a service user’s narrative about a significant event or change they were facing, did you consider which elements should be celebrated and which should be gently questioned? How did you approach this?

Challenge clarification

Aside from the practical issues, such as obtaining informed consent, there is a need to support service users to experience changes in a way that enables them to access and benefit from healthcare services. Therefore, medical aspects and associated challenges need to be incorporated into service-users’ narratives. In John’s case, he needed to understand what the benefits of the surgery would be for his health and the adjustments he would have to make to accommodate the stoma.

Alice and Kieran believed that John faced the following challenges before his hospital admission (Price 2022b):

  • Having sufficient understanding of the cancer diagnosis and the role of the surgery in protecting his future health. John could not process an abstract understanding of risk, but he had to understand why the surgery would be beneficial to his health.

  • Anticipating what living in hospital would be like, including the unfamiliar sights, sounds, smells and potential discomfort following surgery.

  • Managing a stoma bag and new toileting arrangements.

  • Feeling adequately secure in hospital.

Change in the context of person-centred care needs to be understood from ‘inside the problem’, even if this perspective might not always appear coherent or purposeful to healthcare professionals (Price 2022a). Alice and Kieran’s description of the challenges John faced were based on an understanding of the significant changes that being in hospital and undergoing surgery would have in terms of his daily routine and body function. John had his own room in his residential home but would be on a communal ward in hospital. He also required order and predictability to feel ‘safe’ and would therefore need help to anticipate daily hospital routines and the arrangements on the day of his surgery.

These types of challenges for service users might be described in the following ways (Price 2022a):

  • Shift – the degree of changes required in the person’s daily living.

  • Level of threat – that which is new to the person and needs to be learned.

  • Trust disruption – the person’s psychological security may be mediated by familiar people rather than explained procedures, so changing carers as well as the environment could be disruptive for them.

  • The insight of others into the person’s needs. Hospitals often provide communication passports, which are short documents carried by patients to provide a summary of their needs that can be shared quickly (Northway et al 2017). However, it is useful if hospital staff are already aware of the person’s needs, so it is important that learning disability nurses share their appraisal of the challenges faced by service users in advance of their admission.

TIME OUT 5

Reflect on a time when you have liaised with staff from a different area of practice to improve access to services. What were the main challenges involved in this, and what was achieved?

New narrative formulation

In some cases, analysis of the needs of people with learning disabilities is unsuccessful because there is an assumption that it should simply lead to an alternative way of presenting medical information. The issue with conceiving support in purely informational terms is that it overlooks the active way in which service users narrate what is happening so they can make sense of their environment (Northway et al 2017). Narrative is not replaced by information. Information should be incorporated into new accounts of what reassures, motivates and seems manageable to a service user. New narratives, which counter challenges presented by illness or treatment, need to have a clear, person-centred purpose and should (Price 2022a):

  • Bring the change and the coping ability of the service user closer together.

  • Assure the service user that they have adequate control.

  • Enable the service user to request help or information as needed.

  • Facilitate the development of trust between the service user and the unfamiliar healthcare professionals involved in their care.

New narratives may be facilitated by assisting the person to rehearse the upcoming sequence of events and how the procedures involved might feel, and to begin to relate to the ‘new’ staff who will be involved in their care. The process of rehearsing the narrative, which increases a sense of security for the person involved, is enhanced when they actively engage in preparatory measures.

In John’s case, three new narratives were facilitated by Alice and Kieran (Price 2022b):

  • John was encouraged to think about the new staff he would meet. A pre-admission visit to the hospital was arranged, during which John took photographs of the staff he would meet during his stay. He created a scrap book containing the photographs and reassuring images from home, for example of the garden. He was also reassured that he would retain the support of a familiar and trusted person, a volunteer at his residential home called Grace who would visit him in hospital daily.

  • John was encouraged to rehearse toileting differently. Alice and Kieran helped him to imagine how the stoma would feel and what it would look like, and they enabled him to understand that the stoma bag would be secure and help to contain smells.

  • John was supported to imagine how he could ask for help while in hospital. Alice and Kieran acknowledged that events in hospital would be unpredictable and that John would be in close proximity to other patients. They described the daily ward routine, as well as the different routine on the day of the operation, and explained what John could do if he had any concerns and who he might ask for help.

Facilitating a more comprehensive narrative of the nature of his illness – that is, what cancer means – was reserved until after John’s discharge from hospital. In the interim it was explained to John that his illness could worsen if he did not have surgery and that other parts of his body could become unwell too. Sufficient information was shared with John to enable him to provide informed consent to the surgery.

Facilitating the new narratives was broadly successful (Price 2022b). John felt reassured by the continuity of support from Grace and did not define the new healthcare staff as strangers. The day of the operation, the surgery and the stoma formation went as John had anticipated and he felt that the ‘nurses knew what to do’. However, there were two unanticipated aspects of John’s hospital stay. The first aspect was that John used his scrapbook to forge friendly relationships with hospital staff and some of the patients, telling them about his garden and where he lived. One healthcare assistant in particular was friendly and offered John reassurance about the daily ward routines. The second aspect was the environment at night. John became disoriented and distressed one night when he returned to the wrong bay after visiting the toilet. However, his distress was soon allayed by staff.

Formulating new narratives differs from providing information in that the service user is invited to talk about what is about to happen, what they can do and what they might expect of others (Price 2022a). The emphasis shifts from something that is stored and understood (how the service user usually copes) to something that they are supported to explore through narration. Where before the service user drew on experience and memory, they now rehearse the upcoming events with the support of the nurse. To some extent this was a familiar process for Alice because when service users in her area of practice were going on a trip the nurses rehearsed with them what would be involved and how it might seem. The skills involved in doing this could be applied to upcoming medical events, with the support of hospital and clinic liaison nurses, who could provide additional medical information.

After reviewing case studies in person-centred care, Price (2022a) concluded that effective new narratives are often built on:

  • What most concerns the person or what motivates them.

  • Careful consideration of the workload involved in the new thinking. Too many new narratives at once can be confusing, so these should be formulated incrementally.

  • Optimal use of available resources to facilitate new narratives and new ways of living. Grace offered John reassurance and continuity as he formulated new narratives about how staff he was unfamiliar with would help him.

Box 3 illustrates how nurses supported John to develop a more comprehensive and optimistic narrative about hospital and surgery. This was achieved through an incremental process of narrative exploration, revision and confirmation.

Box 3.

How nurses supported John to develop a more comprehensive and optimistic narrative about hospital and surgery

Exploring the narrative and understanding the threat (pre-hospital admission)

  • Exploring John’s anxieties about his illness and what treatment might entail

  • Discerning what appears stressful for John

  • Supporting John to anticipate what hospital admission and surgery entails, with regards to informed consent and how his daily life will change, for example how his toileting will differ

  • Supporting John to anticipate new relationships with unfamiliar staff, explaining that they will care for him and how they will support him

Encouraging a revised narrative that includes new information (the hospital stay)

  • Assisting other healthcare staff to support John by ensuring they have accurate information, for example using a communication passport (Communication Matters 2022)

  • Supporting John to rehearse his experiences to build narratives that support his coping and sense of safety and respect

  • Explaining new experiences, for example how to manage his stoma

Confirming and reaffirming the narrative that works for John (post-hospital and surgery)

  • Supporting John to review his experiences in terms of successful coping and with regard to possible future cancer treatments, for example reanastomosis of the bowel

  • Identifying John’s future information needs and his preferred ways of coping, optimising the use of his support resources

TIME OUT 6

Reflect on ways in which you have supported a service user to imagine new circumstances. How might you describe this process to a colleague who is unfamiliar with supporting people with learning disabilities?

Conclusion

The use of service-user narratives can support people with learning disabilities to access the healthcare services and interventions that they need. Service-user narratives should be considered as insight to be explored and a way to enhance an individual’s experience of healthcare services. The process involves exploring the person’s initial narrative, describing the challenges involved in upcoming changes, and facilitating new narratives that incorporate additional information and sustain the person throughout these challenges.

The case study detailed in this article illustrates the benefits of using narratives to improve care planning. Central to that process is effective liaison with colleagues in different healthcare disciplines and recognition of each other’s expertise. Improving healthcare provision involves combining all relevant areas of expertise, including the service user’s. Rehearsing what treatment or care might be like could support people with learning disabilities to access services and enhance their quality of life.

TIME OUT 7

Identify how exploring service-user narratives applies to your practice and the requirements of your regulatory body

TIME OUT 8

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account. See: rcni.com/reflective-account

Further resources

Chambers C, Ryder E (2018) Supportive Compassionate Healthcare Practice: Understanding the Role of Resilience, Positivity and Wellbeing. Routledge, Abingdon.

De Fina A, Georgakopoulou A (Eds) (2019) The Handbook of Narrative Analysis. Wiley Blackwell, Oxford.

Johnson J, Van Rensselaer A (Eds) (2010) Siblings: The Autism Spectrum Through Our Eyes. Jessica Kingsley Publishers, London.

References

  1. Beardon L (2021) Autism in Adults. Sheldon Press, London.
  2. Brown JB, Thornton T, Stewart M ( Eds ) (2012) Challenges and Solutions: Narratives in Patient-Centered Care. Radcliffe Publishing, London.
  3. Chinn D, Homeyard C (2017) Easy read and accessible information for people with intellectual disabilities: is it worth it? A meta-narrative literature review. Health Expectations. 20, 6, 1189-1200. doi: 10.1111/hex 12520
  4. Communication Matters (2022) Communication Passports. http://www.communicationmatters.org.uk/what-is-aac/types-of-aac/communication-passports (Last accessed: 22 July 2022.)
  5. Damsgaard JB, Simonÿ C, Missel M et al (2021) Can patients’ narratives in nursing enhance the healing process? Nursing Philosophy. 22, 3, e12356. doi: 10.1111/nup.12356
  6. Glintborg C, de la Mata ML (2020) Identity Construction and Illness Narratives in Persons with Disabilities. Routledge, London.
  7. Greenfield G, Ignatowicz AM, Belsi A et al (2014) Wake up, wake up! It’s my life! Patient narratives on person-centeredness in the integrated care context: a qualitative study. BMC Health Services Research. 14, 10, 619. doi: 10.1186/s12913-014-0619-9
  8. Grob R, Schlesinger M, Parker AM et al (2016) Breaking narrative ground: innovative methods of rigorously eliciting and assessing patient narratives. Health Sciences Research. 51, Suppl 2, 1248-1272. doi: 10.1111/1475-6773.12503
  9. Guidelines and Audit Implementation Network (2010) Guidelines on Caring for People with a Learning Disability in General Hospital Settings. http://www.rqia.org.uk/RQIA/files/81/81662c46-b7bb-43a5-9496-a7f2d919c2a3.pdf (Last accessed: 22 July 2022.)
  10. Hamilton C, Atkinson D (2009) ‘A story to tell’: learning from life-stories of older people with intellectual disabilities in Ireland. British Journal of Learning Disabilities. 37, 4, 316-322. doi: 10.1111/j.1468-3156.2009.00588.x
  11. Leaning B, Addeley H (2016) From long-stay hospitals to community care: reconstructing the narratives of people with learning disabilities. British Journal of Learning Disabilities. 44, 2, 167-171. doi: 10.1111/bld.12139
  12. Lewis V, Rose D (2018) A narrative approach to helping an adult with a mild learning disability to confront “the gremlin”. British Journal of Learning Disabilities. 46, 3, 206-211. doi: 10.1111/bld.12228
  13. Marshall K, Coiffait FM, Willoughby-Booth S (2013) Assessing distress in people with intellectual disabilities. Learning Disability Practice. 16, 3, 26-30. doi: 10.7748/ldp2013.04.16.3.26.e1426
  14. McParland J (2015) Narrative therapy in a learning disability context: a review. Tizard Learning Disability Review. 20, 3, 121-129. doi: 10.1108/TLDR-08-2014-0028
  15. Northway R, Rees S, Davies M et al (2017) Hospital passports, patient safety and person-centred care: a review of documents currently used for people with intellectual disabilities in the UK. Journal of Clinical Nursing. 26, 23-24, 5160-5168. doi: 10.1111/jocn.14065
  16. Price B (2022a) Delivering Person-Centred Care in Nursing. Second edition. SAGE Publications, London.
  17. Price B (2022b) Case study two: helping John cope with surgery. In Delivering Person-Centred Care in Nursing. Second edition. SAGE Publications, London, 72-99.
  18. Wilkinson S (2018) Assessing the perioperative communication needs of a patient with learning disabilities: an holistic case study approach. Journal of Perioperative Practice. 28, 10, 278-282. doi: 10.1177/1750458918793381

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