Exploring Implementation of Reasonable Adjustments in Hospitals for People With Intellectual Disability: Using a Realist Lens

Aim

To explore the factors influencing the implementation of reasonable adjustments in hospitals for people with intellectual disability: using a realist lens.

Design

A qualitative study using a realist lens.

Methods

Data collection involved one focus group interview and three semi-structured interviews with healthcare professionals working in hospital or community settings in September 2023. Data were analysed using qualitative content analysis and findings were mapped to the Context and Implementation of Complex Interventions (CICI) framework across the dimension's context, implementation and setting.

Results

Healthcare professionals support the provision of reasonable adjustments in acute hospitals as a person-centred approach to caring for people with intellectual disability. While reasonable adjustments are evident in practice, they are mostly individual-level cases with little evidence of strategic system-level implementation. The factors influencing the implementation of reasonable adjustments in practice were conceptualised using the CICI framework. Context factors spanned the domains of epidemiological (e.g., ageing population), socio-cultural (e.g., historical healthcare), political (e.g., lack of integrated care pathways) and ethical (e.g., provision of person-centred care). Implementation factors spanned the domains of strategies (e.g., leadership strategies), agents (e.g., liaison and advocacy roles) and outcomes (e.g., individual-level reasonable adjustments). The setting for the complex intervention was the acute hospital. System-level indicators for successful implementation include intellectual disability specific policies/procedures for integrated care pathways, education and awareness training for hospital staff, and leadership strategies such as the development of liaison nursing roles and the appropriate allocation of physical and human resources.

Conclusion

A radical change is needed where implementation of reasonable adjustments in acute hospitals are broadened beyond isolated individual-level cases to system-level healthcare. This research highlights the importance of exploring the integrated dimensions of context, implementation and setting in complex interventions such as reasonable adjustments and sets foundation for further implementation research in this area.

Impact

Reasonable adjustments at the system-level within acute hospitals would promote person-centred care and help address the inequities and health disparities experienced by people with intellectual disability. This research uses a realist lens to explore the factors influencing the implementation of reasonable adjustments in acute hospitals for people with intellectual disability. The factors influencing the implementation of reasonable adjustments in practice were conceptualised using the CICI framework across the dimensions of context (domains epidemiological, socio-cultural, political and ethical), implementation (domains strategies, agents and outcomes) and setting. System-level indicators for successful implementation include intellectual disability specific policies/procedures for integrated care pathways, education and awareness training for hospital staff, and leadership strategies such as the development of liaison nursing roles and the appropriate allocation of physical and human resources. This research highlights the importance of exploring the integrated dimensions of context, implementation and setting of complex interventions such as reasonable adjustments and sets a foundation for further implementation research in this area.

Reporting Method

This research adhered to the Equator research reporting guideline: standards for reporting qualitative research.

Patient or Public Contribution

A parent of a child with intellectual disability was involved in the conduct of this research, specifically in the design, data collection and preparation of the manuscript.