A cross‐case comparison of the trauma and orthopaedic hospital experiences of adults with intellectual disabilities using interpretative phenomenological analysis

Abstract Aim To present the cross‐case comparison component of a qualitative study exploring and describing the experiences of adults with an intellectual disability who have received trauma and orthopaedic hospital care for musculoskeletal conditions or injuries in the United Kingdom. Design A qualitative, exploratory study was conducted using 1:1 semi‐structured interviews to describe the lived experiences of trauma and orthopaedic hospital care from the perspectives of people with intellectual disabilities and a carer of a person with profound and multiple intellectual disabilities. The data were analysed using interpretative phenomenological analysis. The Standards for Reporting Qualitative Research guidelines were applied. Results There were common and interconnected experiences across the five participants: communication challenges; lack of person‐centred care; issues related to pain management; lack of confidence in hospital care; the valuable support and expertise of carers; and incompetence of hospital staff and isolation and loneliness.


| INTRODUC TI ON
The level of care provided to people with intellectual disabilities (ID) in general hospitals in the United Kingdom (UK) has been an area of concern due to evidence of abuse, neglect and discrimination (Disability Rights Commission, 2006). A more recent publication by National Health Service England (NHSE) (2018), "The Learning Disabilities Mortality Review" (LeDeR Programme), reported and analysed the deaths of people with intellectual disabilities and demonstrated that many died in hospital care and on average up to 20 years younger than people without an intellectual disability.
The World Health Organization (WHO) (2020) defines intellectual disability as "a significantly reduced ability to understand new or complex information and to learn and apply new skills (impaired intelligence). This results in a reduced ability to cope independently (impaired social functioning) and begins before adulthood, with a lasting effect on development." The Global Burden of Disease Study (2016) provided evidence of the impact of musculoskeletal (MSK) conditions and highlighted the significant disability burden associated with these, which were the second highest contributor to disability. MSK conditions affect people across the life span and in all regions of the world; the most common and disabling MSK conditions were osteoarthritis, back and neck pain, fractures associated with bone fragility, injuries and systemic inflammatory conditions such as rheumatoid arthritis (WHO, 2018).
Fractures may occur from a low impact injury if a person has osteoporosis and this places people with intellectual disabilities at an increased risk of injury following a fall (Cox et al., 2010). McCarron et al. (2011) highlight that poor dietary habits, constipation, poor mobility, low levels of exercise, low levels of vitamin D and obesity contribute to the development and high prevalence of osteoporosis in people with intellectual disabilities. A population-based, cross-sectional study, undertaken in Scotland, UK, concluded that the most prevalent physical health conditions affecting people with intellectual disabilities included osteoporosis, bone deformity and musculoskeletal pain (Kinnear et al., 2018). In this study comprising 1,023 participant responses, 48% of people with intellectual disabilities had MSK conditions, highlighting the high prevalence of MSK conditions and the complexity related to multimorbidity for people with intellectual disabilities.

| BACKG ROU N D
Empirical studies investigating the experiences of people with intellectual disabilities in general hospital settings have primarily been qualitative in nature, gauging the perspectives of carers and staff more than eliciting the perspectives of people with intellectual disabilities. There were few empirical studies with participants with intellectual disabilities, yet it is their interpretation of experiences that is of paramount importance. This corpus of literature has identified a great deal of problematic practice in hospital settings. An exhaustive list of the issues identified is outside of the scope of this paper and has been reported elsewhere (reference removed for review). However, the themes identified in these studies and associated reviews include unsafe care, fear and anxiety by people with intellectual disabilities, failure of hospital staff to provide reasonable adjustments, a lack of knowledge, skills and understanding by staff, poor or negative attitudes by hospital staff towards people with intellectual disabilities, staff or system failure to adjust to the needs of people with intellectual disabilities and lack of support and understanding of the carers role with adults with intellectual disabilities in hospitals (Gibbs et al., 2008;Dinsmore, 2011;Smeltzer et al., 2012;Ali et al., 2013;Bradbury-Jones et al., 2013;Iacono et al., 2014;Tuffrey-Wijne, Goulding, Gordon, et al., 2014;Howieson, 2015;Gibbons et al., 2016;. The systematic review conducted by Iacono et al. (2014)

| Design
Interpretative phenomenological analysis (IPA) was an appropriate research approach for this exploratory, qualitative study which aimed to analyse the participants' experiences. Braun and Clarke (2013) assert that qualitative research puts emphasis on meanings rather than cause and effect and argue that this approach captures the complexity, disorderliness and ambiguity of the real world. As adults with intellectual disabilities have previously been excluded from health research along with evidence of inequalities and inequities in health, a transformative paradigm was appropriate (Mertens, 2009

| Method
IPA analyses and interprets (Smith et al., 2009) was adopted as this study sought to understand the meanings that the participants assigned to their T & O hospital experiences. IPA adopts an idiographic approach with the focus on the experience of each individual participant, and as such, sample numbers are typically small (Reid et al., 2005); this enables a deeper and richer analysis of each individual account to address the research aims. Moreover, the idiographic approach lent itself to the development of a rich account for each participant and was consistent with a person-centred care conceptual framework (McCormack & McCance, 2010) which was the theoretical underpinning for the research. Person-centredness underpinned and guided the collecting, analysing, describing and interpreting of the data throughout the study (Ravitch & Riggan, 2017) and was congruent with the theoretical underpinnings of IPA. The voices of people with intellectual disabilities were seldom present in healthcare research, despite their much poorer general health and frequent use of hospital services. Moreover, it has been argued that this exclusion from health research is due to their perceived heightened vulnerability or their inability to consent or communicate in traditional ways (Crook et al., 2015). The transformative paradigm enabled a focus on human rights and social justice within research (Mertens, 2009), which this investigation incorporates. IPA analyses and interprets participants' experiences of a phenomenon on two levels, first at an individual level followed by second-level analysis to identify areas of shared experiences across the participants. IPA seeks patterns in the data, and it is embedded in a phenomenological epistemology which gives experience primacy and is about understanding people's everyday experience of reality, in great detail, so as to gain an understanding of the phenomenon in question. IPA engages with a double hermeneutic cycle which relates to the participant making sense of their experience first and then the researcher making sense of the participant's experience (Smith et al., 2009). This process emphasizes the dynamic role of the researcher in interpreting the participants' experiences (Smith & Eatough, 2007). The cross-case comparisons only are presented here as they provide another level of analysis from across the cases (Smith et al., 2009). The benefit of crosscase comparison following analysis and interpretation of the individual accounts is that it provides an opportunity to add further credibility and confirmability of the findings as there is strength in the collective voice of the participants with an intellectual disability who are frequently unheard. Whilst not seeking to generalize by conducting the cross-case comparison, it provided a means of looking collectively at this group of people with an intellectual disability and presenting the commonalities of their hospital experiences. Others who advocate cross-case comparison analysis include Flowers et al. (1997) who pointed out that not every participant in their study articulated the same themes.

| Recruitment
There were significant barriers to accessing adults with intellectual disabilities which resulted in an extended period of recruitment spanning more than a year. Sydor (2013) discussed the terms, "hard to reach" and "hidden" which apply to the participants in this study.
"Hard to reach" describes a population that is difficult for researchers to access, and "hidden" refers to a population with no defined limits such that the exact size cannot be known (Sydor, 2013, p. 35).
Indeed, Emerson (2011) discusses the health risks amongst the "hidden majority" of people with intellectual disabilities unknown to services highlighting the status of people in this group as often hidden both in healthcare services and heathcare research.
Participants were recruited in various ways including through the managers of local self-advocacy groups for adults with intellectual disabilities; through national organizations that work with adults with intellectual disabilities and their healthcare professional members; and through a "Service User and Carer group" who contribute to research and teaching at a Higher Educational Institute.

| Inclusion and exclusion criteria for participants
Participants were included if they self-identified as having an intellectual disability, were aged 18 or over, had adequate communication abilities to participate and had experience of T & O hospital care which did not need to be within a specified time. Participants were excluded if it was deemed detrimental, for example, if the person was extremely distressed about the hospital experience or if they were unable to give informed consent. In line with the theoretical underpinnings of IPA, participants were selected purposively because this reflected a defined group for whom the research question had relevance and personal significance. It was deemed important to include a carer of an adult with profound and multiple disabilities as she served to represent her son who did not communicate through traditional verbal speech and whom we could not interview.

| Data collection
One-to-one, semi-structured interviews were conducted with five participants, and this was a useful way of gathering the lived experiences of people with intellectual disabilities (Gilbert, 2004). Four participants self-identified as having an intellectual disability, and one participant was the mother and carer for her adult son with profound and multiple intellectual disabilities. Table 1  Each audio recording was listened to several times prior to transcription verbatim by the first author. Table 1 illustrates the length of each interview, the number of pages of transcription and the adaptations made to facilitate and enable meaningful participation in the data collection process.

| Data analysis and trustworthiness
The participants' idiographic accounts and subsequent themes were analysed and interpreted independently by all three authors, and consensus was reached on a case-by-case basis (Smith etal.,2009).

IPA comprises both idiographic analysis of individual accounts
and cross-case comparison of themes across participants (Smith etal.,2009). This paper presents the latter of these analyses. See Table 1 for participant background information.
Each individual participant's superordinate (main) and subordinate (sub) themes were compared across cases resulting in the master themes (Tables 2 and 3). Here, we present the crosscase comparison. Each master theme is described in turn and organized by the frequency with which they occurred across the narratives.
Several processes were used to establish trustworthiness in the study (Shenton, 2004). These included gathering and presenting a thick description of participant circumstances and characteristics, an audit trail being undertaken at each stage of the research process, and triangulation via independent coding and verification of themes by the second and third authors and reflexivity was captured in a research diary.

| E THI C S
Research Ethics Committee approval for the study was granted by the university ethics committee. The principles stated in the UK Policy Framework for Health and Social Care Research (Health Research Authority (HRA) (2018) were adhered to throughout the study in line with good practice for researchers.

| FINDING S
There were five participants: Kay, Ted, Kelly, Len and Sue whose names have been changed to maintain participants' confidentiality.
The themes derived from the cross-case comparisons are interconnected. Quotations are used to illustrate and amplify the voices of the participants. The use of "…" in the participants' quotations relates to a gap in the text. Table 2 shows the themes, and Table 3 shows the cross-case comparisons of master themes.

| Communication challenges
This theme was represented in all five participant accounts.
Participants reported difficulties with communication whilst they were in hospital, particularly between the hospital staff and themselves.
Ted received unclear communication in hospital: but sometimes they said things which were not true or did not make sense. (Ted) Although the hospital staff spoke with Kay, she did not always understand the language that they used: …I found it hard to understand… erm… long words.
(Kay) …erm…listen to what we say… and understand.
The hospital staff tried to communicate with Alex, but these efforts were minimal overall: …they had a go…um….and I explained to them all that… how he smiles for yes and frowns for no …yeah they did have a little bit of a go but pretty ineffective really.

| Lack of person-centred care
All participants experienced a lack of person-centred care.
Furthermore, some of the issues reported by participants raise serious concerns about quality and patient safety, which are fundamental to person-centred care. Overlapping with the preceding master Ted said that the hospital staff did not know him as a person due to a lack of consistency in the medical staff he was seen by and lack of preparation to find out more about him from the medical notes or from the other staff: (Ted) Sue was highly dissatisfied with Alex's care in hospital because the care given was inferior for a person with an intellectual disability: … they could treat the disabled person as a human being… rather than just a nothing.
(Sue, mother and carer) For Sue, there was indignation that the younger nurses particularly did not care holistically for Alex. They did not demonstrate the empathy, sensitivity and care Sue expected in the care of her son: The younger generation don't know anything at all and they're harsh.
(Sue, mother and carer) Kelly recalled a time where she felt like she was treated like a child rather than an adult in hospital: I'm 32…and I'm not a child, I'm an adult. (Kelly)

| Issues related to pain
All the participants except Sue, the mother and carer, discussed issues related to experiencing pain whilst they were in hospital. Kelly was distressed whilst the clips were being removed from her hip wound which is known to be an uncomfortable procedure and a person with an intellectual disability would require additional time and preparation for this procedure: with.
(Sue, mother and carer) Len did not report this lack of confidence in the hospital system.
He was in hospital for a relatively short period of time compared with the other participants who had many hospital experiences and longer lengths of stay than Len.

| The valuable support and expertise of carers
Kay and Kelly discussed the paramount importance and necessity of having their carers involved in their hospital care.
There was a strong relationship between Kay and her mother, (Ted) Sue was the mother and carer for her son, Alex in hospital and she considered her role was fundamental, although she felt undervalued by the hospital staff. Sue stayed with her son in hospital and undertook most of his essential daily care, rarely leaving him. She was not often relieved of these caring tasks to have her basic needs met such as having food or adequate rest. However, Sue did accept the offer to have a sleep on one occasion as she believed that the nurse would replace her and stay with Alex overnight: … I was very grateful when this nurse said I could go and have a lie down and she said she would look after Alex… She said, I'm here to look after Alex…to completely look after him.
(Sue, mother & carer) After this episode, Sue felt very disappointed as the nurse did not attend or care appropriately for Alex as Sue had expected her to and she was very reluctant to leave Alex again after that, even to eat: … no good God no, only for the loo, absolutely hope-less…if you want something to eat, heaven help you.
(Sue, mother & carer) The hospital staff did not support or care for Sue even though she was performing a vital role in caring for Alex full-time in hospital, instead appearing to see it as an alleviation of their own caring responsibilities.

| Isolation and loneliness
Ted and Len both lived alone at home and discussed their feelings of isolation and loneliness both during and following their hospital admissions. They did not have a family/paid carer with them in hospital, and they were the only males in the study. Ted's account left the impression that he had been on his own in hospital and also that staff did not check on him; he was out of sight in a side room for a significant amount of time which raises serious quality of care and safety concerns: …No-one has ever, ever stayed with me…in a room on my own… … 14 hr I didn't see anyone. (Ted) For Len, there was a feeling of being lonely on discharge from hospital which he did not like. Len did not want to go home and be alone as he was unable to get out of his upstairs flat for a period of time after his injury: .…but then going home on your own, it's horrible…it's lonely.
(Len) injuries. There are interconnections between the themes. However, "confidence" and "incompetence" are presented as different themes because the authors understand "incompetence" as not having the right knowledge, skills and attitudes and "confidence" as the feeling or belief that one can have faith in or rely on someone or something.

| Fear of loss/dying
Overall, the experiences reported were very poor which raises ethical, legal and professional concerns about the quality of care.
The findings herein resonate with some of the prior findings about the general hospital care of people with intellectual disabilities, highlighting challenges with communication (Bradbury-Jones et al., 2013); poor relationships with people with intellectual disabilities in hospital Read, Williams, et al., 2018); unsafe hospital care (Gibbs et al., 2008;Tuffrey-Wijne, Goulding, Gordon, et al., 2014);  Cooper et al. (2014) contend that if nurses are unaware of specific assessment tools for use with people with intellectual disabilities then pain may be missed, and distress increased. There are tools to assist staff in assessing pain when people with intellectual disabilities cannot communicate verbally, such as the Disability Distress Assessment Tool (DISDAT) (Regnard et al., 2007). This tool, used in conjunction with carers' knowledge and appropriate training, can be used to minimize unnecessary pain.

| Quality of care
The reported experiences from the participants demonstrate a lack in the quality of care provided alongside serious safety issues in T & O hospital settings. Quality and safety are key components of person-centred care (Santana et al., 2018).
The current political agenda is directed towards inclusion rather than segregation of people with intellectual disabilities in general hospital care, but this appears to be failing to meet the specific needs of this disadvantaged group of people. Given the ratification of the

| Strengths and limitations
Inclusion of adults with intellectual disabilities as participants is a particular strength of this investigation. However, not all people with intellectual disabilities attend self-advocacy groups or will be in receipt of intellectual disability services; therefore, the participants recruited did not include the "hidden majority" of people with intellectual disabilities (Emerson, 2011). Nevertheless, the aims of this study were to illuminate the experiences of the participants rather than to represent all people with intellectual disabilities who are not a homogenous group (Newell & Burnard, 2010). The accounts provide valuable insights, and further research is needed to elaborate on the findings here.
This qualitative investigation relied on people's memories to describe their past experiences with interviews conducted after the hospital stay. Memory is both changeable and constructed (Barusch, 2011;Blakey et al., 2019;Young Rojahn, 2013), and the accuracy of memory of people with intellectual disabilities has often been questioned (Morales et al., 2017). However, Cohen et al. (2010) contend that what people remember is significant to them and it has been acknowledged that assumptions should not be made that the memory of people with intellectual disabilities is poor; Morales et al. (2017) demonstrated that emotional memory of hospital experiences in people with intellectual disabilities are stable over time. Blakey et al. (2019) contend that it is acceptable in qualitative research to value experiences and feelings over any alleged accuracy of memory and this was the stance adopted in the present study.
Moreover, interviewing people with intellectual disabilities after their hospital experience rather than during the hospitalization was considered less distressing for participants. Although the study sample maybe considered small it is consistent with IPA approaches which focus on in-depth experiences of individual and cross-case analysis and interpretation (Smith et al., 2009).

| Relevance to clinical practice
The estimated number of people who have an intellectual disability globally is rising and as high volume users of trauma and orthopaedic services this is a significant issue for healthcare providers; this research is providing new and valuable insights into this area of practice from the perspective of adults with intellectual disabilities and a mother/carer of an adult with profound and multiple intellectual disabilities.
This study reveals that adults with intellectual disabilities did not have their pain managed effectively; they did not understand what was happening to them in T & O hospital settings, and they were neglected at times. Furthermore, people with intellectual disabilities can participate effectively in research studies and make valuable contributions to the evidence base.

| CON CLUS ION
This is the first known study that has investigated It is recommended that there is urgent action by healthcare organizations that are responsible for training and educating hospital staff to provide person-centred care for people with intellectual disabilities. In particular, effective communication to conduct holistic assessments along with valuing people with intellectual disabilities and their carers is of paramount importance. Further research will be needed with people with intellectual disabilities, who are experts by lived experience and well placed to co-deliver and evaluate the impact of this education and training.

ACK N OWLED G EM ENTS
We are extremely grateful to the participants in the study who gave their time and shared their experiences.

CO N FLI C T O F I NTE R E S T
There is no conflict of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available in