Reasonable Adjustments in Practice: Beyond the Pink Box
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You are looking through the handover information and notice a coloured box beside a patient’s name. Somebody tells you it means the patient has a learning disability.
It is useful information, but it has not yet told you how to care for the person. It does not tell you how they communicate, whether they find a busy ward frightening, how they show pain, how much time they need to process a question or whether there is anything about the usual hospital routine that makes accessing care more difficult for them. Even the coloured box itself may be a local system rather than something you would recognise on another placement.
That is a useful way to think about reasonable adjustments. The flag, symbol or hospital passport can alert you that there is information you need to find, but the adjustment is what you do with that information.
Start with the barrier, not the diagnosis
Reasonable adjustments are changes made to reduce or remove a disadvantage experienced by a disabled person when accessing a service. In England, Scotland and Wales, the duty to make reasonable adjustments comes from the Equality Act 2010. Northern Ireland has separate disability discrimination legislation, so although the principle of removing barriers remains relevant, the legal framework is not identical across the UK.
In practice, the easiest way to understand an adjustment is to look at what is getting in the way of the person receiving care. A standard appointment may assume that somebody can tolerate a crowded waiting room, understand a written letter, answer questions quickly, recognise unfamiliar staff as safe, cope with unexpected touch and explain clearly when something hurts. For some people, one or more of those assumptions creates the barrier.
The answer is not a standard list of “learning disability adjustments”. One person may need Easy Read information and additional processing time. Another may understand spoken information well but become overwhelmed by noise and need somewhere quieter to wait. Someone may use pictures, signs, objects of reference or a communication device. Another person may need a familiar supporter present while still wanting staff to speak directly to them. A longer appointment, a different appointment time, preparation before a procedure or a different approach to pain assessment may make the difference between technically offering a service and making that service genuinely accessible.
The Nursing and Midwifery Council (NMC) standards reflect this in nursing practice: where someone has communication needs or a disability, nurses need to adapt communication and information so that the person can understand, engage and have equitable access to care.
A flag can point you towards the adjustment, but it cannot replace the conversation
There is no universal UK “pink box”. Hospitals and health boards can use local electronic markers, colours and alerts differently, so never assume that a symbol means the same thing when you move between placements. Find out what the local system records and what you are expected to do when you see it.
England now also has the national Reasonable Adjustment Digital Flag. It is designed to allow publicly funded health and social care services in England to identify, record, share, review and update the reasonable adjustments a person needs. NHS England requires relevant providers to be able to use the national flag by 30 September 2026. This is an England-only system; it should not be described as the way reasonable adjustments are recorded throughout the UK.
A hospital or health and care passport serves a different but related purpose. It can contain practical information about communication, routines, sensory needs, medicines, eating and drinking, pain, distress, what helps and what people supporting the patient know about their usual presentation. Read it when it is available and relevant, but do not treat it as a substitute for the person in front of you. Needs can change, information can become outdated and the patient may be able to tell you what they need themselves.
That last point is easy to lose in a busy clinical environment. A relative or support worker may know somebody extremely well and their knowledge can be invaluable, particularly when you are trying to recognise whether the patient is behaving differently from usual. But begin with the patient. Introduce yourself to them. Direct questions to them in a way they can understand. Give them time to respond. Then use the people and communication resources around them to support that interaction rather than allowing the conversation to happen entirely over their head.
Communication is part of the clinical assessment
Reasonable adjustments are sometimes described as though they are mainly about making a patient's experience more comfortable. They can do that, but they can also affect whether you obtain an accurate assessment at all.
Imagine somebody who does not usually describe pain using a numerical scale. Asking “What is your pain from zero to ten?” repeatedly does not become a better assessment simply because it is the standard question on the ward. You may need to learn how that person normally communicates discomfort, look for changes in behaviour or function, use an appropriate pain assessment approach and listen to somebody who knows their baseline. A person becoming quiet, distressed, withdrawn, agitated or resistant to touch may be communicating something clinically significant.
This is where diagnostic overshadowing becomes particularly important. Diagnostic overshadowing occurs when physical or mental health symptoms are attributed to a person's learning disability or another existing condition without adequate assessment. If a patient who is usually sociable becomes withdrawn, or someone who normally accepts personal care suddenly pushes staff away, “that is just how they are” is not an assessment. Ask what is different. Look for pain, infection, constipation, medication effects, delirium, fear, sensory distress and other possible causes according to the clinical situation.
Reasonable adjustments can therefore improve the information available to you. Reducing noise may make it possible for the patient to engage. Showing equipment before using it may reduce fear enough to complete an examination. Allowing processing time may produce an answer that would have been missed if the question was immediately repeated or redirected to a carer. The adjustment is not separate from good assessment; sometimes it is what makes good assessment possible.
Support decision-making without assuming incapacity
A learning disability does not automatically mean that somebody lacks capacity to make decisions about their healthcare. Needing Easy Read information, communicating without speech or relying on another person for some areas of daily life does not by itself answer the question of capacity.
The legal frameworks differ across the UK, but a common nursing principle is that communication and support should be adapted so the person has the best possible opportunity to understand and participate. Capacity is also decision-specific. Someone may need considerable support with a complex treatment decision while making many other decisions independently.
This is another reason reasonable adjustments and capacity cannot be separated too quickly. If information has only been given in a form the person cannot understand, or they have not been given enough time or their usual communication support, you need to consider whether the barrier to participation is being created by the way healthcare is being delivered.
Families and carers can contribute important knowledge, but being a parent, relative, “next of kin” or support worker does not automatically give somebody legal authority to consent to treatment for an adult. If there are questions about capacity, consent or formal decision-making authority, involve the registered nurse and wider clinical team and follow the law and policy that apply where you are practising.
What this looks like when you are the student nurse
You do not need to arrive on placement knowing every communication tool or every possible adjustment. What you do need is the habit of noticing when the usual way of doing something is not working for the patient.
If somebody becomes distressed every time staff approach with equipment, find out what they understand about what is about to happen. If a patient keeps saying yes to every question, do not automatically assume that means they have understood. If a carer tells you, “He is not himself today,” take that information seriously and work out what has changed. If a hospital passport says that the patient needs one instruction at a time, carry that into your own care rather than expecting the person to adapt to your usual communication style.
Then tell the team what works. A good adjustment loses much of its value if every new member of staff makes the patient start again. Record relevant information according to local policy and include useful communication or care needs in handover. “Patient has a learning disability” tells the next nurse very little. “Uses short spoken sentences, needs extra processing time, becomes distressed by unexpected touch and prefers equipment to be shown before observations” gives them something they can use.
Learning disability liaison nurses and other specialist teams can be extremely helpful where they are available, particularly when care is complex. Their involvement does not remove the responsibility of the rest of the team to provide accessible care. Reasonable adjustments belong in everyday nursing practice.
So when you see a pink box, flag, alert or hospital passport, do not stop at recognising what it represents locally. Use it as the beginning of the assessment. Find out what the barrier is, ask what helps, involve the patient, listen to people who know them well and carry the useful information forward. The goal is not to make everybody fit the usual way the ward works. Sometimes good nursing means changing the way the ward works for the person in front of you.
References and further reading
NHS England. Reasonable adjustments.
NHS England. What is the Reasonable Adjustment Digital Flag?
NHS England Digital. Reasonable Adjustment Flag.
Nursing and Midwifery Council. Standards of proficiency for registered nurses.
Nursing and Midwifery Council. The Code.