Impact of practice leadership management style on staff experience in services for people with intellectual disability and challenging behaviour: A further examination and partial replication

A complex systems perspective on chronic aggression and self-injury: case study of a woman with mild intellectual disability and borderline personality disorder

BACKGROUND

Challenging behaviors like aggression and self-injury are dangerous for clients and staff in residential care. These behaviors are not well understood and therefore often labeled as "complex". Yet it remains vague what this supposed complexity entails at the individual level. This case-study used a three-step mixed-methods analytical strategy, inspired by complex systems theory. First, we construed a holistic summary of relevant factors in her daily life. Second, we described her challenging behavioral trajectory by identifying stable phases. Third, instability and extraordinary events in her environment were evaluated as potential change-inducing mechanisms between different phases.

CASE PRESENTATION

A woman, living at a residential facility, diagnosed with mild intellectual disability and borderline personality disorder, who shows a chronic pattern of aggressive and self-injurious incidents. She used ecological momentary assessments to self-rate challenging behaviors daily for 560 days.

CONCLUSIONS

A qualitative summary of caretaker records revealed many internal and environmental factors relevant to her daily life. Her clinician narrowed these down to 11 staff hypothesized risk- and protective factors, such as reliving trauma, experiencing pain, receiving medical care or compliments. Coercive measures increased the chance of challenging behavior the day after and psychological therapy sessions decreased the chance of self-injury the day after. The majority of contemporaneous and lagged associations between these 11 factors and self-reported challenging behaviors were non-significant, indicating that challenging behaviors are not governed by mono-causal if-then relations, speaking to its complex nature. Despite this complexity there were patterns in the temporal ordering of incidents. Aggression and self-injury occurred on respectively 13% and 50% of the 560 days. On this timeline 11 distinct stable phases were identified that alternated between four unique states: high levels of aggression and self-injury, average aggression and self-injury, low aggression and self-injury, and low aggression with high self-injury. Eight out of ten transitions between phases were triggered by extraordinary events in her environment, or preceded by increased fluctuations in her self-ratings, or a combination of these two. Desirable patterns emerged more often and were less easily malleable, indicating that when she experiences bad times, keeping in mind that better times lie ahead is hopeful and realistic.

The Self-Perpetuating Turnover Cycle: Frontline Supervisors and Direct Support Professionals Reflect on Its Causes and Impacts

Direct support professionals (DSPs) and frontline supervisors (FLSs) have critical roles in home and community-based services for people with intellectual and developmental disabilities (IDD). Recruitment and retention issues have plagued the workforce in long-term supports and services and were exacerbated by the COVID-19 pandemic. Data from the fourth Direct Support Workforce COVID-19 Survey provided national DSP and FLS perspectives on factors contributing to turnover and retention challenges and their effects on the workforce and people supported. Participants identified obstacles with recruitment and retention, workplace outcomes related to turnover, and negative impacts on the supports and services people with IDD rely on to live and work in their communities. Policy and practice recommendations to address the workforce crisis are provided.

A multiple case study investigating changes in organizations serving residents with intellectual disabilities and challenging behaviours

BACKGROUND

the present authors examined changes made in disability service organizations supporting residents with intellectual disabilities and challenging behaviours, because these changes may influence residents' support and subsequently their challenging behaviours.

METHOD

In this multiple case study, the present authors collected and qualitatively analysed data (organizational documents, meetings records and focus group reports) on organizational changes made in two specialized Dutch disability service organizations, using ecological theory as a sensitizing framework and the constant comparative method.

RESULTS

Themes describing organizational changes in this context were as follows: a messy start to the transition; staff, professionals and managers remain at a distance; staff members' ability to change; clear boundaries between formal and informal caregivers; and staff's feelings of being unheard.

CONCLUSIONS

Organizational changes can enhance, but also limit, the quality of residential support services provided to people with intellectual disabilities and challenging behaviours. The change process and impact of organizational changes on residents must be examined closely.

Cross-sectional investigation of relationships between the organisational environment and challenging behaviours in support services for residents with intellectual disabilities

Background

This study was conducted to assess relationships between the organisational environment and three types of challenging behaviour (self-injurious, aggressive/destructive and stereotypical) in support services for residents with intellectual disabilities using ecological theory.

Method

A cross-sectional questionnaire-based design was used to identify relationships between ecological system aspects at multiple levels (micro-, meso-, exo-, macro- and chronosystems) and challenging behaviours of residents. A questionnaire was distributed to care professionals and managers working in specialised Dutch service organisations for residents with intellectual disabilities and challenging behaviour. The data were examined by Pearson correlation and multivariate regression analyses.

Results

The questionnaire was completed by 922 respondents from 21 organisations. Responses revealed that organisational aspects at the micro-, meso-, exo- and macrosystem levels play roles in residents' challenging behaviour. These aspects range from staff members' ability to sensitively interact with residents to grouping of residents with challenging behaviour, and staff turnover.

Conclusions

In the prevention and management of challenging behaviour of residents with intellectual disabilities, the consideration of ecological aspects at all system levels in the organisational environment is required.

Senior manager decision-making and interactions with frontline staff in intellectual disability organisations: A Delphi study

Very little is known of the activities of the most senior managers in organisations providing social care in the community to people with intellectual disabilities. Yet the importance of the focus and activities of senior managers in directing and supporting staff practice and staff experiences is likely to be central to an organisation's functioning and support provided for staff and service users. This study employed Delphi methodology with a panel of 11 senior managers, mostly chief executives, managing small to very large organisations providing support for people with intellectual disabilities, in the UK. Answering three rounds of questions, senior managers described their face-to-face and non-face-to-face contacts with staff and decision-making. Narrative data were subject to quantitative and thematic analysis. In the last round, themes were subject to quantitative analysis. Most contacts between senior managers and staff were in formal structured contexts and all managers used social media to promote the organisations' ambitions regarding good practice. The panel focused upon accessing and understanding the informal aspects of their organisations and staff factors. Decisions were both short-term reactive and long-term strategic and an effort to link these was felt to improve organisational functioning. A framework for understanding senior managers' activities emerged showing two sources of demands and opportunity, extra-organisational focused upon meeting legal and regulatory demands and intra-organisational focused upon understanding and influencing informal staff practices/experiences and cultures within their organisations.

Managers' views of skilled support

BACKGROUND

Quality of life of people with intellectual and developmental disabilities has been found to primarily depend on whether staff are providing facilitative and enabling support that helps to compensate for severity of disability. Managers have a key role in facilitating staff to provide such support.

METHOD

Qualitative interviews were conducted with 35 managers of supported accommodation services to explore service aims and the nature of, and challenges in providing, skilled support. Key themes were identified using a Thematic Networks Analysis.

RESULTS

Service aims were rarely formalised, were related to the individuals supported and not to the organisation. Managers found it difficult to define skilled support, other than by reference to individuals. Practice leadership roles were challenged as a result of austerity measures.

CONCLUSIONS

Front-line managers need more information and training in skilled support, with stronger leadership from senior management to provide the motivation and resources needed.

Effectiveness of Caregiver Training in Mindfulness-Based Positive Behavior Support (MBPBS) vs. Training-as-Usual (TAU): A Randomized Controlled Trial

Caregivers of individuals with intellectual and developmental disabilities (IDD) often end up having their medical and psychological well-being compromised due to the stressful nature of caregiving, especially when those in their care engage in aggressive behavior. In this study, we provided caregivers with mindfulness-based training to enable them to better manage their psychological well-being and, through this, to also enhance specific indices of quality of life of the individuals in their care. Thus, the aim of the present study was to evaluate in a randomized controlled trial (RCT) the comparative effectiveness of Mindfulness-Based Positive Behavior Support (MBPBS) and Training-as-Usual (TAU) for caregivers in a congregate care facility for individuals with severe and profound IDD. The comparative effects of the two training conditions were assessed in terms of caregiver variables care recipient variable (number of aggressive events), and agency variables Results showed that MBPBS was significantly more effective than TAU in enabling the caregivers to manage their perceived psychological stress, and to reduce the use of physical restraints and stat medications for aggressive behavior of the individuals in their care. In addition, there were significant reductions in aggressive events by the individuals in their care, 1:1 staffing of individuals with aggressive behavior, and staff turnover. Furthermore, the MBPBS training was significantly more cost-effective than the TAU training. If replicated in future RCT studies, MBPBS may provide an effective means of enhancing socially acceptable bidirectional engagement of caregivers and care recipients within a person-centered context.

Caregiver Training in Mindfulness-Based Positive Behavior Supports (MBPBS): Effects on Caregivers and Adults with Intellectual and Developmental Disabilities

Caregivers often manage the aggressive behavior of individuals with intellectual and developmental disabilities that reside in community group homes. Sometimes this results in adverse outcomes for both the caregivers and the care recipients. We provided a 7-day intensive Mindfulness-Based Positive Behavior Support (MBPBS) training to caregivers from community group homes and assessed the outcomes in terms of caregiver variables, individuals' behaviors, and an administrative outcome. When compared to pre-MBPBS training, the MBPBS training resulted in the caregivers using significantly less physical restraints, and staff stress and staff turnover were considerably reduced. The frequency of injury to caregivers and peers caused by the individuals was significantly reduced. A benefit-cost analysis showed substantial financial savings due to staff participation in the MBPBS program. This study provides further proof-of-concept for the effectiveness of MBPBS training for caregivers, and strengthens the call for training staff in mindfulness meditation.