The effectiveness of staff support: evaluating active support training using a conditional probability approach

Development of the Leiden Independence Questionnaire for Support Staff: a measure of staff behaviour regarding promoting independence of people with intellectual disabilities

BACKGROUND

Support staff of adults with intellectual disability (ID) play an important role in promoting independence in home and community settings. However, little is known about the types of behaviours staff should use to promote independence and instruments that assess such behaviour do not yet exist. The aim of this study was therefore to develop and initially validate a reliable questionnaire that measures the degree to which support staff display behaviours that promote independence in people with ID.

METHOD

The Leiden Independence Questionnaire for Support Staff (LIQSS) was constructed to measure the extent to which support staff promote independence in people with ID. The LIQSS was completed by 142 staff members working with people with ID. For the psychometric evaluation of the LIQSS, a principal component analysis was performed with an oblique rotation in all items. Next, the principal component analysis was performed with a forced three-component extraction, and three sub-scales were computed. To assess internal consistency, Cronbach's α was calculated for each of the sub-scales.

RESULTS

The LIQSS was found to consist of three internally consistent (Cronbach's α was respectively 0.92, 0.79 and 0.76) and meaningful components: (1) communication, agreements and coordination; (2) positive encouragement and tailoring; and (3) supporting independent performance. The final 22 items had factor loadings between 0.44 and 0.91 on their corresponding component and a minimal difference in loading to the other factors of 0.20.

CONCLUSIONS

The LIQSS appears to be an instrument with positive face validity and reliability (internal consistency) that assesses the degree to which support staff promote independence in people with ID. To increase the instrument's value for both scientific research and clinical practice, studies should focus on the further validation of the LIQSS.

Effectiveness of Active Support for adults with intellectual disability in residential settings: Systematic review and meta-analysis

BACKGROUND

The review examined the effectiveness of Active Support (RQ1) and stakeholders' experiences of the model (RQ2).

METHOD

Data were meta-analysed (RQ1; studies = 14) and synthesized narratively (RQ2; studies = 10).

RESULTS

By follow-up (6 months post-training), effect sizes (RQ1) for resident total activity engagement were significant and ranged from small (d = 0.33, 95% CIs: 0.10-0.50) to large (Tau-U = 0.95, 95% CIs: 0.64-1.25) depending on study design. Follow-up changes in staff assistance were moderate (d = 0.56, 95% CIs: 0.23-0.89; Tau-U 0.63, 95% CIs: 0.32-0.93) and large for quality of support (d = 1.03, 95% CIs: 0.61-1.44). Other outcomes did not change.

CONCLUSIONS

Active Support was more effective following complete staff training, in larger settings, at lower staff-to-resident ratios and with less experienced staff. Active Support training and outcomes were valued by staff and residents (RQ2), and staff experienced increased job satisfaction. Lower staff turnover and organizational readiness appear crucial for maintaining implementation.

Improving Quality of Life Outcomes in Supported Accommodation for People with Intellectual Disability: What Makes a Difference?

BACKGROUND

The quality of life (QOL) of people with intellectual disability living in supported accommodation services is variable, influenced by many possible factors. Various frameworks have attempted to identify these factors without assigning value, direction of influence or relative impact on outcomes.

METHODS

A realist review of the literature aimed to expose different propositions about variables influencing QOL outcomes and review the strength of supporting evidence for these, to identify their relative influence. Evidence was reviewed for and against each of five clusters.

RESULTS

Evidence was strongest for the presence of staff practices (use of Active Support), front-line management practice (use of practice leadership), culture (enabling and motivating), human resources policies and practice (that support front-line leaders and recruitment of staff with the right values), adequate resources, and small, dispersed and homelike settings.

CONCLUSIONS

The evidence informs policy and practice but in some clusters remains limited, warranting further research which measures outcomes on all QOL domains.

The relationship among attributions, emotions, and interpersonal styles of staff working with clients with intellectual disabilities and challenging behavior

Several studies have tested Weiner's model, which suggests a relationship among causal attributions regarding challenging behavior (CB), emotions, and helping behavior of staff. No studies have focused on interpersonal styles. The goals of this study were to investigate the influence of type of CB on attributions, emotions and interpersonal style of staff, the relationships among staff attributions, emotions, and interpersonal style, and the mediating function of emotions in the relation between attributions and interpersonal style. Participants were 99 staff members. CB aimed at the environment was related to higher levels of negative emotions, attributions and certain interpersonal styles such as controlling behavior. In addition, a relationship between emotions, attributions, and interpersonal style was found. However, there was no mediating function of emotions in the relationships between attributions and interpersonal style. Future research should take a more dynamic view of staff behavior and staff-client interaction into account.

Thinking on your feet: understanding the immediate responses of staff to adults who challenge intellectual disability services

BACKGROUND

A gap prevails between the conceptualization of good practice in challenging behaviour management and its implementation in intellectual disability services. This study aimed to investigate staff members' perspectives of managing clients with challenging behaviours in residential services.

MATERIALS AND METHODS

Semi-structured interviews were conducted with eleven staff in two services. Additionally, service documents on challenging behaviour management were examined in these services. A qualitative methodology was used to investigate staff members' immediate responses to clients' difficult behaviours and their decision-making processes.

RESULTS

The immediate responses of staff were conceptualized as the result of complex appraisals shaped by their service context involving the core processes of making the right choice and prioritizing the best interests of all involved.

CONCLUSIONS

Staff members' responses were understood as a dynamic and retroactive process, where their past and current challenging behaviour management experiences in the service influenced their responses to clients in the future.

Staff behavior toward children and adolescents in a residential facility: a self-report questionnaire

The purpose of the present study was to examine psychometric properties of the Staff Behavior toward Clients questionnaire (SBC), a self-report measure for care staff working with children and adolescents with mild to borderline intellectual disabilities in residential care. Ninetynine care staff completed the SBC and the Strengths and Difficulties Questionnaire (SDQ) for 99 of their clients. Factor analysis revealed four factors (i.e. behavior regulation, client-directed care, teaching and empowerment). Results indicated excellent internal consistency of all factors and ability of the SBC to detect differences in client populations with respect to behavior problems. These data suggest that the SBC could provide a reliable and valid measure of staff behavior toward clients in residential facilities.

The sequential relationship between parent attentional cues and sustained attention to objects in young children with autism

This study examined the sequential relationship between parent attentional cues and sustained attention to objects in young children with autism during a 20 min free-play interaction session. Twenty-five parent-child dyads with a preschool child with autism participated. Results indicated that (a) parent attentional cues that maintained the child's focus of attention were more likely to support child sustained object attention than parent attentional cues that redirected the child from his or her focus of attention or introduced a new focus of attention (d = 4.46), and (b) parent attentional cues that included three or more parent behaviors were more likely to support child sustained object attention than parent attentional cues that included one or two parent behaviors (d = 1.03).

'It's pretty hard with our ones, they can't talk, the more able bodied can participate': staff attitudes about the applicability of disability policies to people with severe and profound intellectual disabilities

BACKGROUND

The level of resident's adaptive behaviour and staff facilitative practices are key sources of variation in outcomes for residents in community-based residential services. The higher the resident support needs the poorer their outcome. Although substantial investment has been made in values-based training for staff, their attitudes and the impact of these on practice is largely unexplored.

METHOD AND FINDINGS

The first study used ethnographic and action research methods to examine the daily lives of 25 residents with severe and profound intellectual disabilities (ID), who lived in five small group homes, and the attitudes of the staff supporting them. Thematic analysis of the data led to a proposition that although staff accept principles of inclusion, choice and participation for people with ID in general, they do not consider it feasible to apply these to the people with severe and profound ID to whom they provide support. The findings from a second study that used a group comparison design and administered a short questionnaire about staff attitudes to 144 direct-care staff and first-line managers working in disability services confirmed this hypothesis.

CONCLUSIONS

The study suggests more focused attention is needed to staff understanding the values embedded in current policies and their application to people with more severe disabilities.

Active support: a critical review and commentary

BACKGROUND

Active Support (AS) is an approach for promoting increased engagement in activities by people with intellectual disability (ID).

METHOD

We critically reviewed the available research on AS, and added a commentary to help guide future research and practice.

RESULTS

Despite weaknesses in the research design of some studies, there is consistent evidence that AS results in increased engagement in activities. There is also some limited evidence of other beneficial outcomes. All published research to date has involved people with ID in community group homes with 24-hour staffing.

CONCLUSION

The established efficacy of AS for increasing engagement means that research attention can now be given to: (a) developing AS to enhance its positive impact on outcomes such as choice and relationships; (b) exploring the wider implementation of AS beyond community group homes and people with ID; and (c) examining the effectiveness of wide-scale implementation of AS, with careful attention to issues such as management, organisational and staffing factors, and cost.

Staff behaviour and resident engagement before and after active support training

BACKGROUND

Identifying the factors associated with greater increases in resident engagement has the potential to enhance the effectiveness of active support (AS).

METHOD

Observational data from Stancliffe, Harman, Toogood, and McVilly's (2007) study of AS were analysed to evaluate amount of staff help, effectiveness of staff help, and staff use of praise.

RESULTS

Lag analyses showed that antecedent staff help was consistently followed by resident engagement at pre-test. This strong association did not increase significantly at post-test. Resident engagement was more likely to follow staff help than the other way around. There was an increase from pre-test to post-test in help and praise by staff. The higher absolute amount of praise was largely the result of the increase in staff help.

CONCLUSIONS

The amount of staff help, its effectiveness, and use of praise by staff may each be important in increasing engagement. These factors should continue to be the focus of research attention and applied efforts to help ensure active support is consistently effective.

Interactive training for active support: perspectives from staff

BACKGROUND

In this study, we describe the experience of participating in interactive training (IT) for active support (AS). Staff (N = 58) working with adults with an intellectual disability (ID) received IT on providing effective assistance for participation in daily activities.

METHOD

Semi-structured interviews were conducted with staff (N = 37) on their experience of IT, the way it affected their work, and their views on the implementation of AS.

RESULTS

High levels of satisfaction with IT were reported. Most staff identified at least one skill learnt during IT that they were still using 8 months later. No clear and consistent picture of AS implementation emerged across the service; staff identified a number of barriers, with lack of managerial support as the most significant.

CONCLUSIONS

Interactive training can directly affect staff behaviour and has the advantage of being positively perceived by staff. However IT alone cannot ensure successful AS implementation, which is affected by a number of other factors, such as managerial support and input, residents' challenging behaviours, and staffing levels.

Interactive training

BACKGROUND

Active support (AS) was developed to help staff organise and deliver practical support for meaningful client engagement in everyday activities. Both the amount and momentary effectiveness of staff support for client engagement have been found to increase following AS training. Training typically consists of a combination of workshops and onsite coaching sessions. To date, onsite training procedures have not been described or evaluated independently of AS workshops.

METHOD

An onsite training procedure used in AS--interactive training (IT)--was evaluated independently of AS workshops through direct observation of staff and client behaviour. Staff views were canvassed via a questionnaire.

RESULTS

Following interactive training, staff assistance and client engagement increased. Staff views on the experience were positive.

CONCLUSIONS

Results from this preliminary study suggest that further research on the effectiveness of interactive training is warranted.

Disability support workers' experience of interaction with a person with profound intellectual disability

BACKGROUND

The primary communication partner for many people with profound intellectual disability (PID) who are living in supported accommodation is their disability support worker (DSW). The experiences of DSWs in interacting with people with PID have received limited attention in the literature.

METHOD

The nature of interactions between people with PID and DSWs was explored from the perspective of three DSWs through an analysis of interview data using a phenomenological approach.

RESULTS

It was evident from the data that communicating in a way that was perceived to be the preferred style of the person with PID was important to the DSWs. This style, however, was often perceived to be in conflict with their employing organisation's policy and preferred practice.

CONCLUSION

The descriptions in this study have implications for the conceptualisation of best practice in interacting with people with PID. Further research on interactions involving behaviours that may be perceived as inconsistent with concepts of age-appropriate interactions and professional boundaries is recommended.

Quality-enhancing interventions for people with profound intellectual and multiple disabilities: a review of the empirical research literature

BACKGROUND

This study provides an overview of empirical research on the effectiveness of quality-enhancing interventions for people with profound intellectual and multiple disabilities (PIMD).

METHOD

Through computerised searches of the PsycINFO and ERIC databases, and using several search criteria specifically relating to the target group and to the subject of this review, 16 studies were identified.

RESULTS

The interventions described are targeted at the physical and material well-being, emotional well-being, social interactions, choices, and personal development of individuals with PIMD, but do not address community participation and rights. The majority of the studies report positive effects of the interventions on staff and/or client behaviour. However these effects should be interpreted with caution because of methodological and other considerations.

CONCLUSIONS

Current research gives only limited insight into the effectiveness of quality-enhancing interventions for people with PIMD. To foster evidence-based practice, further studies of larger groups and with more robust designs are warranted. The potential differential effects associated with client characteristics and the context of the implementation should also be considered.

Staff training and challenging behaviour: who needs it?

Staff working directly with people who have challenging behaviour in learning disability services need to be D good at what they do. These staff are trained by their employers to manage and to treat challenging behaviours and to improve the quality of life of people in their care. While such training is generally well evaluated by care staff, there is limited evidence that training alone changes poor attitudes or improves staff performance. Training has not been linked to quality of outcomes for service users. From research on treating challenging behaviour, achieving maintenance of behavioural gains after treatment has been discontinued is the exception rather than the rule. Can the same be said for maintaining gains achieved through staff training in the area of challenging behaviour? This discussion article reviews the value of training for staff working with people with challenging behaviour.

Exploring the evaluation of antiepileptic drug change in people with intellectual disabilities and high-frequency epileptic seizures: seizure control and sustained responsiveness to the environment

PURPOSE

Optimum antiepilepsy medication should be successful in reducing seizures with minimal adverse effects on the patient's ability to concentrate or general level of awareness. The purpose was to investigate the potential of a method of measuring responsiveness to environmental events as a means of reflecting awareness levels among people with intellectual disabilities undergoing review of medication for high-frequency epileptic seizures.

METHODS

Observations of 22 participants referred to a specialist clinic were conducted three times a month over a 5-month period following the initial baseline measures and clinical intervention. Behavioral responsiveness was measured by calculating the likelihood of appropriate activity occurring given the occurrence of staff interaction. This likelihood was represented by the statistic Yule's Q. Seizure frequency was also evaluated.

RESULTS

Participant responsiveness after drug review was similar to baseline indicating an absence of long-term adverse effects. Participants experienced a significant decrease in seizure frequency.

CONCLUSION

It was concluded that drug review led to seizure reduction while behavioral measurement confirmed no loss of responsiveness.

Responsiveness to staff support: evaluating the impact of individual characteristics on the effectiveness of active support training using a conditional probability approach

BACKGROUND

Active support training was fully conducted in 38 community houses accommodating 106 adults with intellectual disabilities (ID; group 1), but not in a further 36 accommodating 82 adults with ID (group 2). The aims of the present study were to analyse whether staff became more effective in supporting resident activity after the implementation of active support, and whether there was evidence of differential responsiveness by people with differing status in relation to adaptive behaviour, psychiatric diagnosis, challenging behaviour or autism.

METHODS

Observations of staff:resident interaction and resident engagement in activity were taken before and after active support training. Changes in Yule's Q statistics, indicating the likelihood that resident engagement in activity followed staff giving residents verbal instruction or non-verbal assistance, were compared for the two groups. In addition, changes in similar statistics were compared for residents within group 1: (1) with Adaptive Behaviour Scale (ABS) scores above and below 180; and (2) with and without severe challenging behaviour, the triad of social impairments and mental illness.

RESULTS

Yule's Q for engagement given non-verbal assistance significantly increased post-training among group 1, but not among group 2. Similar significant increases were found among group 1 residents with ABS scores below 180 without challenging behaviour, with and without the triad of social impairments, and without mental illness, but not with an ABS score above 180, with challenging behaviour and with mental illness.

CONCLUSION

The present analysis reinforces previous studies on the effectiveness of active support training for adults with more severe ID (i.e. with ABS scores below 180). Active support was as effective for people with the triad of social impairments as for those without it. However, the effectiveness of support offered to people with challenging behaviour or mental illness did not significantly increase.

Engagement in meaningful activity and "active support" of people with intellectual disabilities in residential care

Forty-nine adults with learning disabilities living in 13 small staffed homes in England were studied as part of larger projects in 1997 and again in 2000. A pre-test/post-test comparison group design was used to assess differences in staff implementation of "active support," service user engagement in meaningful activities and adaptive behaviour. Homes which adopted active support showed significantly increased engagement in meaningful activity and adaptive behaviour between 1997 and 2000. A comparison group showed no significant change.

Environmental opportunities and supports for exercising self-determination in community-based residential settings

Information was collected on the environmental opportunities for exercising self-determination among 281 adults with mental retardation receiving community-based residential supports. The results indicated that: (1) the majority of participants had little or no opportunity to exercise self-determination over major life decisions (e.g., with whom and where to live, the recruitment and retention of care staff); (2) even in more mundane areas, such as where and when to eat, the majority of participants were not supported to exercise effective control; (3) variation in environmental opportunities to exercise self-determination was strongly related to a range of factors including participant ability, previous residential history, and structural and procedural aspects of the residential supports currently provided.

Factors associated with expressed satisfaction among people with intellectual disability receiving residential supports

The aim of the present study was to identify factors associated with variations in the levels of expressed satisfaction among adults with intellectual disability (ID) receiving residential supports. Semi-structured interviews were conducted with 96 people with ID. Forty-five subjects lived in village communities and 51 received community-based residential supports. Ratings were made of the participants' expressed levels of satisfaction in seven domains: (1) their home; (2) daytime activities; (3) social and recreational activities; (4) support from services; (5) friendships and relationships; (6) choices available to them; and (7) risks. The data indicated that: (1) interviewees living in village communities expressed greater satisfaction with friendships and relationships than interviewees living in community-based residential supports; (2) in the other six domains of life satisfaction which were investigated, there were no statistically significant differences between groups; (3) interviewees expressed greater satisfaction with their accommodation and day activities than with friendships, risks and support received; and (4) a wide range of variables relating to the personal characteristics of the interviewees and support received were associated with variations in levels of expressed satisfaction. Variation in the levels of expressed satisfaction was reliably associated with variables relating to the personal characteristics of the interviewees and the nature of the support received.

Social networks of people with mental retardation in residential settings

Information was collected on the social networks of 500 adults with mental retardation receiving different types of residential supports. Results indicated that (a) the reported median size of participants' social networks (excluding staff) was 2 people; (b) 83% of participants were reported to have a staff member; 72%, a member of their family; 54%, another person with mental retardation; and 30%, a person who did not fit into any of these categories in their social network; (c) variation in the size and composition of participants' social networks was associated with a range of variables, including the personal characteristics of residents (age, autism, ability, and challenging behavior), the type of previous and current accommodation, staffing ratios, institutional climate, and the implementation of "active support."

Opportunity and the promotion of activity among adults with severe intellectual disability living in community residences: the impact of training staff in active support

Active support, a package of procedures which includes activity planning, support planning and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe intellectual disability following a multiple baseline design. The residents were directly observed to ascertain the level of assistance they received from staff and their engagement in activity. The introduction of active support increased the levels of assistance residents received, their engagement in domestic activities and their total engagement in activity. The intervention did not affect the level of social engagement. Across individuals, increases in assistance and engagement in activity were significantly and positively correlated. Both were significantly inversely related to resident adaptive behaviour. At baseline, staff gave more attention and assistance to people who were behaviourally more able. After the introduction of active support, receipt of attention was unrelated to adaptive behaviour and the behaviourally less able received more assistance. The disparity in activity between the more and less able was reduced. Gains were maintained in the majority of houses.