OUTCOME DATA ON 15 TRAINING COURSES
Andrew
A McDonnell
Submitted for Publication to Mental Retardation.
ABSTRACT
Aggressive behaviors tend to be long term in nature. Despite this fact, comparatively little research has been conducted into the short term management of these behaviors. This paper presents describes a three day training course in the management of challenging behaviors. 15 separate training events totalling 275 care staff are presented. It was found that staff self reports of confidence increased significantly post training in 9 of the events. Increases were also reported in knowledge scores for 10 of the training courses. 1 training event reported decreases in both measures. A six month telephone follow up of the 15 services indicated that the majority of staff appeared to find the training course useful. The implications of these findings for the efficacy of care staff training in the management of challenging behaviors are discussed.
Aggressive
behaviours can evoke extreme responses in staff (Oliver, 1993; Singh,
Lloyd & Kendall, 1990). Many of these behaviors appear to be long
term in nature (Reiss & Havercamp, 1997). Published research has
tended to focus on longer term intervention strategies (Allen, 1998).
Short term behavior management strategies have received comparatively
little academic attention (McDonnell & Sturmey, 1993).
Behavior management
has been distinguished from behavior treatment in the management of
aggression (Gardner & Moffatt, 1990, Carr, Robinson & Palumbo,
1990). Behavior treatment strategies aim to produce ‘ Enduring
behavior change that will persist across time and situations’ (p93).
Whereas behavior management aims to reduce aggressive behaviors in the
short term (Gardner & Cole, 1987).
Behavioral research on aggression has tended to focus primarily
on behavior change approaches (Allen, 1998)). The outcome literature
has produced some empirical evidence for such strategies with a number
of methodological limitations (Scotti, Evans, Meyer & Walker, 1991;
Whitaker, 1993; Scotti, Ujcich, Weigle, Holland, & Kirk, 1996)
Short term behavior management strategies has received relatively
little empirical evaluation in the literature (Allen, 1998, McDonnell
& Sturmey, 1993).
The
influence of staff behavior on the maintainence of challenging behaviors
has become an important emergent issue in the last decade (Hastings
& Remington, 1994). Staff contingent attention can have direct effects on the frequencies
of challenging behaviors (Taylor & Carr, 1992). Intagliata, Rinck
& Calkins (1985) surveyed 190 group homes and hospitals and found
that 67% of group homes and 85% of hospitals
reported having experience of violent and destructive behaviors.
Staff injuries can also occur after the implementation of practices
such as physical restraint.(Spreat, Lipinski, Hill & Halpin, 1986).
Given, that staff can encounter quite extreme behaviors; it is not surprising
that many staff may be operating an avoidance model (Taylor & Carr,
1992).
Researchers
have acknowledged the importance of training staff who work with people
with mental retardation (Cullen, 1992). Staff training in behavioral
skills has been a well documented area of research (Bernstein, 1982;
Cullen, 1992). Training is viewed as necessary but not sufficient in
itself to produce behavioral change (Cullen, 1992). Training in the
management of aggression has been acknowledged as important (Emerson,
McGill & Mansell, 1993). Surprisingly Little data exists on the
efficacy of staff training in behavior management practices (McDonnell
& Sturmey, 1993).
Research has been
conducted in psychiatric settings which indicates that staff training
in behaviour management strategies can reduce rates of assaultive behaviour
and lower levels of injury to staff and people with mental retardation
(Infantino & Musingo, 1985; Mortimer, 1995). Comparatively, little
research has been conducted in the mental retardation field.
In an innovative study, Allen, MacDonald, Dunn & Doyle (1997)
described the outcome of a series of staff training courses in behavior
management techniques. They reported reductions both in staff injuries
and the usage of restraint. A two day crisis intervention workshop (Baker
& Bissmire, 1998) reported a slight reduction in reported incidents
at two month follow up. It is concerning that the authors reported increases
in physical responses to challenging behaviors at follow up. McDonnell
(1997) reported on the outcome of a three day behavior management training
course, which focused on nonaversive
behavior management strategies known as ‘low arousal approaches’
( McDonnell, 1998) and the physical management of behaviors. A physical
restraint procedure involving an ordinary armchair was taught to all
participants (McDonnell, Sturmey & Dearden, 1993; McDonnell &
Sturmey, 1998). It was found that both staff knowledge and confidence
scores increased immediately after training. McDonnell (1997) argued
that confidence was a critical moderator variable in the management
of aggressive behaviors. Care should be taken when interpreting these
results as it was based on a relatively small sample of subjects.
The
paucity of data on staff training behavior management is a concerning
trend. More research data would appear to be required and less reliance
anecdotal information. This paper presents outcome data on 15 training
courses based on the McDonnell (1997) study. It attempts to replicate
the original findings across a variety of residential settings.
METHOD
Participants
and Settings
275 care staff
participated in 15 separate training events. The mean age = 34.4
years SD = 10.6 years. There were 182 female staff and 93 males.
The staff were selected from a wide range of community residential establishments
for people with a mental retardation in the United Kingdom. 10 of these
services catered less than 10 residents. 5 involved services with greater
than 10 residents. All of the services had individuals who presented
with aggressive behaviors. In all 15 establishments training had been
requested as a response to a crises with particular individuals within
their services.
Dependent Measures
Two measures were
developed to evaluate the training course. The first was a 15 item challenging
behavior confidence scale. The second measure was a 20 item multiple
choice knowledge test.
The Challenging
Behavior Confidence Scale
The confidence scale contained 15 items relating to
managing challenging behaviors in caring environments. The questionnaire
was divided into three categories, items 1 to 5 contained behavioral
statements about “potentially violent” people, items 6 to
10 contained behavioral statements that would be carried out during
a violent incident and items 11 to 15 contained statements about physical
interventions. The scale was subjected to a Principle Components Analysis
(PCA). The PCA method was
used to extract all factors having an eigenvalue greater than 0. A three
factor solution, accounting for 70.8% of the total variance. These factors
were then rotated using the varimax rotation procedure. Factor 1,
with an eigenvalue of 6.53, loaded highest on items that are concerned
with physical interventions during a violent incident. Factor 2, with
an eigenvalue of 1.57, loaded most highly with those items that contain
behavioral statements that would be carried out during a violent incident.
Factor 3, with an eigenvalue
of 1.55, loaded most highly with those items that contain behavioral
statements about "potentially violent" people (McDonnell,
Jones & Jones, 1998). The "Confidence" questionnaire produced
a Cronbachs alpha reliability coefficient of 0.92
for the entire scale, indicating a high degree of internal reliability
between the 15 items comprising the scale.
The Challenging
Behavior Knowledge Test
20 items were selected
which sampled areas of the training course. These included: legal issues
(2 questions), behavioral knowledge (6 questions), strategies for defusing
incidents (4 questions), and descriptions of responses to the physical
management of challenging behaviors (8 questions). All responses took
a multiple choice format.
Course content
On Day One, the
group were provided with an understanding of the law as it relates to
violence and aggression in the caring profession. This entailed group
exercises in understanding qualitative differences in violence and aggression;
causes of challenging behavior; discussions of participants’ experiences
of challenging behavior, with two facilitators; strategies for defusing
incidents that avoided confrontation so called ‘low arousal approaches’
(McDonnell,1998; McDonnell, Reeves, Johnson & Lane, 1998).
Day Two introduced physical methods of managing challenging behavior.
The physical skills were selected on the basis that they represented
frequent physical encounters with people with mental retardation. (McDonnell,
Johnson & Allen, 1998). These behaviors included hair pulling, biting,
scratching, being grabbed by the wrists, and giving physical assistance
to colleagues. Techniques did not involve the abnormal manipulation
of wrist joints and rated high on the indices of social acceptability.
These strategies were integrated with the interpersonal skills taught
on Day One. Role plays were conducted to help participants facilitate
these skills and involved a facilitator replicating a situation that
would require physical defusion methods. Feedback was then given to
staff.
On Day Three a non violent physical restraint method was taught
to care staff (McDonnell et al, 1993, McDonnell & Sturmey,
1998). A final role play test was administered to all participants in
which a facilitator would describe a situation where they, as a client,
would have to be physically restrained and then act out the behavior.
Role play test
Each course participant
was asked to demonstrate the physical restraint procedure taught on
the last day off the training course. A course facilitator would attempt
to mimic aggressive behaviors which would require the course participant
to ask a colleague for assistance to restrain the facilitator. Attempts
were made to make the role plays as realistic as possible. Each role
play lasted approximately 5 minutes. All role plays were video taped.
The physical restraint
procedure was task analysed into 9 key steps (McDonnell, 1997). Two
observers were asked to independently rate 45 of the role play videos.
The two scores of the observers were compared by dividing the number
of agreements by the number of agreements + the number of disagreements
and multiplying by 100. This produced an inter rater reliability coefficient
of 96%.
Integrity of
the independent variable
To ensure that
there was consistency between training events, the training courses
were task analysed into 21 key units. The trainers had to indicate that
each component had been completed on a course checklist. There was 100%
agreement between the 14 course checklists. Two training courses were
monitored at random throughout the three days by an independent observer
to check that each course module accurately reflected the information
presented on the checklists. There was also 100% agreement between the
course trainer and the independent assessor.
6 month follow
up survey
Six months after
the initial training managers in the 15 services were contacted and
asked a series of consumer satisfaction questions. The four days selected
to make telephone contact were chosen at random. The interviewer described
the purpose of the interview and requested that 2 senior managers who
attended the workshop to provide responses to 5 short questions. 27
(12 services produced 2 senior managers and in 3 services only 1 manager
responded) senior staff were asked the following questions 1) How useful
have you found the training course in the management of challenging
behaviors ? 2) What areas
of the training course were the most helpful ? 3) What areas were the
least helpful ? 4) To your knowledge have you had to use any of the
physical procedures taught on the training course ? 5) How effective
are these procedures 6)
What changes (if any) do you think that the training has made to your
work practice ? 7) Do you feel that the training has made your staff
more or less confident in managing challenging behaviors or has their
been no change at all ?
PROCEDURE
All of the course
participants were given the following instructions. ‘You are about
to experience a three day training course in the management of challenging
behaviors. This training is researched based, which means that we will
be asking to complete two questionnaires at the beginning and end of
the course. The first questionnaire is a 15 item measure which will
ask you to answer a number of questions about managing challenging behaviors.
Try to answer these honestly. It is important to rate your responses
in terms of how you would respond ‘right now’ to these situations.
The second questionnaire
contains multiple choice questions about challenging behavior. We would
appreciate it if you could attempt all 20 questions. We will administer
similar questionnaires at the end of the training event.
All of the results will be treated as strictly confidential.
RESULTS
Knowledge measures
were subjected to a two way ANOVA. There was a significant difference
in the pre and post knowledge training course F(1, 253)= 94.8,
p<0.01. There was also a significant effect in terms of between
course scores F(14, 253)= 8.77, p<0.01. An analysis
of the data using Scheffes multiple comparison procedure indicated that
9 courses demonstrated statistically significant increases in mean scores
at the 1% level (p<.01) and 1 course at the 5% level (p<.05).
Whilst one course showed a decrease (p<.01). There was no
effect of sex on pre and post training scores F(1,253) =.01 (ns)
or between the courses F(14, 253) = 0.94, (ns).
The confidence
scores were also analysed using a 2 way ANOVA. There was a significant
main effect in changes of scores pre and post training F(1,253)
= 45.97, p<0.01. There was a significant effect of confidence
scores compared between the courses F(14,253) = 2.63, p<0.01.
There was no effect of sex on pre and post scores F(1,253) =.01
(ns). There was no effect of sex on between course comparisons
F(14,253) = 1.42 (ns). Scheffes multiple comparison test
produced significant increases at the 1% level for 6 training courses
(p<.01) 3 courses produced significant changes at the 5% level
(p<.05). One course had a significant reduction in confidence
(p<.05).
INSERT FIGURE 1 HERE
The role play score
were calculated for all 275 course participants. A score of 8 out of
9 steps was required to achieve a pass criterion. All participants achieved
a pass. (181 participants achieved an 8/9 pass and 94 achieved a 9/9
perfect pass score). No course participants reported injuries to the
facilitators at the end of each training course.
27 senior managers
agreed to be interviewed. (2 each from 12 training courses and 3 from
the remaining services). 23 interviewees reported the training to be
useful, 2 respondents were undecided and 2 respondents reported the
training to have been not
useful. The second question asked participants to rate what areas of
the training they found most useful ? 14 respondents reported the strategies
suggested for defusing incidents (low arousal approaches) as the most
useful. 10 respondents reported physical restraint as the most useful
component. 2 participants reported the role play practice as useful,
2 people did not respond to this question. To the question what did
they find least useful about the training. 15 respondents could not
specify a response. 7 managers indicated the role play components as
least useful. 4 people reported ‘legal issues’ as the least
useful. 1 respondent stated that ‘it was all pretty useless’.
23 managers reported
that some of the physical skills taught on the training course had been
used in their residential services to their knowledge. 18 of these respondents
reported the methods as effective, 3 were unsure and 2 respondents reported
that the methods were ineffective. To the question what changes were
required to the training courses ? 21 respondents reported that no changes
were necessary. 4 requested that the training course should be longer
in duration. 1 person felt that the restraint procedure required changing
and 1 respondent stated that the entire course needed changing as it
was ‘too soft on people with mental retardation’. Finally,
22 respondents reported that in their opinion their staff were
more confident in managing behaviors after the training course. 5 respondents
reported no change in the confidence of their staff teams post training.
DISCUSSION
This
paper has demonstrated statistically significant increases in knowledge
and confidence scores for the vast majority of training events. These
results further replicate the findings of an earlier published study
(McDonnell, 1997) However, not all training courses did increase and
one group had significant decreases in both knowledge and confidence
scores. Anecdotal information indicates that the participants clearly
indicated that the training was ‘too soft’ and would not work
on the people in their service.
It is important to note that not all training will have desirable
outcomes (Cullen, 1992).
Increases in confidence
are important especially as aggressive behaviors can invoke powerful
responses in carers (Oliver, 1993; Singh, & Repp, 1990). It would
appear to be a reasonable working hypothesis that carers who report
that they are more confident in dealing with challenging situations,
may in some instances manage behaviors more effectively (McDonnell,
1997). It is interesting
that the vast majority of the managers in interviewed in the telephone
survey reported that their staff were more confident since the training
had taken place. Although
such an assertion may have some face validity further research is needed
to emprically demonstrate whether confidence is a critical variable
in the management of challenging behaviors.
Increases in knowledge
scores were perhaps a little less surprising as the items reflected
material presented to participants over the three days. Participants
could demonstrate improvements in this measure over a relatively short
period of time. It is a debatable point whether knowledge increases
would directly effect staff behavior.
Knowledge of behavioral principles does not always necessarily
have an effect on staff behavior (O’Dell, 1979). Further research
would be needed to answer this question with regard to this training.
The consumer satisfaction
responses of service managers at six month follow up would appear to
provide some limited data to the effectiveness of the training. However,
care should be taken when evaluating the responses of individuals as
their opinions may not necessarily reflect the working practices in
these residential services. It would appear at face value that the training
did have an impact in these services. It is also important to note that
the staff team that reported significant decreases in knowledge and
confidence scores also supplied the most negative management feedback.
It is interesting that this staff team appeared to find the training
‘too soft’. Particular reference was made to the notion of
low arousal approaches which sometimes can involve reinforcing behaviors
in the short term to manage crises and reduce confrontation (McDonnell,
1998). It has been documented that a problem with such strategies is
that staff may feel that they are ‘giving in’ to people who
present management difficulties (McDonnell, et al, 1998). This
particular staff team expressed a view that they believed that these
approaches would make the behavior of their residents worse. In direct
contrast over 50% of the managers surveyed specifically named low arousal
approaches as the most useful component of the training course. Given,
that research into the effectiveness of behavior management strategies
is relatively crude (Allen, 1998; McDonnell, & Sturmey, 1993).
More research is needed into both staff perceptions of behavior
management strategies and their relative effectiveness.
There are a number
of methodological problems with this study. First, no control group
was utilised. There are ethical problems in having waiting list or no
treatment control for staff who are experiencing high risk aggressive
behaviors. Indeed, the vast majority of this training was conducted
in a reactive manner as a response to behavioral crises. Second, the
lack of follow up data does not allow us to demonstrate whether the
reported increases maintained over time. Third, no data was presented
on staff behavior prior to and post training. Therefore, it is difficult
to demonstrate whether the effects of training did generalise to the
workplace. It would also have been useful to have monitored both staff
and client injury and assault data prior to and after training. Other
authors have demonstrated decreases in such indices after training.
(Allen, et al, 1997).
It is difficult
to analyse which components of the training were the most effective. The majority of managers did report low
arousal approaches (McDonnell, 1998; McDonnell, et al, 1998)
and the physical restraint method (McDonnell & Sturmey, 1998) as
the most useful components of the training. 23 managers did report that
physical skills had been use in their services, although this study
is unable to assess the frequency of their usage
It is important to examine outcomes in this field, training may
not always achieve the desired result. One training group had decreases
in both knowledge and confidence measures. There were also some training
courses which showed no statistically significant increases although
Figure 1 clearly shows a positive trend for the majority of these courses.
The physical skills
taught on training courses clearly require further evaluation. Allen,
et al, (1997) reported decreases in physical responses to challenging
behaviors after training.
In direct contrast to this finding another study reported increases
in the use of physical management strategies (Baker & Bissmire,
1998). Clearly, there are times when carers are confronted with aggressive
behaviors which may require some form of physical restraint (Harris,
1996). No data on outcome on the implementation of physical skills has
been presented in this paper. Future research needs to evaluate the
effectiveness, usage and social validation of physical skills training
(McDonnell & Jones, 1998).
Staff behaviors
are critical in the management of aggressive behaviors (Hastings &
Remington, 1994). However, staff training is regarded as necessary but
not sufficient on its own to achieve behavioral change (Cullen, 1992).
Behavioral change may only be one aspect of this type of intervention.
Staff perceptions of aggressive behaviors would appear to be an area
ripe for research (McDonnell, Johnson & Allen, 1998). This study
has not addressed the belief systems of staff. Do staff beliefs and
attitudes change after such training ? Future research is needed to
focus on these cognitive factors.
In conclusion,
this paper has presented a limited data set which describes a series
of training courses in the management of aggressive behaviors. While
the study contains a number of methodological deficiencies it does make
an attempt to empirically justify staff training. If we accept that
challenging behaviors do tend to be long term in their nature (Reiss
& Havercamp, 1997) then, much more research is required into the
content and training of short term behavior management strategies to
direct care staff.
REFERENCES
Allen, D. (1998). Physical aggression in people with
learning disabilities
(Manuscript submitted for publication).
Allen,
D., McDonald, L., Dunn, C., & Doyle, T. (1997). Changing care staff
approaches to the prevention and management of aggressive
behavior in a residential treatment unit for persons with mental retardation
and challenging behavior. Research in Developmental Disabilities,
18, 101-112.
Baker,
P.A., & Bissmire, D. (1998). Crisis management of people with learning
disabilities who present with challenges: An evaluation
of crisis intervention and prevention (SCIP). (Manuscript submitted
for publication).
Bernstein,
G.S. (1982). Training of behavior change agents: A conceptual review.
Behavior Therapy, 13,
1-23.
Carr,
E.G., Robinson, S. & Palumbo, L.W. (1990) The Wrong Issue: Aversive
vs.
Nonaversive Treatment. The Right Issue: Functional vs. Nonfunctional Treatment.
In Repp, A.C. & Singh, N.N. (Eds)
Perspectives on the use of Nonaversive and Aversive Interventions
for Persons with Developmental Disabilities. Illinois: Sycamore.
Cullen,
C. (1992) Staff training and management for intellectual disability
services. International Review of Research in Mental
Retardation, 18, 225-245.
Emerson,
E., McGill, P. & Mansell, J. (1993). Severe Learning Disabilities
and
Challenging Behaviours: Designing High Quality Services.
London: Chapman Hall.
Gardner,
W.I. & Cole, C.L. (1987). Behavior treatment, behavior management
and
behavior control: needed distinction. Behavioral
and Residential Treatment, 2,
37-53.
Gardner,
W.I. & Moffatt, C.W. (1990). Aggressive behavior: definition, assessment,
treatment. International Review of Psychiatry,
2, 91-100.
Harris,
P.C. (1996). Physical restraint
procedures for managing challenging behaviors
presented by mentally retarded adults and children.
Research in Developmental Disabilities 17,
99-134.
Hastings,
R.P. & Remington, B. (1994).
Rules of Engagement: Towards an Analysis
of Staff Responses to Challenging Behaviours.
Research in Developmental Disabilities. 15,
279-298.
Infantino,
J.A., & Musingo S.Y.
(1983). Assaults and injuries among staff with and
without aggression control techniques. Hospital
and Community Psychiatry,
36, 1312-1314.
Intagliata,
J., Rinck, C.,
& Calkins, C. (1986).
Staff response to maladaptive
behavior in public and community residential facilities.
Mental Retardation, 24,
93-98.
McDonnell,
A. (1997) Training care staff to manage challenging behaviour: an
evaluation of a three day training course. The British
Journal of Developmental Disabilities, 43. 156-161
McDonnell,
A. & Sturmey, P & Dearden, R.L.(1993).The acceptability of physical
restraint procedures for people with a learning difficulty.
Behavioural and Cognitive Psychotherapy, 21, 225-264.
McDonnell,
A.A. & Sturmey, P. (1993).
Managing Violent and Aggressive
Behaviour: Towards Better Practice.
In R.S.P. Jones & C.B. Eayrs (Eds). Challenging Behaviour
and Intellectual Disability: A Psychological Perspective.
Avon: BILD.
McDonnell,
A.A., Reeves, S., Johnson, A., & Lane, A. (1998).Managing challenging
behaviour in an adult with learning disabilities: The
use of a low arousal approach. Behavioural and Cognitive Psychotherapy,
26, 163-171
McDonnell,
A.A., Johnson, A., & Allen, J. (1998). Care staff perceptions of
challenging behaviors. (Manuscript submitted for publication).
McDonnell,
A.A. & Sturmey, P.S. (1998). The acceptability of three physical
restraint procedures: a comparison of young people
and professional groups. (Paper submitted for publication).
McDonnell,
A.A. (1998). Developing non aversive behavior management technology:
The use of low arousal approaches. (Manuscript submitted
for publication)
McDonnell,
A.A & Jones, P, O. (1998). The role of clinical psychology in the
physical management of challenging behaviours. (Manuscript
submitted for publication)
Mortimer,
A. (1995) Reducing violence on a secure ward. Psychiatric Bulletin.
19,
605-608.
O’Dell.,
S.L., Tarler-Benolo, LL & Flynn, J.M.(1979). An instrument to measure
knowledge of behavioral principles as applied to children.
Journal of Behavior
Therapy and Experimental Psychiatry,
10, 29-34.
Oliver,
C. (1993) Self-injurious behaviour: From response to strategy. In C.
Kiernan
(Ed.), Research to Practice? Implications of Research
on the Challenging Behaviour of People with Learning Disabilities.
Kidderminster: BILD.
Reiss
S. & Havercamp, S.M. (1997)
Sensitivity theory and mental
retardation: Why
functional analysis is not enough.
American Journal on Mental Retardation. 101, 553-566.
Scotti,
J.R., Evans, I.M., Meyer, L.M. & Walker, P. (1991) A Meta-Analysis
of
Intervention Research with Problem Behavior: Treatment
Validity and Standards of practice. American Journal on Mental Retardation, 96,
233-256.
Scotti,
J.R., Ujcich, K.J., Weigle, K.L., Holland, C.M. & Kirk, K.S. (1996).
Interventions with challenging behavior of persons
with developmental disabilites: A review of current research practices.
Journal of the Association for Persons with Severe Handicaps,
21,123-134.
Singh,
N.N., Lloyd, J.W., &
Kendall., K.A. (1990). Nonaversive and aversive
interventions: Introduction. In A Repp & N Singh
(Eds.). Perspectives on the use of nonaversive and aversive interventions
for persdons with developmental disabilites, Sycamore: Sycamore
Publishing company
Spreat,
S.,Lipinski, D., Hill, J. & Halpin, M.E. (1986). Safety indices
associated with
the use of contingent restraint procedures. Applied
Research in Mental Retardation,7,
475-481.
Taylor,
J.C. & Carr, E.G. (1992) Severe problem behaviors related to social
interaction 2: A systems analysis . Behavior Modification,
16, 336-371.
Whitaker,
S. (1993) The reduction of sggression in people with learning difficulties:
A review of psychological methods. British Journal
of Clinical Psychology, 32,
1-37.
Figure 1: Differences in knowledge and confidence scores after completion of training
