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

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Abstract

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 mental retardation following a multiple baseline design. Real-time observational data were collected on the level of assistance residents received from staff and their engagement in activity. Active Support was shown in a companion paper (Jones et al., 1999) to increase the levels of assistance residents received and their engagement in activity. Increased assistance was particularly experienced by the behaviorally less able and the disparity in activity between the more and less able was reduced. In the analysis presented here, the effectiveness of assistance was evaluated before and after Active Support training by calculating the likelihood of engagement occurring given the occurrence of assistance. This likelihood was represented by the statistic, Yule’s Q. Yule’s Q significantly increased following Active Support training, an increase that was maintained at follow-up. The increased effectiveness of assistance was related to other research findings on the relationship between staff: resident interaction patterns and resident behavior.

Introduction

Without sufficient, effective assistance from carers people with severe or profound mental retardation are unable to engage in the activities of everyday living as much as their more independent fellow citizens (Felce & Perry, 1995). However, it has frequently been found that people in residential services with low adaptive behavior or intellectual competence receive little practical support from staff Duker et al 1989, Duker et al 1991, Hewson and Walker 1992, Felce and Perry 1995. These findings illustrate that the low emphasis on promoting resident independence associated with traditional institutional services (Pratt et al 1976, Grant and Moores 1977, Burg et al 1979;) has continued into the present day. The problem may no longer be extremely low rates of staff:resident interaction per se but rather its nature and purpose. For example, Hewson & Walker (1992) and Felce & Perry (1995) found that the great majority of staff interaction with residents was in the form of conversation, which made little contribution to enabling residents to participate in activity. Moreover, Saunders & Spradlin (1991) argue that low or episodic staff involvement with individuals and a lack of constructive resident activity may co-exist with or even arise from widely held notions of active treatment.

Traditional active treatment according to Saunders & Spradlin (1991) involves a pre-occupation with individual needs assessment, objective setting, and the development and implementation of treatment plans, with a particular emphasis on skill acquisition. The importance accorded these processes may mean that staff and the service as a whole lose sight of the primary function of a residential setting as a place for individuals to live. Rather than prioritizing what individuals cannot do, they argue that active treatment would in line with this primary function enable residents to use their existing capabilities to the full and maximize immediate participation in the activities of daily living. Plans for behavioral development would remain relevant but would be subordinated to this wider view of the quality of individuals’ daily existence. They describe ‘Supported Routines’ as one possible way of implementing this orientation. In the Supported Routines approach, “it becomes the responsibility of the facility to assist the individual in adopting and performing a daily routine that is enjoyable and functional. The facility must support that routine by creating the necessary environmental and social conditions within which it can occur and be sustained. The facility must also ensure that the routines are similar to the types and purposes of the routines evidenced by persons without handicaps in the general community” (Saunders & Spradlin, 1991, p. 24).

A similar view has been promoted by researchers in Britain in the advocacy of an approach termed ‘Active Support’ McGill and Toogood 1993, Emerson and Hatton 1994, Felce 1996, Mansell 1998. Active Support is designed to impact on what Saunders and Spradlin (1991) refer to as the necessary environmental and social conditions to support routine activity. First, staff plan opportunities for resident activity based on a weekly routine of major household tasks, the need for more occasional household tasks and knowledge of residents’ preferred social, leisure, and other pursuits. Residents are consulted as much as possible but for many this cannot replace the necessity for staff to adopt a pro-active policy to promote the opportunities required to provide a reasonably full day. Although based on routine, individual activity plans are finalized every day by the staff on duty so the timing and occurrence of activities remain flexible. Second, staff plan their own division of responsibility for supporting planned resident activity at the same time. Third, when supporting participation, staff provide increasing degrees of help in relation to each step of an activity until the person is able to engage successfully in it - progressing if necessary from explicit verbal instruction to gestural or physical prompting to demonstration to physical guidance. Fourth, staff give the majority of their attention to residents when they are constructively occupied. Fifth, staff monitor the opportunities provided to individuals each day.

Each of these components has empirical support. Clear allocation of staff to duties and arranging the setting so that staff work alone with residents rather than being in the company of other members of staff has been shown to be more important in increasing staff interaction with residents than increasing the number of staff Harris et al 1974, Mansell et al 1982a, Mansell et al 1982b, Seys and Duker 1988, Duker et al 1991, Felce et al 1991. Repp, Barton, & Brulle (1981) found that non-verbal instruction either with or without physical assistance was more likely to help residents respond correctly than verbal instruction, although this was by far the most usual form of instruction employed. Therefore, providing a different form of help if verbal instruction proves ineffective is likely to be better than repeated verbal instruction. Provision of attention contingent upon engagement has been shown experimentally to increase activity levels Porterfield et al 1980, Mansell et al 1982a, Mansell et al 1982b. Self-monitoring and feedback have been shown to increase on-task staff performance (e.g., Richman, Riordan, Reiss, Pyles & Bailey, 1988).

Active Support was first developed in a research demonstration project on community housing services for adults with severe or profound mental retardation Felce et al 1986, Mansell et al 1987, Felce 1989. A review of British deinstitutionalization research (Emerson & Hatton, 1994) and subsequent more specific analysis (Felce, 1996) concluded that the approach resulted in residents receiving more assistance from staff and being more generally engaged in activity than is typically found. A recent experimental evaluation tested this conclusion (Jones et al., 1999). Implementation of Active Support increased the average proportion of time each resident 1) received assistance from 5.9% to 23.3%; 2) engaged in domestic activities from 12.8% to 32.2%; and, 3) engaged in social, domestic, personal, leisure or educational activity from 33.1% to 53.4%. Across individuals, increases in assistance and engagement in activity were significantly and positively correlated. Both were significantly inversely related to resident adaptive behavior. In baseline, staff gave more attention and assistance to people who were behaviorally more able. After the introduction of Active Support, receipt of attention was unrelated to adaptive behavior and the behaviorally 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 six months after the last post-baseline data point, 8 to 12 months after intervention.

The above gives evidence that the quantity of resident engagement was related to the quantity of assistance received. However, the fact that Active Support training encourages staff to use non-verbal instruction and physical guidance in place of potentially ineffective verbal instruction would suggest that the relationship between assistance and engagement in activity may change. Assistance should be more effective in promoting resident engagement. A limitation of the Jones et al. (1999) study was that assistance was observed as a single category that combined verbal and non-verbal forms of instruction and guidance. It was, therefore, not possible to demonstrate whether the implementation of Active Support changed the quality of assistance residents received. However, it is possible to investigate the effectiveness of assistance in promoting engagement in activity directly by studying the conditional relationship between resident engagement and the provision of assistance in the real-time behavioral record collected. The purpose of this study was to conduct this analysis.

Section snippets

Participants and settings

Nineteen residents living in five staffed community houses participated. The houses were selected to obtain representation of people with severe mental retardation. Resident ages ranged from 30 years to 67 years with a mean of 48 years. Twelve residents were male, eight had physical disabilities, five sensory impairments, four were rated as having severe challenging behavior, and three had dual diagnosis. Fourteen residents could walk independently and a similar number were continent. Nine had

Results

At baseline, Yule’s Q was above zero for every resident, indicating that assistance promoted engagement in activity (baseline mean, 0.79; range, 0.23–0.96). Following intervention, Yule’s Q increased for 17 of the 19 residents (post-intervention mean, 0.92; range, 0.74–0.99). Overall change was significant (T = 8.5, p < 0.001). Changes in Yule’s Q between baseline and post-intervention are shown in Fig. 1. There was a tendency for pre-post difference in Yule’s Q to be inversely correlated with

Discussion

A significant intervention effect was demonstrated across the 5 houses in the overall evaluation of Active Support, which was independent of differences between houses (Jones et al., 1999). The more structured approach to planning activity and staff support taken together with the specific training on how to interact to provide effective assistance within the Active Support model led to higher levels of staff assistance given to residents and increased resident engagement in activity. The

Acknowledgements

This research was supported by the Wales Office of Research and Development for Health and Social Care. We are grateful to the service agency, residences and the people who live and work in them for their collaboration.

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