Full title: Effect of service structure and organisation on staff care practices in small community homes for people with intellectual disabilities

Transcription

1 Title page Full title: Effect of service structure and organisation on staff care practices in small community homes for people with intellectual disabilities Running title: Effect of service structure and organisation on staff care practices Authors: Jim Mansell, Julie Beadle-Brown, Beckie Whelton, Celia Beckett and Aislinn Hutchinson Keywords: residential care, quality of care, active support Address for correspondence: Prof J L Mansell Tizard Centre University of Kent Beverley Farm Canterbury Kent CT2 7LZ United Kingdom j.mansell@kent.ac.uk Published as Mansell, J., Beadle-Brown, J., Whelton, R., Beckett, C. and Hutchinson, A. (2007) Effect of service structure and organisation on staff care practices in small community homes for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities

2 Full title: Effect of service structure and organisation on staff care practices in small community homes for people with intellectual disabilities - 1 -

3 Abstract Background An important question is what factors influence the extent to which staff provide active support. Methods Engagement, care practices and a range of staff and organisational characteristics were studied in 72 residential homes serving 359 adults with intellectual disabilities. Managers in 36 settings were trained in person-centred active support (PCAS). A group comparison design and multivariate analysis was used to investigate the relationship between variables. Results The PCAS group showed more active support, assistance, other contact from staff and engagement in meaningful activity but no difference in choice-making or assessment of participation in activities of daily living. The PCAS group had more staff with a professional qualification, were more likely to think that challenging behaviour was caused by lack of stimulation, had attitudes more in line with a policy of community care, rated most care tasks as less difficult, and were more organised to deliver active support. The comparison group were more likely to think that challenging behaviour was learned negative behaviour, showed more teamwork and were more satisfied. Multivariate analysis identified a range of staff and organisational variables associated with engagement and active support. Conclusions The results suggest that some variables which have not hitherto been studied in relation to active support are associated with it. Professional qualification, knowledge and experience appear to be important as do some staff attitudes, clear management guidance, more frequent - 2 -

4 supervision and team meetings, training and support for staff to help residents engage in meaningful activity

5 Introduction Engagement in meaningful activity is a central outcome for services for people with intellectual disabilities. Approaches to the measurement of quality in intellectual disability services typically identify a range of different domains which are important, such as Schalock et al. s (2002) domains of quality of life (emotional well-being, interpersonal relations, material well-being, personal development, physical well-being, self-determination, social inclusion and rights) or O Brien s (1987) five accomplishments (presence, choice, competence, respect and integration). Central to many of these is the actual day-to-day experience of the individual. For example, personal development is only likely to be possible if the individual participates in activities which broaden their experience and allow them to develop new skills and interests; interpersonal relations and social inclusion depend on interacting with other people; physical health depends on lifestyle and activity (Robertson et al., 2000). In this way, engagement in meaningful activity and relationships is a particularly important outcome in that it is the vehicle by which many aspects of quality of life are realised (Bellamy et al., 1990; Mansell et al., 1987a; Risley, 1996; Saunders and Spradlin, 1991). Although, in general, community-based residential services for people with intellectual disabilities show higher levels of engagement in meaningful activity than the institutions they replaced (Emerson and Hatton, 1994), a continuing concern of commentators is the extensive inactivity and isolation still seen in community services. Previous research has shown that, apart from adaptive behaviour, the most important determinant of levels of meaningful activity by people living in community residential services are staff care practices (Felce et al., 2000a; Felce, de Kock and Repp, 1986; Felce et al., 2000b; Felce and Perry, 1995; 1996; Jones et al., 1999; Mansell, 1994; Thompson et al., 1996). The care practices most commonly - 1 -

6 associated with increased engagement in meaningful activity were developed in Andover (Mansell et al., 1987b) and refined as active support (Brown, Toogood and Brown, 1987; Jones et al., 1996; Mansell et al., 2005). In its most recent formulation (Mansell et al., 2005), active support focuses on providing direct assistance to people with severe and profound intellectual disabilities to facilitate engagement in meaningful activity and relationships. Staff are taught to identify opportunities for engagement and facilitate it through methods such as prompting, successive approximation, differential reinforcement and fading. Services are encouraged to organise themselves to support staff in this endeavour. Studies of care practices show that residents in staffed group homes receive direct assistance from staff of this kind for a very small proportion of the time - typically well under 10%, or less than 6 minutes in every hour (Felce, Lowe and Jones, 2002b; Felce and Perry, 1995; Hatton et al., 1995; Jones et al., 2001a; Jones et al., 1999). For people with the most severe disabilities, assistance is received for only about one minute each hour (Emerson et al., 1999; Mansell, 1995). In demonstration projects where staff have been trained in active support, each resident received assistance for about a quarter of the time (Felce, de Kock and Repp, 1986; Jones et al., 1999). For people with multiple disabilities or serious challenging behaviour, substantial increases in assistance have been achieved in specialised group homes (Hatton et al., 1995; Mansell, 1995). Therefore an important question is what factors influence the extent to which staff provide active support. Of course, assumptions about what factors might influence staff care practices underpin most service management and much of the movement to reform services for people with intellectual disabilities over the last 40 years. Factors which have been studied, in their own right or in relation to care practices, include: - 2 -

7 (i) Setting characteristics: the type of service (Emerson and Hatton, 1994; Tizard, 1960) and size (Balla, 1976; Landesman-Dwyer, Sackett and Kleinman, 1980; Stancliffe, 1997; Tossebro, 1995) (ii) Staffing: the ratio of staff to residents (Felce et al., 1991; Harris et al., 1974; Mansell et al., 1982); staff qualifications and experience (Allen, Pahl and Quine, 1990); receipt of training and staff knowledge (Bradshaw et al., 2004; Cullen, 1988; Hastings, Reed and Watts, 1997; Jones et al., 1999; Levy, Levy and Samowitz, 1994; Mansell et al., 2003); turnover; (Baumeister and Zaharia, 1987; Felce, Lowe and Beswick, 1993; Hatton and Emerson, 1998; Lakin et al., 1982); attitudes (Department of Health and Social Security, 1979; Henry et al., 1996; Kordoutis et al., 1995; Stenfert Kroese and Fleming, 1992) (iii) Organisational hygiene: job satisfaction (Dyer and Quine, 1998; Hatton et al., 1999); stress (Elliott and Rose, 1997; Hatton, 1995; Potts et al., 1995; Rose, 1995, 1997); role clarity and conflict (Allen, Pahl and Quine, 1990) (iv) Management: autonomy of managers (King, Raynes and Tizard, 1971); systems for organising care (Emerson et al., 2000; Felce, Lowe and Jones, 2002b; Jacobson, 1990; Reid and Whitman, 1983) None of these factors have been simply and consistently identified as predicting good care practices. As Hastings, Remington and Hatton (1995) noted, it is likely that factors influencing care practices operate in combination. For example, Jones et al (2001b) showed that both classroom and practical training were required for staff to change their practice in using active support. There is also some evidence that effects may be contingent on particular situational factors. Early studies of the effect of size on care practices (Balla, 1976; King, Raynes and Tizard, 1971) suggested little or no relationship. These were studies of relatively - 3 -

8 large settings. Only when very small-scale community-based services were studied did size become important (Tossebro, 1995). This implies that it is important to study a wider range of service and staff characteristics than has typically been studied in the past, when examining effect on care practices and outcomes for service users, and to combine multivariate with comparative methods to determine the relative importance of particular variables. It also implies that attention should be given to factors that might be specific to particular service models, such as the staffed group homes which are now the most common form of provision in Britain, North America and Australia (Braddock et al., 2001). Recent studies have found very limited evidence for the effect of service and staff characteristics on care practices and outcome. Felce, Lowe and Jones (2002a; 2002b) studied 29 staffed houses, looking at staff numbers, qualifications, experience, systems for organising care and management milieu. They found evidence that higher staff ratio and more experienced staff predicted high levels of assistance from staff, but that systems for organising care and milieu did not. In a larger study of 60 houses, Felce et al (2003) also found evidence for the effect of staff ratio and also evidence that systems for organising care were important in influencing the amount of staff attention received by residents. Mansell et al (2003) studied 76 staffed houses, looking at staff numbers, experience, turnover, seniority and participation in in-service training. They found no organisational or staffing characteristics predicted extent of active support. These studies omit some potentially important factors. For example, it seems plausible to expect the values of staff, as expressed through their attitudes, to be important; and for organisational hygiene factors such as teamwork, leadership, role clarity, satisfaction and stress to be considered. The aim of this study was therefore to explore the effect of a wider - 4 -

9 range of organisational variables on the extent of active support in community-based residential services. Method Participants and settings Participants were 359 adults with intellectual disabilities living in 72 residential homes provided by a national charity throughout England, and 354 staff employed to provide support in each home. Homes were selected by the charity ensuring coverage of all regions it served; 36 homes were nominated by the charity for the introduction of active support. For each of these homes a broadly comparable home was identified in the same region by the charity. It was not possible to assess the comparability of the homes prior to the start of the study. Residents were included in this study if observational data concerning their participation in meaningful activity and of staff care practices had been collected and if consent (or agreement of a proxy, if it was not possible to obtain informed consent from the person) had been obtained; staff were included if they were observed working with residents or if they completed questionnaires (described below). Training intervention Managers in 36 settings were trained in person-centred active support by the first two authors using the materials published by Mansell et al (2005). Training comprised a one-day classroom based workshop involving presentations, individual and group exercises and video illustrations. This was followed by a one-day practicum workshop carried out in a day centre whose attendees and staff volunteered to assist. This workshop involved managers attending the training in providing support to enable people with intellectual disabilities to participate - 5 -

10 in different activities (eg cooking, laundry, cleaning, gardening), and also observing and giving feedback to each other on the quality of support they provided. Following this workshop, each manager returned to their own service and practiced providing active support themselves. They produced a minute video of themselves supporting a resident which was rated and feedback provided by the second author. Each manager then produced a second video which was used to certify that they had achieved the required standard. Finally a third workshop focused on managers providing training themselves and issues of implementation within their services. Managers were provided with the training materials used by the authors and then expected to train their own staff using similar methods. Support was provided to managers through regional coordinators and monthly telephone conferences during this process. Data was not, however, collected on the training provided by managers to staff. Measurement Information was collected on the adaptive and problem behaviour of residents, aspects of the organisation and staffing of each home, staff values, priorities, formal qualifications, stress and job satisfaction, the care practices of staff and the extent to which residents were observed engaging in meaningful activity. Data collection took place on average 5 months (range 3-13 months) after managers had been trained in person-centred active support. Data collection was carried out by the third, fourth and fifth authors. Adaptive and problem behaviour of residents The adaptive and problem behaviour of participants was assessed using a Short User Survey comprising demographic information, the Short Adaptive Behavior Scale (SABS: Hatton et - 6 -

11 al., 2001; Nihira, Leland and Lambert, 1993), an item on quality of social interaction from the Schedule of Handicaps, Behaviour and Skills (HBS: Wing and Gould, 1978) and the Aberrant Behavior Checklist (ABC: Aman et al., 1985). This was sent by post to the manager of every service, who was asked to ensure that each questionnaire was completed by the member of staff who knew the individual resident best. Data were summarised into a percentage SABS score, a dichotomous variable indicating whether the person had social impairment or not, and the five factors of the ABC (irritability, lethargy, stereotypy, hyperactivity and inappropriate speech). The reliability and validity of the ABS (from which the SABS was drawn), BPI and the HBS have been studied and reported as acceptable by their authors. It was not possible to assess inter-rater reliability in this study due to practical constraints. Organisation and staffing Information on the organisation and staffing of each home was collected using the Revised Residential Services Settings Questionnaire (RRSSQ: Welsh Centre for Learning Disabilities, Institute for Health Research and Centre for the Economics of Mental Health, 2003). This was completed by interview with the manager or deputy manager of each home. RRSSQ includes sections devoted to the setting, building design, staffing, person-centred planning, assessment and teaching, planning resident activities, staff support for resident activity and staff training and supervision arrangements. Staffing information was used to calculate staff ratio and seniority of the staff team. The total staff in post was calculated as the number of whole-time-equivalent staff actually employed by the charity to support the residents in each home at the point of data collection, including - 7 -

12 where appropriate a share of a first-line manager post. The staff ratio was calculated as the number of residents per whole-time-equivalent staff in post. The seniority of the staff team was calculated as the percentage of whole-time-equivalent staff in post graded as Manager. The sections of the RRSSQ relating to systems for organising care yielded separate subscale scores for individual planning (maximum score 11), assessment and teaching (maximum score 8), planning of activities (maximum score 10), planning staff support for resident activity (maximum score 4) and training and supervision of staff (maximum score14). The total score was also calculated (maximum score 47). Staff experience and satisfaction Staff characteristics, experience and satisfaction was assessed using the Staff Experience and Satisfaction Questionnaire (LD) (Beadle-Brown, Gifford and Mansell, 2003), developed for use in this study. The questionnaire is divided into 4 sections: Section A provides demographic information on staff (gender, age, length of experience, previous employment, qualifications, etc.) and information on training. Section B focuses of staff satisfaction and experience of working in their current environment; how they spend their time; and how stressed they are. Many of the subsections matched the measures used by Carpenter et al (2000) in mental health services. Job satisfaction was assessed using the Dyer and Hoffenberg (1975) scale, with the addition of a further 7 items examining satisfaction with holiday/sick pay entitlement, relationships with service users, training, the values of their organisation and relationship and contact with senior management. Quality of management was assessed using the 15- item scale originally by Freeman ((1993), cited in Carpenter et al (2000)). The quality of teamwork section comprised six of the eight items from Freeman s teamwork scale. Role ambiguity/role clarity was assessed using the scale used by Rizzo et al (1970). Additional - 8 -

13 items were added to look at frequency and usefulness of supervision and team meetings, how staff spent their time on particular tasks and how difficult and important they rated those tasks. Finally, the Malaise Inventory (Rutter, Tizard and Whitmore, 1970) was used as a measure of stress. Internal consistency for each of the scales listed above is presented in Table 1. Section C focuses on knowledge of learning disability and challenging behaviour. It used the Challenging Behaviour Attributions Scale (Hastings, 1997) although without the scenarios used by Hastings staff were asked to complete the items thinking about people with challenging behaviour in general. Domain scores were calculated as per Hastings (1997). Internal consistency was found to be over 0.7 except on the Stimulation domain (see Table 1). This section also included 16 multiple choice items based on the questions used by Oliver et al (1996); 5 items concerned awareness of responses to challenging behaviour and 9 knowledge of challenging behaviour. The measure produced a total score of number of Action questions answered as Behavioural and Correct and the number of knowledge questions correctly answered. Staff were also asked to identify O Brien s (1987) five service accomplishments and to say what they understood by the terms learning disability and normalisation. Section D focused on attitudes towards community care and towards people with learning disabilities. Knapp et al s (1992) questions on attitudes to community care were revised slightly so that there were four attitude statements on whether community care was better for different populations (all people with community care needs, people with learning disability, staff/carers and for the community). In addition, 21 other attitude statements were used. These were developed using updated versions of the questions used in the Jay Report (Department of Health and Social Security, 1979) and questions more relevant to current social views. The statements concerned attitudes towards people with intellectual - 9 -

14 disabilities and their rights and how staff should behave and support people. Items were counter-balanced using reversal techniques. Internal consistency for the two subscales is presented in Table 1. For most of the established measures, test-retest reliability is reported as good (Carpenter et al., 2000; Hastings, 1997). Test-retest reliability was not tested for this particular sample but data on test-retest reliability on this and subsequent versions of the SESQ-LD are available from the authors. A summary of this data where available is presented in Table full questionnaires were returned from a total of 546 questionnaires sent out (a return rate of 42%). Fifty-nine services returned some staff questionnaires (82%). There were no statistically significant differences between services where staff questionnaires were returned and those where none were returned in terms of size of home, staff:resident ratio, resident adaptive behaviour or challenging behaviour. Care practices Each home was visited in order to observe the way staff provided support to residents. Observations were made over an approximately 2 hour period around a meal time because this seemed likely to provide many opportunities to see staff providing support. For each resident, the nature and quality of staff support was rated for the whole session using a 15- item rating scale, the Active Support Measure (ASM) (Mansell and Elliott, 1996). Details of this measure are given by Mansell et al (2003). Inter-rater reliability of the ASM in that study was high but was not assessed in this study. The Index of Participation in Daily Living (Raynes et al., 1994) was also completed for each resident by the keyworker

15 Engagement in meaningful activity, challenging behaviour and contact from staff At the same time that ratings of active support were made, researchers recorded resident activity and interaction in each home. They made a one-minute momentary time-sample using the following categories: Social Activity Communication with someone else, includes attempts to speak, vocalise, attend to, sign or gesture in a manner which appears to gain or maintain the attention of another person, including receiving something handed to the person. Non-social activity Challenging behaviour Assistance Getting ready for or doing a meaningful activity such as self-help, personal care, leisure, housework or gardening. Any disturbed or problem behaviour, including aggression, self-injury, destruction of property, pica etc Help from other people (eg staff, other users, visitors) which appears to be intended to facilitate engagement in meaningful activity and relationships, including holding materials or equipment in the right position, reminding, prompting or asking the person, directions or instructions, demonstration or modelling and guiding or helping. Other contact Any other contact from other people (eg staff, other users, visitors) not already classified as assistance. Observations were made of each resident for five minutes, then of the next resident for five minutes and so on around all the residents present until the two hours was complete

16 Given the practical constraints of widely scattered services, it was only possible to check inter-rater reliability in three services, one for each possible pairing of three observers. Independent observations were made by a second observer in these services for between 66 and 84 minutes. Agreement was assessed using Cohen s kappa (Cohen, 1960); kappa values for each pair of observers were 0.91, 0.94 and 1 (all p<0.0001). Choice The Choice Making Scale (Conroy and Feinstein, 1986) was completed for each resident by their keyworker. Design and analysis The design was a group comparison design between settings where residents were supported by staff whose managers had been trained in active support and comparison settings. The data were analysed using SPSS (SPSS Inc, 2004). Some data (resident characteristics, care practices, engagement in meaningful activity) were collected at the level of the individual resident; some (RRSSQ) at the level of the staffed house; and some (SESQ) at the level of individual staff. Since there is evidence of variation in outcome for residents with different characteristics, analysis was carried out at the level of individual residents using RRSSQ values for each house and SESQ values averaged across staff respondents from each house. Group comparisons were made using t-test for normally distributed ratio data (eg resident age), Mann-Whitney U tests for non-parametric ordinal data (Siegel and Castellan, 1988) or Chi-square tests for nominal data

17 Subsequently, multivariate analysis was undertaken using linear regression. Since there was substantial overlap between the PCAS and comparison groups on many relevant variables, regression was carried out on the whole sample (n=359). Two dependent variables were studied; engagement in meaningful activity by residents and active support. Engagement in meaningful activity was defined as the percentage of time the residents spent in any social or non-social activity; active support was defined as the percentage score on the ASM. Engagement was regressed against nine blocks of variables in a forced entry method as follows: Block 1 Resident characteristics (Age, SABS percentage score, Factors 1-5 of the ABC, social impairment, gender and ethnicity). Block 2 Staffing (staff:resident ratio, proportion of senior staff, experience in intellectual disability services, experience in current service, sickness absence, age profile of staff) Block 3 Knowledge and training (CHABA, knowledge of challenging behaviour, and of O Brien s 5 service accomplishments, proportion of staff with professional qualification) Block 4 Staff stress and satisfaction (Malaise inventory score, proportion of staff with psychiatric morbidity, job satisfaction with 24 issues) Block 5 Attitudes (to 28 issues concerning treatment of people with intellectual disabilities) Block 6 Management, teamwork, supervision and clarity (ratings of 17 aspects of management quality, frequency, usefulness and satisfaction with frequency of

18 team and supervision meetings, ratings of quality of teamwork, role clarity and conflict) Block 7 Task difficulty (staff ratings of difficulty of 15 tasks involved in supporting people with intellectual disabilities) Block 8 Systems for organising care (subscale scores of the RRSSQ for individual planning, assessment and teaching, planning activity, staff support of resident activity and staff training) Block 9 Care practices (ASM percentage score, proportion of time each resident received assistance and proportion of time each resident received other contact) For regression of active support, block 9 was omitted. Variables within each block were selected if t values were significant at <0.05. Variables were checked for multicollinearity and where found, correlated variables were removed. The remaining variables were then selected for a final regression using a forced entry method. The final regression was then repeated excluding resident characteristics to explore the effect of variables which could be more appropriately manipulated by service managers (since services have to provide support for people with all levels of disability). Results The first section presents results of the comparison between residents living in services where managers had been trained in person-centred active support and residents living in other services

19 Resident characteristics and outcome Table 2 compares the two groups of residents and shows that the groups were comparable in terms of their age, adaptive behaviour, social impairment, gender and ethnicity. The SABS score for the whole sample is comparable with ABS Part One scores averaging 175 (range ) (Hatton et al., 2001). In terms of challenging behaviour, the groups were comparable in terms of ABC Factors 1-4 but the comparison group had a significantly higher average score on Factor 5 (inappropriate speech). The PCAS group showed significantly higher implementation of active support, higher levels of assistance, other contact from staff and engagement in meaningful activity. In the PCAS group, 53% of residents were judged to be receiving good active support (ASM score>30), compared with 29% in the comparison group. There were no differences in participation in daily living or choice making. Service characteristics Staffing Table 3 presents information on certain staff characteristics. There were no significant differences between the groups in terms of staff:resident ratio or the proportion of senior staff in the team. The PCAS group had significantly more staff with a professional qualification (z=4.145, p<0.001). Staff in the comparison group tended to attribute challenging behaviour to negative learnt behaviour explanations more than the PCAS group (z=2.753, p<0.01), while those in the PCAS group tended to attribute challenging behaviour to the need for stimulation more than the control group (z=2.416, p<0.05). In terms of staff experience of working in services for people with intellectual disabilities, the PCAS group had significantly

20 more people who had worked in intellectual disability services for more than 6 months but less than 5 years, while the comparison group had more people who had worked for less than 6 months or more than 5 years. In terms of length of time in current service, there were no differences between the groups. Overall, 46% of staff had worked in the current service for less than six months and a further 32% had worked there for between 6 months and 1 year. There were no significant differences between the groups in the pattern of sickness absence (78% reported that they had taken less than 5 days sick leave in the past 12 months). A higher percentage of staff in the comparison group reported taking between 6 and 10 days sick leave in the last year (mean 9.91% compared to 5.45%; z=3.119, p<0.01). There was no consistent pattern in the age profile of staff. The majority of staff (approximately 80%) were over 35 years of age; 25% were over 50 years of age. Staff in the comparison group were more satisfied with their job (z=3.663, p<0.001), but there was no difference between the groups in psychiatric morbidity due to stress, role clarity or role conflict. Staff attitudes and ratings of task difficulty The PCAS group had attitudes significantly more in line with a policy of community care and empowerment for people with intellectual disabilities (z=3.880, p<0.001) The PCAS group rated most tasks they were asked to consider as less difficult than the comparison group (Table 4). Management, teamwork and supervision There was no difference between the groups in satisfaction with the team s manager, or in ratings of the usefulness of team meetings or supervision (Table 5). Staff in services in the

21 comparison group were more satisfied with frequency of meetings and supervision and rated their staff teams as showing more teamwork. Systems for organising care The PCAS group showed markedly higher scores on all sections of the RRSSQ (Table 6). Multivariate analysis Exploration of the relationships between variables using multiple regression confirmed the importance of adaptive behaviour and active support in predicting engagement in meaningful activity (Table 7). The final model explained 52% of the variance in engagement. Higher engagement was predicted by younger, more able White British residents, with less stereotypy but with more inappropriate speech; by staff who had worked in hospital and who were more knowledgeable about challenging behaviour; and where staff provided active support. When the variables referring to resident characteristics were left out of the analysis (Table 8), the final model explained 45% of the variance. In addition to knowledge of challenging behaviour, knowledge of behavioural approaches to challenging behaviour now appeared to be important. In addition to the percentage of staff who had worked in hospitals, higher engagement was predicted by lower staff ratio, staff who were satisfied with the flexibility of their hours of work, more conflict about how tasks should be done and stronger rating that co-workers acted on staff members advice. The inclusion of staff ratio possibly reflected resident dependence since these were significantly correlated (rho=0.55). Table 9 shows the results of regression on active support score. The model explained 44% of the variance. Higher active support scores were predicted by higher resident adaptive

22 behaviour; more qualified staff, who received supervision more than annually, but who reported more conflict in terms of whether tasks they did were likely to be accepted by everyone around them, who reported housework to be difficult but who reported monitoring progress and activity to be easier; staff attitudes in favour of staff talking to service users; managers judged to keep staff informed about plans and tasks; and where there were rotas and schedules for allocating staff to support residents activity and training in methods of involving service users in activity. Discussion Levels of engagement in meaningful activity in both PCAS and comparison groups were substantially higher than in Jones et al (2001a; 1999) and higher than in Felce et al (2002b). Levels of observed assistance in the PCAS group were lower than after training in Jones et al (2001a; 1999). It seems likely, therefore, that the rather higher adaptive behaviour scores in this group explain the higher engagement than in other studies. Nevertheless there was a modest difference between PCAS and comparison groups in engagement in meaningful activity, observed assistance and active support and this study offers further evidence that active support leads to higher engagement. Regression of engagement in meaningful activity confirmed that adaptive behaviour and active support were important predictors of engagement in meaningful activity. In addition, two factors of the ABC were found to be significant in the regression. Factor 3, which concerns stereotyped behaviour, was negatively associated with engagement so that the less stereotyped behaviour the resident showed, the higher their engagement in meaningful activity. Factor 5 (inappropriate speech) was positively associated with engagement. This may reflect the

23 presence in the sample of more able people with inappropriate speech who were able to participate more in activities. The lack of difference between the groups in IPDL scores presumably reflects the limited difference in engagement between the groups. This may reflect weaknesses in implementation. It was not possible to obtain data on the extent to which managers actually trained their staff following their own training and this has been shown to be important in earlier work (Jones et al., 2001b). The finding that there was no difference in choice-making between the groups is interesting and worthy of further investigation because active support is intended to promote choice. Stancliffe et al (in press) found no change in choice in a longitudinal study of active support. In terms of resources like staff ratio and the proportion of senior staff in the team, there were no significant differences between the PCAS and comparison groups. Ratio appeared in the regression equation when resident characteristics were removed but probably simply reflects these. This is consistent with the majority of studies which have examined staff ratio in relation to outcomes for the people served. In this study the PCAS group had a higher proportion of professionally qualified staff, which also figured in the regression of active support. Two specific knowledge items from the SESQ were predictive in the regression of engagement. Research on the impact of training has generally presented a mixed picture, in which it is relatively easy to train staff but rather difficult to show that they sustain trained performance when they return to services (Anderson, 1987; Cullen, 1992; Woods and Cullen, 1983). Caution should therefore be exercised in attributing an over-riding impact to professional qualification to explain the

24 results of this study. Professional training, either in its own right or as an indicator of general education, may however indicate a greater propensity to make effective use of in-service training like that involved in active support. Given new models of professional training based on combining classroom and workplace work are emerging in England (Ward, 1999), it may be appropriate to further examine its effectiveness in improving care practice. Differences in the experience of the staff teams are hard to interpret given that each team will have had members with a range of length of experience in intellectual disability services. Perhaps more notable is that 46% of staff had worked in the current service for less than six months. Given the importance of close personal knowledge of the residents in order to provide effective support (for example in respect of communication, challenging behaviour, intimate or complex care), such a large proportion of relatively new staff may hinder the implementation of approaches like active support. In the regression of engagement, the higher the proportion of the team who had previously worked in an intellectual disability hospital the higher was engagement. This may reflect some aspect of experience or expertise present to a lesser extent in community services that is helpful to staff trying to implement active support for example, it may be that people who had worked in hospitals were more confident in working with people who present challenging behaviour. Remaining differences between the groups could be a consequence of training in active support as well as a possible reason for its adoption. Higher job satisfaction and teamwork scores in the comparison group may reflect the effect of organisational change. Implementing new care practices may reasonably be expected to disrupt existing arrangements (both in the sense of making staff less comfortable with current arrangements as well as in respect of practical matters). Staff may be more conscious of the need for further improvement and

25 therefore may be more dissatisfied. The difference in satisfaction and teamwork did not prevent the PCAS group providing more active support and enabling residents to engage more in meaningful activity. It may be that given time to become more practiced, staff implementing active support will experience more satisfaction and better teamwork. Better attitudes may also reflect active support training. In the multivariate analysis, one item from the attitudes scale was present in the final regression of active support. Staff saying they should spend a large part of their day talking to service users predicted active support. The PCAS group rated many common support-related tasks as less difficult than the comparison group. Some of these, like talking to service users or helping them do household activities, are clearly related to active support training and it seems plausible that an effect of such training is to make it easier for staff to undertake such tasks with the people they support. Although there were no significant differences between the groups on the SESQ questions about management, regression identified one item associated with active support. The more staff rated their manager as letting them know about plans and tasks for their day-to-day work the higher was engagement and active support. This is consistent with research showing that clear specification of expectations and requirements aids effective performance (Reid, Parsons and Green, 1989). PCAS training emphasises the use of team meetings and individual staff supervision to shape up the quality of active support. The comparison group were more satisfied with the frequency of supervision and team meetings but this did not prevent higher engagement and active support in the PCAS group. Regression identified that staff reporting team meetings

26 only happening once a year predicted less active support. Thus actual practice may be more important than satisfaction with frequency. Higher scores on the RRSSQ may also reflect PCAS training although the RRSSQ focuses on administrative mechanisms like written plans, whereas the training given places a primary focus on changing staff behaviour rather than paperwork. The levels found in this study (allowing for differences in presentation of the data) were broadly comparable with the 47 houses studied by Perry and Felce (2003). Like this study, they found no relationship between RRSSQ scores and engagement. In this study the support and training subscales of the RRSSQ was both predictive of active support but not of engagement. There are some important limitations to this study. It was an exploratory study. The nonrandom comparison group design does not allow demonstration of causality: the differences between the groups may reflect pre-existing differences. It is not possible to conclude that engagement in meaningful activity and relationships increased in the experimental group, only that it differed from the comparison group. The identification of particular scale items in the regression analysis reflects their power as predictors rather than their validity. However the results do suggest that some variables which have not hitherto been studied in relation to active support are associated with it. Professional qualification, knowledge and experience appear to be important as do some staff attitudes, clear management guidance, more frequent supervision, and support and training for staff to help residents engage in meaningful activity. Despite the limitations of regression as a method, it does seem that the way in which some of these issues matter is rather specific and that general ratings of eg management may be less useful than finding what precisely works to increase active support and, through it, resident engagement in meaningful activity

27 Acknowledgements The authors wish to thank the people with intellectual disabilities and their staff who provided the information used in this study; and the charity which provided access to its services and funded part of the study. Support for the preparation of this manuscript was also provided to the first author during a visiting fellowship at the Institute of Advanced Study, La Trobe University, Melbourne, Australia

28 References Allen, P., Pahl, J. and Quine, L. (1990) Care Staff in Transition. London: Her Majesty's Stationery Office. Aman, M. G., Singh, N. N., Stewart, A. W. and Field, C. J. (1985) The aberrant behavior checklist: A behavior rating scale for the assessment of treatment effects. American Journal of Mental Deficiency, 89(5), Anderson, S. R. (1987) The management of staff behaviour in residential treatment facilities: a review of training techniques. In J. Hogg & P. Mittler (Eds.), Staff training in mental handicap (pp ). Beckenham: Croom Helm. Balla, D. A. (1976) Relationship of institution size to quality of care: A review of literature. American Journal of Mental Deficiency, 81(2), Baumeister, A. A. and Zaharia, E. S. (1987) Withdrawal and commitment of basic-care staff in residential programs. In S. Landesman & P. Vietze (Eds.), Living Environments and Mental Retardation (pp ). Washington, DC: American Association on Mental Retardation. Beadle-Brown, J., Gifford, J. and Mansell, J. (2003) Staff Experience and Satisfaction Questionnaire (Learning Disability). Canterbury: Tizard Centre. Bellamy, G. T., Newton, J. S., LeBaron, N. M. and Horner, R. H. (1990) Quality of life and lifestyle outcome: a challenge for residential programs. In R. L. Schalock & M. J. Begab (Eds.), Quality of life: perspectives and issues (pp ). Washington: American Association on Mental Retardation. Braddock, D., Emerson, E., Felce, D. and Stancliffe, R. J. (2001) Living Circumstances of Children and Adults With Mental Retardation or Developmental Disabilities in the United States, Canada, England and Wales, and Australia. Mental Retardation and Developmental Disabilities Research Reviews, 7(2), Bradshaw, J., McGill, P., Stretton, R., Kelly-Pike, A., Moore, J., Macdonald, S., Eastop, Z. and Marks, B. (2004) Implementation and evaluation of active support. Journal of Applied Research in Intellectual Disabilities, 17(3), Brown, H., Toogood, A. and Brown, V. (1987) Participation in Everyday Activities. Brighton: Pavilion. Carpenter, J., Ring, C., Sangster, A., Cambridge, P. and Hatzidimitriadou, E. (2000) From the asylum to the community: A longitudinal study of staff involved in the transition from Tone Vale Hospital to community-based services. Journal of Mental Health, 9(2), Cohen, J. A. (1960) A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20, Conroy, J. W. and Feinstein, C. S. (1986) The Choice-Making Scale. Philadelphia: Conroy and Feinstein Associates

29 Cullen, C. (1988) A review of staff training: The emperor's old clothes. Irish Journal of Psychology, 9(2), Cullen, C. (1992) Staff Training and Management for Intellectual Disability Services. International Review of Research in Mental Retardation, 18, Department of Health and Social Security. (1979) Report of the Committee of Enquiry into Mental Handicap Nursing and Care (Chairman: Peggy Jay). London: Her Majesty's Stationery Office. Dyer, J. and Hoffenberg, M. (1975) Evaluating the quality of working life - Some reflections on production and cost and a method for problem definition. In L. Davis & A. Cherns (Eds.), The Quality of Working Life (Vol. 1). New York: Free Press. Dyer, S. and Quine, L. (1998) Predictors of job satisfaction and burnout among the direct care staff of a community learning disability service. Journal of Applied Research in Intellectual Disabilities, 11(4), Elliott, J. and Rose, J. (1997) An investigation of stress experienced by managers by community homes for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 10(1), Emerson, E. and Hatton, C. (1994) Moving Out: Relocation from Hospital to Community. London: Her Majesty's Stationery Office. Emerson, E., Robertson, J., Gregory, N., Hatton, C., Kessissoglou, S., Hallam, A., Knapp, M., Jarbrink, K., Walsh, P. N. and Netten, A. (2000) Quality and costs of communitybased residential supports, village communities, and residential campuses in the United Kingdom. American Journal on Mental Retardation, 105(2), Emerson, E., Robertson, J., Gregory, N., Kessissoglou, S., Hatton, C., Hallam, A., Knapp, M., Järbrink, K. and Netten, A. (1999) Quality and costs of residential supports for people with learning disabilities: an observational study of supports provided to people with severe and complex learning disabilities in residential campuses and dispersed housing schemes. Manchester: Hester Adrian Research Centre. Felce, D., Bowley, C., Baxter, H., Jones, E., Lowe, K. and Emerson, E. (2000a) The effectiveness of staff support: evaluating Active Support training using a conditional probability approach. Research in Developmental Disabilities, 21, Felce, D., de Kock, U. and Repp, A. C. (1986) An eco-behavioural comparison of small community-based houses and traditional large hospitals for severely and profoundly mentally handicapped adults. Applied Research in Mental Retardation, 7, Felce, D., Jones, E., Lowe, K. and Perry, J. (2003) Rational resourcing and productivity: relationships among staff input, resident characteristics, and group home quality. American Journal of Mental Retardation, 108(3), Felce, D., Lowe, K., Beecham, J. and Hallam, A. (2000b) Exploring the relationships between costs and quality of services for adults with severe intellectual disabilities and the most severe challenging behaviours in Wales: A multivariate regression analysis. Journal of Intellectual & Developmental Disability, 25(4),

30 Felce, D., Lowe, K. and Beswick, J. (1993) Staff turnover in ordinary housing services for people with severe or profound mental handicaps. Community Care, 37, Felce, D., Lowe, K. and Jones, E. (2002a) Association between the provision characteristics and operation of supported housing services and resident outcomes. Journal of Applied Research in Intellectual Disabilities, 15(4), Felce, D., Lowe, K. and Jones, E. (2002b) Staff activity in supported housing services. Journal of Applied Research in Intellectual Disabilities, 15(4), Felce, D. and Perry, J. (1995) The extent of support for ordinary living provided in staffed housing: The relationship between staffing levels, resident characteristics, staff:resident interactions and resident activity patterns. Social Science and Medicine, 40(6), Felce, D., Repp, A. C., Thomas, M., Ager, A. and Blunden, R. (1991) The relationship of staff:client ratios, interactions and residential placement. Research in Developmental Disabilities, 12, Freeman, M. (1993) Evaluation of a training programme for carers working in community homes for those with learning difficulties: University of Sussex. Harris, J. M., Veit, S. W., Allen, G. J. and Chinsky, J. M. (1974) Aide-resident ratio and ward population density as mediators of social interaction. American Journal of Mental Deficiency, 79, Hastings, R., Remington, B. and Hatton, C. (1995) Future directions for research on staff performance in services for people with learning disabilities. Mental Handicap Research, 8, Hastings, R. P. (1997) Measuring staff perceptions of challenging behaviour: The Challenging Behaviour Attributions Scale (CHABA). Journal of Intellectual Disability Research, 41(6), Hastings, R. P., Reed, T. S. and Watts, M. J. (1997) Community staff causal attributions about challenging behaviours in people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 10(3), Hatton, C. (1995) Staff stress in services for people with learning disabilities and sensory impairments. Focus(June), 2-7. Hatton, C. and Emerson, E. (1998) Brief report: Organisational predictors of actual staff turnover in a service for people with multiple disabilities. Journal of Applied Research in Intellectual Disabilities, 11(2), Hatton, C., Emerson, E., Rivers, M., Mason, H., Mason, L., Swarbrick, R., Kiernan, C., Reeves, D. and Alborz, A. (1999) Factors associated with staff stress and work satisfaction in services for people with intellectual disability. Journal of Intellectual Disability Research, 43(4), Hatton, C., Emerson, E., Robertson, J., Gregory, N., Kessissoglou, S., Perry, J., Felce, D., Lowe, K., Walsh, P. N., Linehan, C. and Hillery, J. (2001) The adaptive behavior