Transcript Slide 1

An evaluation of a reputed exemplary residential
support service for people with intellectual disability
and severe challenging behaviour
Or, Getting direct support staff to do what they’re
supposed to be doing!
Tim Clement & Professor Christine Bigby
School of Social Work and Social Policy
Wednesday 3rd March 2010
11.45 – 12.15
Acknowledgements
Office of the Senior Practitioner
• Frank Lambrick
Welcome Support Services
• Staff
• Service-users
Aims
To share some findings from an evaluation of a residential support service for
adults with intellectual disabilities' and severe challenging behaviour
We invite you to draw on your own experience to consider and reflect on:
• The use of program theory in ‘designing’ interventions.
• The credibility of the program theory and practice framework outlined in this
presentation
Lessons from the research
Andover
“The world passes the pilot project
by. The wider service system
continues unchanged, either not
noticing the innovation in its midst or
resenting it for the resources and
acclaim it attracts”.
(Mansell, McGill and Emerson, 1994, p.81).
Models and frameworks
The production of service user lifestyles (Mansell, McGill & Emerson, 1994)
Resources
Opportunities
(Service location, design)
Principles
Staff and service users
(Number, background)
Organization
Staff rota
User timetable
Allocation of staff to users and activities
(Shift planning)
Individually orientated guides
Group orientated guides
(IP, programmes, prescriptions)
(Sequencing and scheduling activities)
Staff support
Help
(Preparation, setting events, assistance)
Encouragement
(Differential reinforcement)
Service user lifestyle
(Presence, competence, choice, respect, community participation)
Why does a program do what it does?
A program theory explains ‘why a
program does what it does’.
Welcome Support Services’ primary mission
The primary mission of Welcome
Support Services is to enhance the
quality of life of the people we
support. To achieve this goal we aim
to provide a wide range of quality
support services, to create
opportunities designed to meet
individual needs and to motivate the
people we support to work towards
achieving their goals (D116)
Framing the evaluation
Evaluation hierarchy
Assessment of program
cost and efficiency
Assessment of program
outcome/impact
Assessment of program
process and implementation
Assessment of program design
and theory
Assessment of need for the program
•
Are we able to describe a program model,
paying particular attention to defining its
program goals and objectives.
Framing the evaluation
Evaluation hierarchy
Evaluation questions
Assessment of program
cost and efficiency
Assessment of program
outcome/impact
•
Is the program having the desired effects?
Assessment of program
process and implementation
•
Is the program operating as planned?
Assessment of program design
and theory
•
Can we describe the program model, paying
particular attention to defining the program
goals and objectives.
Assessment of need for the program
Program theory – First version (i)
Assessment
Planning
Gather information
about the residents
from a variety of
sources.
 Initial assessment
(e.g. Supports
Intensity Scale,
Functional Behaviour
Analysis)
 Ongoing (e.g.
Feedback from day
programs, incident
reports)
Orientated
towards
‘quality of life’
outcomes.
Direct support staff
need specific
Knowledge and skills
to work with people
with challenging
behaviour.
Clear
standards
PersonCentred
Planning
Induction,
orientation,
and (ongoing)
training
(classroom,
on-line, and in
situ).
Implementation
Continuous
activity
Long-term plans are
turned into day-to-day
activity ( Essential
Support Summary,
proactive strategies,
protocols
Ongoing documentation
of service activity
Support staff
Service-users
Practice Framework
 Active listening
 Active support
 Choice and control
 Positive language
 Plan of the day
Ongoing
management
attention (practice
leadership,
orientation to each
shift, observation.
Evaluation
Support to serviceusers a focus of
particular scrutiny
Monitoring against
clear standards
 Self
 Peer
 Families
 Managers
 Others (e.g.
Office of the
Senior
Practitioner)
Periodic Service
Review
Opportunities for
discussion,
feedback, and
coaching, and
support (e.g.
house meetings).
Program theory – First version (ii)
Assessment
Planning
Gather information
about the residents
from a variety of
sources.
 Initial assessment
(e.g. Supports
Intensity Scale,
Functional Behaviour
Analysis)
 Ongoing (e.g.
Feedback from day
programs, incident
reports)
Orientated
towards
‘quality of life’
outcomes.
Direct support staff
need specific
knowledge and skills
to work with people
with challenging
behaviour.
Clear
standards
PersonCentred
Planning
Induction,
orientation,
and (ongoing)
training
(classroom,
on-line, and in
situ).
Implementation
Continuous
activity
Long-term plans are
turned into day-to-day
activity ( Essential
Support Summary,
proactive strategies,
protocols
Ongoing documentation
of service activity
Support staff
Service-users
Practice Framework
 Active listening
 Active support
 Choice and control
 Positive language
 Plan of the day
Ongoing
management
attention (practice
leadership,
orientation to each
shift, observation.
Evaluation
Support to serviceusers a focus of
particular scrutiny
Monitoring against
clear standards
 Self
 Peer
 Families
 Managers
 Others (e.g.
Office of the
Senior
Practitioner)
Periodic Service
Review
Opportunities for
discussion,
feedback, and
coaching, and
support (e.g.
house meetings).
Practice Framework
Positive
language
Active
support
Choice and
control
Active
listening
Plan of
the day
Positive Behaviour Support
What two direct support staff said about the practice framework
We don’t call it the practice framework; in
common language we’ll call it the ‘Welcome
Support Services’ protocol’. It’s what they put in
place, the strategies, the person-centred
support, encouraging positive behaviour, the
reinforcing, the regularity of everything. It’s all
been put in place by Welcome Support Services
and what they’ve learnt over the years is if it’s
not followed, then there is repercussions
(I/P21/200509).
The ‘moment of truth’
Serviceuser
• Quality of staff performance
• Patterns of staff behaviour
• Quality of face-to-face
interactions
• The way in which staff work
with service-users
Interface
Support
staff
Staff as mediators
• Quality of life
• The good life
• Meaningful engagement
• Active participation
How the Practice Coordinator talks about the practice framework
It’s also my role to make sure that
the staff have the tool-bag that they
need and the tools that they need to
meet that expectation, along with
support from each other, their
Coordinator, and me as a coach. If
people struggle then we provide
more coaching and sharpen the
tools that they have (I/P25/050609).
Plain English
A lot of the information that’s in the training manual doesn’t necessarily
have a name to it. It doesn’t say that this is called, ‘Positive Behaviour
Support’, or this is called being ‘person-centred’, but some of the
information that’s in there is clearly around that. We’ve become more, I
don’t know what the word is, not sophisticated, but more thought’s gone
into how we pass on the information to staff (I/P26/040609).
Setting clear expectations
What I say at the start, and I can be a bit
down the line with people, I say that we have
a really clear idea about how we want people
to deliver service and it’s not negotiable.
What we’re here to do is to give you the
outline or the information that you need to
know to be able to deliver the service in the
way we want you to deliver it.
In the training we talk about our mission
statement as being to enhance the quality of
life for the people we support. What does that
mean? It means nothing unless you give
people some clear direction about what we
expect from you. I think the training can do
that. If people in the training said, ‘I don’t
want to do it that way, I think this works
better’, then I would say, ‘No, this is the way
we know’ (I/P26/040609).
Active listening (i)
Egan (1994) distinguishes between:
• Attending
• Listening
Active listening underpins everything, because
unless we’re actually listening to someone,
we’re not hearing and able to support them at
all….We don’t talk about active listening as
though it’s only happening through your ears.
For a lot of the people that are supported within
our agency who are non-verbal, active listening
is paramount to being able to provide the right
support to them….We believe that unless we’re
sitting and we’re still and we’re silent that’s really
difficult to hear someone (I/P24/290509).
Active listening (ii) - Listening
It’s listening to everything, not just what they’re
saying but also body language and things like
that. Asking questions about them, trying to work
out what is actually going on, paying attention to
everything….The first day when you come out to
meet Paul you could see that he was pacing by
the door, so you could see that even though he’s
not verbally saying anything that he wants to go
out, but he’s waiting for you to say that’s okay.
Part of Welcome’s framework is by using active
listening that people don’t have to escalate and
have incidents. You can see him and go, ‘It’s
okay to go out’ (I/P20/140509).
Active listening (iii) - Being
Geoff leans forward and puts his
forehead against Frank’s, so that
they touch lightly. Geoff touches
Frank’s ear. A few moments later,
Frank touches Geoff’s ear
(F/P3/190409).
Plan of the Day (i)
Date of Plan: 17/04/09
Completed by Paul with: Alan
5:00 am – 7:00am – morning shift:
Shower routine
Breakfast
The Plan of the Day belongs to the person
and it has to work in a way that suits them
and their communication style. The Plan of
the Day is not ours. It’s a job description for
staff, but it’s developed by the person. It
should be a tool that staff come in and say,
‘Freddie, show me what I need to do today.
Show me how and when you need my
support’ (I/P24/290509).
Listen to music
Say bye to Brian
7:00 am – 3:00pm – day shift:
Say hello to Alan
Have morning tea
Tidy up in the yard
Make bacon and egg rolls for lunch
Have a rest and listen to music
Goodbye to Alan
3:00 pm – 9:00pm – sleepover shift
Say hello to Geraldine
Have afternoon tea
Drive and pick up fish and chips
Watch footy training
Off to bed and sleep well
Plan of the Day (ii): The importance of routine and structure
Routine’s probably pretty important
for him. If it’s all over the place I
think that’s when he’ll do some
behaviours (I/P19/150509).
Positive language (i)
We started up a new service and this young lady came
from a different service provider. She’d gone through
child protection and had been supported through DHS,
and when she came to us it was really apparent that
every time she heard the word ‘No’ she would display
quite aggressive behaviour….We quickly had to work
with the staff in figuring out how do we say ‘Yes’ instead
of ‘No’, and it was difficult because staff would ask
questions like, ‘Well what if she wakes up at 1:00 a.m.
and says, ‘I want McDonalds’. How are supposed to say
‘Yes’ to that?’ I said, ‘Well let’s incorporate the rest of her
day. We can say, ‘McDonalds would be really nice but
when do you think you can have McDonalds?’ It’s not
about saying yes all the time. That’s why we’ve changed
it [from ‘Yes language’] to positive language
(I/P24/290509).
Positive language (ii)
We’ve been told not to say ‘No’….If you kept on giving [coffee] to Paul, he’ll have one hundred
coffees a day. He loves coffee; but say he’s had his breakfast, he’s had his coffee, then five
minutes later he’ll come up and he’ll go, ‘I have coffee’, and you’ll say, ‘Yes, you can have coffee,
but at 10 o’clock’. So, you’re not saying, ‘You can’t have it’, but he’s going to have it at morning
tea….This way, it’s reassuring. He’s going to get it, but not right now. If you say ‘No’ he’s probably
thinking, ‘Hang on, he’s not going to give me any coffees!’; so he’ll be thinking, ‘I’m not going to get
any coffee today’, so he might start playing up a little bit; but if he knows he’s going to get it, he’ll
be happy (I/P19/150509).
Active Support
Theoretical underpinnings
• Normalisation
• Social Role Valorisation
• Behavioural Psychology
Training for staff team
• Two-day workshop
• Practice-based
interactive training
Style of staff interaction
• Hierarchy of graded
assistance
• Task analysis
• Positive reinforcement
Outcomes
• Increase positive interactions
• Increase in time residents
spend in constructive activities
• Changed staff attitudes
Organisational systems
• Planning tools
• Monitoring systems
• Management input
Active Support: A way of assisting people with intellectual disabilities to participate in meaningful activity
Choice and control
In the mornings Frank can create stress levels
for himself and staff. An example is, if his
cupboard is open he will take all the clothes out,
but still not know what he wants to wear. Once
you start picking stuff for him, then he’ll refuse to
put it on. So what I traditionally do is you lay out
two shirts, so that’s his choice, not ten
shirts….Which one will I wear today, this one or
this one? This one, okay, the other one goes
back in the cupboard. The choice is done, this is
what you’re wearing, and you seem to be happy
about it (I/P22/150509).
The practice framework and challenging behaviour
Positive
language
Active
support
Choice
and
control
Active
listening
Plan of
the day
Positive Behaviour Support
• Proactive strategies?
• Provision of a supportive environment?
Revisiting the evaluation questions
Evaluation hierarchy
Evaluation questions
Assessment of program
cost and efficiency
Assessment of program
outcome/impact
Assessment of program
process and implementation
Assessment of program design
and theory
Assessment of need for the program
• Is the program having the desired
effects?
• Is the program operating as planned?
• Can we describe the program model,
paying particular attention to defining
the program goals and objectives.
The importance of program theory
Managers need to determine the
kinds of staff performance that
produce the outcomes desired by
service users and their advocates
and the kinds of management that
support good work by staff, rather
than relying on accident or attitudes
to produce the results
Mansell, McGiill and Emerson (1994, p.76)
t.clement@latrobe,edu.au
[email protected]