Resident Involvement in Activity in Small Community Homes for People with Learning Disabilities

Background Determining the relative importance of variables including client characteristics, setting features, staffing and care practices on the lives of people with learning disabilities in residential care continues to be a relevant topic for research. Methods Measurements were made of the adaptive and problem behaviour of 343 adults with intellectual disabilities living in 76 residential homes and of various aspects of staffing, care practices (extent of active support) and resident engagement in meaningful activity. Ordinal and logistic regression was used to identify variables best predicting engagement and care practices. Results Only adaptive behaviour and care practices predicted resident engagement in meaningful activity; only age and adaptive behaviour predicted care practices. Conclusions Given the limited scope for changing resident adaptive behaviour, attention should be given to improve active support in residential homes in order to promote greater engagement in meaningful activity by people with learning disabilities.     

Community‐based Residential Supports for People with Intellectual Disabilities and Challenging Behaviour: The Views of Neighbours

Background The issue of the views of neighbours of community‐based residential supports for people with intellectual disabilities and challenging behaviour has not been examined till date. This study looks at the views of neighbours of two types of community‐based residential supports: non‐congregate settings where the minority of residents have challenging behaviour; and congregate settings where the majority of residents have challenging behaviour. Materials and methods A self‐completion questionnaire was used to collect information on contact between neighbours, residents and staff, and the views of neighbours. Information was also collected by semi‐structured interview with service staff on the characteristics of settings. Results Sixty‐four questionnaires were returned. Contact between neighbours and service users was limited for both types of setting, with two‐thirds of neighbours not knowing any service users by name, and a third having had no active contact with service users. Neighbours of non‐congregate settings were more likely to think that community care was a ‘good policy’ (76%) than neighbours of congregate settings (53%) and to believe that there were benefits to the neighbourhood from having the group home in the area (46% versus 29%) but these differences were not significant. Contact with people with intellectual disabilities was associated with more positive attitudes to community care and specific characteristics of the settings. Conclusions Contact between neighbours and people with severe intellectual disabilities and challenging behaviour is limited. However, the majority of neighbours are positive about community care and the problems reported by neighbours are predominantly minor. The results point to the key role that contact plays in fostering positive attitudes. Findings regarding differences between congregate and non‐congregate settings are limited by the small number of responses from neighbours of congregate settings.     

Implementation and Evaluation of Active Support

Objectives Active support was implemented in three community houses (active support houses), with 11 service users with severe learning disabilities. Methods This was evaluated with reference to changes in levels of engagement, challenging behaviour (major and minor) and staff contact, measured against three comparison services (non‐active support houses). Results All measures increased for the active support houses. Significant increases in activity levels were found in one house. Statistically significant increases in activity and minor challenging behaviour were also found when all active support houses were compared with all non‐active support houses. In the non‐active support houses, all measures decreased, with the exception of mean level of staff contact in one house. Conclusions Unlike previous research findings, those service users who were less able did not receive comparatively more support from staff post‐training and changes appeared unrelated to staff contact.     

Developing a Clinical Framework for Children/Youth Residential Treatment

The idea of implementing consistent overall clinical approaches in residential treatment facilities may improve care by influencing family engagement, interactional styles of residential staff and clinicians with children and youth, specific therapeutic interventions including the management of problematic behaviors, milieu approaches, and group interventions, as well as inform programmatic structure, rules, and expectations of residential living. A clinical framework should demonstrate contemporary and evidence supported practices in order to achieve meaningful success. This article summarizes a literature search and discussion points regarding family/community engagement, individualized assessment/treatment, interprofessional teams, and organizational factors in developing a clinical framework for children/youth residential treatment.     

The Impact of Autism or Severe Challenging Behaviour on Lifestyle Outcome in Community Housing

Background The triad of impairments characteristic of autistic spectrum disorders and severe challenging behaviours are reasonably common among adults with intellectual disabilities. The aim was to investigate whether they had an impact on lifestyle among such adults living in staff‐supported community housing. Methods Data were collected on the adaptive and challenging behaviour, social impairment, attention from staff, social and community activities, household participation and engagement in activity of 427 adults living in 146 staffed houses. Presence of the triad of impairments characteristic of autistic spectrum disorders was based on items from the Disability Assessment Schedule. Categorization of severe challenging behaviour was based on scores on two domains of the Aberrant Behavior Checklist. Participants were divided into groups with and without the relevant characteristics and sub‐samples selected which were matched on Adaptive Behavior Scale scores. Lifestyle outcomes were compared. In addition, multiple regression was used to examine the association between lifestyle outcomes and the presence of autistic spectrum disorders or severe challenging behaviours after controlling for other participant characteristics. Results After controlling for adaptive behaviour, there were no significant differences between those with and without the triad of impairments. People with severe challenging behaviour received significantly more staff attention but were similar in terms of social, community and household activities. The regression analyses found small negative associations between Aberrant Behavior Checklist scores and variety of social and community activities and household participation after controlling for Adaptive Behavior Scale scores. Conclusions Results support previous findings that low adaptive behaviour has a negative impact on lifestyle outcome. Compared with this, the presence of autistic spectrum disorders or severe challenging behaviour has little effect.     

Factors Relating to Staff Attributions of Control Over Challenging Behaviour

Background Previous research has suggested that severity of intellectual disability (ID) and topography of behaviour may influence staff causal attributions regarding challenging behaviour. Subsequently, these causal attributions may influence helping behaviours. This study investigated the relationship between attributions of control over challenging behaviour and individual and organizational factors. Methods A cross‐sectional survey using a between‐subjects natural groups design was employed. Care staff and managers completed measures to examine the relationship between staff attributions of control over challenging behaviour and client‐related variables, staff‐related variables and functioning of the organization. Results Staff attributed challenging behaviour as being less under personal control if the organization was of better quality. Staff attributions of control over challenging behaviours were lower if staff displayed positive attitudes towards the client, the physical and social environment was appropriate and the overall approach to delivering care seemed well‐structured. There was no relationship between staff attributions of control and ability of the individual or the overall level of challenging behaviour. However, with respect to specific topographies (i.e. physically aggressive and self‐injurious behaviour) there were different profiles of causal attributions made. Discussion Organizational factors, staff behaviour and the topography of challenging behaviour can each influence the attributions of control that staff make. Any interventions that seek to increase the helping behaviour of staff through manipulation of the attributions that they make need to consider both individual factors (topography of behaviour) and environmental factors (staff behaviour and the quality of the service and organization).     

Nurses' perception of the quality of care they provide to hospitalized drug addicts: Testing the Theory of Reasoned Action

A correlational design was used to examine nursing staff attitudes and subjective norms manifested in intended and actual care of drug users based on the Theory of Reasoned Action. One hundred and thirty‐five nursing staff from three central Israeli hospitals completed a questionnaire examining theory‐based variables as well as sociodemographic and professional characteristics. Most respondents reported a high to very high level of actual or intended care of drug users. Nurses' stronger intentions to provide quality care to drug users were associated with more positive attitudes. Nursing staff members had moderately negative attitudes towards drug users. Nurses were found to hold negative stereotypes of drug addict patients and most considered the management of this group difficult. Positive attitudes towards drug users, perceived expectations of others and perceived correctness of the behaviour are important in their effect on the intention of nurses to provide high‐quality care to hospitalized patients addicted to drugs.     

Person‐Centred Active Support – Increasing Choice,Promoting Independence and Reducing Challenging Behaviour

Background Previous research has found that active support is effective at increasing levels of participation in activities and supporting a good quality of life for people with intellectual disabilities. However, there has been little research on the effect of active support on other outcome measures. Methods This study uses observational methodology, combined with staff‐rated measures, to explore the impact of the implementation of person‐centred active support on the lives of 30 people with severe and profound intellectual disabilities living in small group homes. Results Analysis indicated that significant increases in both the amount of assistance people received and the quality of that assistance were accompanied by significant increases in engagement, participation, choice‐making opportunities and a significant reduction in challenging behaviour and in particular, self‐stimulatory behaviour. Conclusions The paper discusses the implications of the findings for both practice and for further research.     

The Effect of Active Support Interactive Training on the Daily Lives of Adults with an Intellectual Disability

Background Interactive training (IT) is one of the two staff training components of the active support (AS) model. The present study explores how effective IT is when offered to staff divorced in time from the AS workshops, the other training component. We explored the effects of IT on resident activity engagement, challenging behaviours and staff assistance. Materials and Methods Twenty‐one adults with an intellectual disability living in residential settings participated. Observations and ratings of staff and resident behaviours were obtained before, immediately after the training sessions, and at 6 months follow‐up. Results Group‐level analyses indicated a short‐lived improvement in quality of staff support but, in general, there was an overall lack of change in staff behaviours, resident engagement and – observed and rated – challenging behaviours. However, subgroup analyses indicated that there was a significant improvement in engagement immediately after IT for a distinct subgroup of participants; those who had significantly higher aggressive behaviour ratings at the beginning of the study. Conclusions Findings support the combination of the training components of AS for improvements in the quality of life for people with intellectual disability. IT may also be worthy of future study as a potential stand‐alone intervention for people with the most difficult challenging behaviours.     

Community Staff Causal Attributions about Challenging Behaviours in People with Intellectual Disabilities

Recent theoretically-driven models have suggested that care staff causal attributions about challenging behaviours may influence staff intervention behaviour. Previous research on staff attributions has been concerned mainly with institution staff. The present study focused on community staff attributions as compared with those of inexperienced healthcare workers (student nurses). A total sample of 94 participants were asked to rate the likely causes of one of three topographies of challenging behaviour (self-injury, aggression or stereotypy) using 25 attributional items presented in a questionnaire. Results showed that experienced care staff and inexperienced students differed in their views on likely causes of challenging behaviours, although this was not restricted to a single type of causal factor. The experienced staff as a group rated social and emotional variables as likely causes of challenging behaviours. Finally, both experienced and inexperienced participants distinguished between behavioural topographies in terms of their causes. Stereotypy was viewed as a self-stimulatory activity, whilst aggression and self-injury were rated as more likely to be caused by social and emotional factors. The implications of research in this area for staff training and behavioural intervention are outlined. In addition, suggestions for future research are discussed.     

RESIDENT BEHAVIOUR AND STAFF INTERACTION WITH PEOPLE WITH INTELLECTUAL DISABILITIES AND SERIOUSLY CHALLENGING BEHAVIOUR IN RESIDENTIAL SERVICES

The behaviour of 16 residents with severe intellectual disabilities and severely challenging behaviour and the interactions they received from staff were observed. Eight people lived in traditional hospitals and eight in community settings. The two groups were individually matched by adaptive ability. Differences in the occurrence of various categories of staff/resident interaction and resident activity between die two groups were not statistically significant. There was some indication that interaction and engagement in activity were improved in those community settings which were genuinely small and based on ordinary housing. However, a more striking finding for all residents was their lack of constructive occupation and the low level of assistance given by staff to help individuals participate more. Although generally responsive to the social overtures of residents, staff were otherwise not found to have an evident focus on encouraging resident engagement in activity. Two case studies are presented which, with other recent research, point to the impact which the content and focus of staff attention can have on resident activity patterns. Comparison to research on people with less severe challenging behaviour supports the contention that individuals with the most severe challenging behaviours tend to lead more impoverished lives.     

Predicting Placement Breakdown: Individual and Environmental Factors Associated with the Success or Failure of Community Residential Placements for Adults with Intellectual Disabilities

Background Individuals with intellectual disabilities are more likely to experience a breakdown in their community residential placement if they display ‘challenging’ behaviour. However, some individuals with behaviour that poses a severe challenge live successfully in community services long‐term, indicating that other factors are also important. This study seeks to test the validity of a proposed framework for placement breakdown that incorporates elements of Weiner’s theory of helping behaviour, in particular, staff attributions of control about the causes of an individual’s challenging behaviour. Method The study employed a between‐subjects design with two non‐experimental groups, controlling for the presence of challenging behaviour. One of these groups experienced a placement breakdown, whilst the other remained in the same placement. Staff completed questionnaires measuring a range of individual and service‐related factors. Results No differences were found between the groups in overall levels of challenging behaviour, although the breakdown group displayed higher rates of ‘intentional’ antisocial behaviour. Breakdown was predicted by a combination of increased community self‐sufficiency skills, attributions of a greater degree of control by the most senior members of staff, and lower levels of interaction and help from staff. Services in which a breakdown occurred were also of poorer overall quality, particularly in terms of staff resources and energy levels, the physical environment and administrative systems. Individuals experiencing breakdown were more likely to have had at least one acute behavioural or psychiatric admission. Conclusions Support was obtained for the proposed framework, indicating that staff attributions of control may play a mediating role between the challenging behaviour of an individual and the subsequent risk of placement breakdown. This has implications clinically in the identification of those at greater risk, given that this may not necessarily be those with the most severe challenging behaviour. Interventions to reduce this risk will need to address the way that staff think about challenging behaviour. Further research is required to test the validity of the framework.     

Resettlement Outcomes for People with Severe Challenging Behaviour Moving from Institutional to Community Living

Background The purpose of this study was to evaluate the quality of life consequences arising from the resettlement of adults with challenging behaviour severe enough to be deemed to require continuing healthcare from a traditional learning disability hospital to new purpose‐built bungalows. The new accommodation was provided by a specialist NHS trust through special project arrangements designed to ensure that the provision of homelike accommodation in the community was coupled with ‘state of the art’ staff training. Methods There were 19 participants. Baseline data were collected on their adaptive and challenging behaviour and psychiatric status. Data on a variety of quality of care and lifestyle indicators were collected when the entire sample was in hospital (T₁), when a minority had moved to the community, but the majority remained in hospital (T₂), when the majority had moved to the community but a minority remained in hospital (T₃) and at follow‐up (T₄), when all lived in the community. Results There were almost no areas of significant deterioration in quality of care or lifestyle outcome arising from moving to the community. The community provision was more homelike and associated with some improvement in working methods and staff contact received by participants, increased family contact, greater participant involvement in household activity and constructive activity generally and reduction in staff‐reported challenging behaviour. Increases in the range and frequency of social and community activities over time were found but such increase also occurred while people remained in the hospital. Conclusions This evaluation has shown that the quality of care and lifestyle outcomes associated with new NHS community settings for adults with learning disabilities and severe challenging behaviour assessed as requiring continuing healthcare were generally equivalent or superior to previous hospital levels. In this, findings were similar to other more general deinstitutionalisation studies. Certain improvement over time was found within the follow‐up period studied. Further follow‐up may be relevant as developing the desired working culture among staff from an institutional background may take longer than was given within the length of this study.     

Evidence-based practice and determinants of research use in elderly care in Sweden

RATIONALE AND OBJECTIVE: Evidence-based practice is a strategic ingredient in today's health care. Despite extensive efforts to produce and disseminate clinical guidelines, research uptake is still a difficult task. In Sweden, elderly care (EC) has shifted from hospital care to community-based care, and the major nursing-staff group in EC has no university education. These and other factors make implementation of evidence-based care particularly challenging in EC settings. The purpose of this study was to identify determinants of research utilization in EC. METHOD: Two questionnaires that cover research utilization and organizational climate were mailed to all staff (n = 132) working in seven EC units. The response rate was 67%. RESULTS: Of all respondents, 28% reported that they used research findings in daily practice (the RU group). Remaining respondents constituted the non-RU group. Significant differences existed between the RU group and the non-RU group as per six individual and six organizational factors. Using logistic regression models, four factors were significantly related to research utilization, namely: attitudes toward research (OR = 5.52, P = 0.004); seeking research that is related to clinical practice (OR = 5.56, P = 0.019); support from unit manager (OR = 4.03, P = 0.044) and access to research findings at work place (OR = 6.65, P = 0.005). CONCLUSIONS: Individual and organizational factors were associated with the use of research in EC. Despite distinguishing conditions in EC settings, identified factors reflect well-known determinants of research use that, as in many other health care contexts, should be considered in the endeavours of evidence-based practice.     

Attitudes toward dementia‐related aggression among staff in Japanese aged care settings

Aim and objective. This study investigated attitudes of Japanese aged care staff toward aggression by people with dementia. Relationships between staff attitudes, professional characteristics and clinical practice were explored. Background. Aggressive behaviour is often demonstrated by people with dementia and may be influenced by many factors including an inability by the individual to appropriately express their needs, difficulties with assessment, as well as organisational and practice issues. Design. Survey. Method. Twenty‐seven facilities/organisations located in the western and middle parts of Japan were surveyed. Staff (n = 675) employed in these facilities provided personal and professional information and completed the Attitudes Towards Aggression Scale. Results. Staff who were older, had more clinical experience, higher education and/or a higher position reported more positive attitudes towards patient aggression. Staff with negative attitudes towards patients who are aggressive reported using chemical and/or physical restraint more often than staff with positive attitudes. Conclusions. Dementia education as well as restraint policy will be useful in addressing negative staff attitudes, in particular it may help to reverse the myth that restraint is necessary for staff protection. Furthermore, staff counseling may help to reduce stressors and to change staff negative attitudes towards people with dementia who display aggression. Relevance to clinical practice. The findings show that negative staff attitudes may adversely affect clinical decision making and patient care. Measuring attitudes can identify areas requiring education or skill development and enable changes in attitudes to be monitored over time.     

A Communication Training Programme for Residential Staff Working with Adults with Challenging Behaviour: Pilot Data on Intervention Effects

Background Challenging behaviour often serves a communicative function. It therefore stands to reason that the residential staff working in developmental disability services require training to foster appropriate communicative interactions with adults with challenging behaviour. Method Eighteen members of staff working in three residential services participated in a 4 week communication training programme. The programme focused on staff attitudes to and beliefs about challenging behaviour, communicative interactions between staff and residents and working as a team. Objective measurements were made of the effects of the training programme on staff use of augmentative and alternative communication, praise and use of inappropriate language in a multiple‐baseline design across three organizations. Changes in the rate of challenging behaviours among the residents were also evaluated. Results As staff's use of AAC and praise increased, and inappropriate language decreased, there was some concomitant decrease in residents’ levels of challenging behaviour; however, these results were not sustained in the long‐term. Conclusion This pilot data suggest that an approach to staff training based on modifying attitudes and beliefs is potentially beneficial to both staff and residents.     

Effects of non-facilitated meaningful activities for people with dementia in long-term care facilities: A systematic review

This systematic review sought to evaluate the effectiveness of non-facilitated meaningful activities for older people with dementia in long-term care facilities. Searches were conducted in PubMed; CINAHL; EMBASE; Web of science; PsycINFO; Cochrane; ProQuest; and ClinicalTrials.gov to identify articles published between January 2004 and October 2019. A total of six studies were included. Results implied that current randomised controlled trials or controlled trials about non-facilitated meaningful activities for people with living dementia in long-term care facilitates are limited, but those included in this review were of adequate methodological quality. Meaningful non-facilitated activities, such as music, stimulated family presence, animal-like social robot PARO/plush toy and lifelike dolls, may have beneficial effects on agitation, emotional well-being, feelings of pleasure, engagement, and sleep quality. However, there remains a lack of conclusive and robust evidence to support these psychological and physiological effects of non-facilitated meaningful activities for older people with dementia living in long-term care facilities by care staff.     

Active Support,Participation and Depression

Background Staff training in Active Support is designed to enable direct support staff to increase the engagement and participation of people with intellectual disabilities in a range of daily activities. Method Residents (n = 41) and staff of nine group homes participated. The effectiveness of Active Support was evaluated with a pre‐test:post‐test design, using a number of standardized assessments and other questionnaires, with group home staff as informants. These assessments were conducted before Active Support training and an average of 6.5 months later. Results Following implementation of Active Support residents experienced significant increases in domestic participation and adaptive behaviour. There were significant decreases in internalized challenging behaviour, overall challenging behaviour and depression. There was no significant pre–post change in other forms of challenging behaviour. Conclusions Our findings confirm and extend previous Active Support research showing that implementation of Active Support is followed by increased resident participation in activities. The significant improvements in adaptive behaviour, challenging behaviour and depression are of particular interest as the present study is among the first to report such effects. The study’s limitations are discussed.