LEARNING DISABILITIES

Health Evidence Bulletins - Wales

Literature searches completed on: 31st December 1999

9: Staff Training

This bulletin is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.

The Statements The Evidence
9a. Staff are supporting clients with a range of challenging behaviours, including aggressioni,ii,iii and sexually inappropriate behaviouriv in community settings, and such staff are likely to be the victims of assault. i. Harris, P. The nature and extent of aggressive behaviour amongst people with learning difficulties (mental handicap) in a single health district. Journal of Intellectual Disability Research 1993; 37: 221-42
(Type IV evidence - survey of the prevalence rates different categories of challenging behaviour including: aggression, self-injury, stereotyped and withdrawal behaviours. Study covered one health district and included 78 services. Based on base population data available, the overall prevalence rate of aggression was estimated at 17.6%)
ii. Department of Health. Services for People with Learning Disabilities and Challenging Behaviours or Mental Health Needs. Report of the Project Group. London: HMSO, 1993
(Type V evidence - expert committee analysis of the approaches of a number of services, service commissioners and providers to challenging behaviour, with a recommendation that models of care should centre around community based residences)
iii. McKenzie K, Simpson F, Matheson E, et al. Challenging experiences. Learning Disability Practice 2000; 2(3): 8-11
(Type IV evidence - survey covering three geographical areas and including 53 social care and 40 health staff working in intellectual disability services, and control group (n=30) who did not. Study found 73% of former group had experienced workplace assault, compared with 7% of the latter group)
iv. McKenzie K, Matheson E, McKaskie K, et al. Health and social care staff responses to working with people with a learning disability who display sexual offending type behaviours. Journal of Sexual Aggression 2000; (In Press)
(Type IV evidence - survey of 81 social care staff and 15 health staff. The latter group were employed to provide medium security accommodation to sex offenders. 59% of the former group supported a client who had committed a sexual offence or displayed an offending type behaviour. The range of behaviours was similar to that displayed by clients supported by the former group)

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9b. Well trained and skilled staff are identified as essential in the provision of quality community servicesi,ii,iii,iv,v. i. Scottish Executive. The Same as You: A Review of Services for People with Learning Disabilities. Edinburgh: Scottish Executive, 2000
http://www.scotland.gov.uk/ldsr/docs/tsay-00.asp
[accessed 8.12.00]
(Type V evidence - policy document based on expert opinion, consultation exercises, workshops and commissioned research. Concluded there is a need to develop a Scottish Centre to provide and promote staff training)
ii. Department of Health. Services for People with Learning Disabilities and Challenging Behaviours or Mental Health Needs. Report of the Project Group. London: HMSO, 1993
(Type V evidence - expert committee analysis of the approaches of a number of services, service commissioners and providers to challenging behaviour, identifying the factors required for good quality challenging behaviour services)
iii. Department of Health and Social Security. Better Services for the Mentally Handicapped. London: HMSO, 1971
(Type V evidence - early policy document based on expert opinion, identifying staff skills and training as central to community care provision)
iv. Social Services Inspectorate. Training for Community Care- A Strategy. London: Department of Health, 1990
(Type V evidence - strategy document based on expert opinion)
v. Mittler PJ. Staff development: changing needs and service context in Britain in Hogg J, Mittler P. (eds.) Staff training in Mental Handicap. London: Croom Helm, 1987
(Type V evidence - expert opinion based on overview of staff and service development issues)

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9c. Both health and social care staff have been found to be lacking knowledge about the basic defining features of an intellectual disabilityi,ii and their duty of care to intervene if clients put themselves or others at riskiii,iv. i. McKenzie K, Murray GC, Higgon J & Matheson E. What is a learning disability? - Do people need to be reminded. Learning
Disability Practice 1999: 2(1): 8-11
(Type IV evidence - survey of 163 health and social care staff which found all groups had low levels of knowledge about the criteria for a intellectual disability)
ii. McKenzie K, Murray GC, Matheson E. Learning disability services - a survey of general practitioners opinion. Scottish Medicine 1999: 17(5): 4-6
iii. Brown H, Hunt N, Stein J. Alarming but very necessary: Working with staff groups around the sexual abuse of adults with learning disabilities. Journal of Intellectual Disability Research 1994: 38(4): 393-412
(Type IV evidence - survey of 83 staff regarding knowledge of sexual abuse issues. It was found that staff were uncertain about their roles and responsibilities and that sexual abuse was dealt with haphazardly)
iv. Lyall I, Holland A, Collins S. Offending by adults with learning disabilities and the attitudes of staff to offending behaviour. Journal of Intellectual Disability Research 1995: 39(6): 22-31
(Type IV evidence - survey of residential and day care provision in the Cambridge Health District which found the tolerance of some dangerous and antisocial behaviour of clients was high)

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9d. Staff have been found to be lacking knowledge, training and confidence in managing challenging behaviour and sexually inappropriate behaviouri,ii,iii,iv,v. i. Hastings RP, Remington B. Staff behaviour and its implications for people with learning disabilities and challenging behaviours. British Journal of Clinical Psychology 1994; 33: 423-38
(Type III evidence - review of observational and experimental studies: staff behaviour maintains challenging behaviours by negative or positive reinforcement).
ii. Bromley J, Emerson E. Beliefs and emotional reactions of care staff working with people with challenging behaviour. Journal of Intellectual Disability Research 1995; 39: 341-52
(Type IV evidence - survey of 70 staff supporting clients with an intellectual disability. Staff reported colleagues often reacted inappropriately to displays of challenging behaviour e.g. by showing fear and disgust)
iii. McKenzie K, McIntyre S, Matheson, Murray GC. Health and social care workers’ understanding of the meaning and management of challenging behaviour in learning disability services. Journal of Learning Disabilities for Nursing, Health And Social Care 1999; 3(2): 98-105
(Type IV evidence: questionnaire examining the knowledge of 95 health and social care staff working in intellectual disability services about the factors important in managing challenging behaviour).
iv. Murray GC, McKenzie K, Quigley A, Sinclair B. The relationship between training and the experience of aggression in the work-place in social care staff working in learning disability services. Journal of Learning Disabilities for Nursing, Health and Social Care 2000; 3(4): 214-218
(Type IV evidence - survey of 50 social care staff. The minority had received training in prevention and management and levels of confidence varied widely)
v. McKenzie K, Matheson E, McKaskie K, et al. Health and social care staff responses to working with people with a learning disability who display sexual offending type behaviours. Journal of Sexual Aggression 2000; ( In Press)
(Type IV evidence - randomised controlled survey of 81 social care and 15 health staff supporting clients with a forensic or sexual offence background. Few had received formal training in dealing with prevention and management of offending type behaviour)

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9e. Staff behaviour has been shown to effect the occurrence or non-occurrence of challenging behaviouri,ii,iii. i. Hastings RP, Remington B. Staff behaviour and its implications for people with learning disabilities and challenging behaviours. British Journal of Clinical Psychology 1994; 33: 423-38
(Type III evidence - review of observational and experimental studies. Staff behaviour maintains challenging behaviours by negative or positive reinforcement and implicating the role of social interaction as a maintaining factor)
ii. Hastings RP. Staff strategies and explanations for intervening with challenging behaviours. Journal of Intellectual Disability Research 1996; 40(2): 166-75
(Type IV evidence - cohort study examining staff (n=109) descriptions of their reactions to a challenging behaviour scenario)
iii. Donnellan A, La Vigna G, Shoultz N, Fassbender L. Progress Without Punishment. London: Teachers College Press, 1988
(Type V evidence - expert opinion outlining constructive, non-aversive approaches to challenging behaviour based on case studies, clinical experience and the implementation of psychological principles)
9f. Training may range from time-limited formal and informal training coursesi,ii,iii to ongoing inputiv. i. Care Sector Consortium. National Occupational Standards for Care. London: HMSO, 1992
(Type V evidence - example of formal National Vocational Qualifications (NVQs) for staff working in intellectual disability services)
ii. McVilly KR. Residential staff: How they view their training and professional support. British Journal of Learning Disabilities 1997; 25: 18-25
(Type IV evidence - review of some formal training courses available to staff working with clients with an intellectual disability)
iii. McKenzie K, Matheson E, Patrick S, et al. An evaluation of the impact of a one-day challenging behaviour course on the knowledge of health and social care staff working in learning disability services. Journal of Intellectual Disabilities 2000; 4(2): 153-165
(Type II evidence - randomised control study: the impact of a one day training course on the knowledge of 59 health and social care staff, compared to a control group of 73 untrained staff)
iv. Taylor I, O'Reilly M, Lancioni G. An evaluation of an ongoing consultation model to train teachers to treat challenging behaviour. International Journal of Disability, Development and Education 1996; 43(3): 203-18
(Type III evidence - interventional study evaluating the impact of a psychologist providing continuing advice to staff working with a client who exhibited high rates of self-injury)

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9g. A substantial number of staff have not received trainingi,ii or report that it is inadequate to meet the needs of their jobii. i. Smith B, Wun W-L, Cumella S. Training for staff caring for people with learning disability. British Journal of Learning Disabilities 1996; 24: 20-5
(Type IV evidence - survey of 299 staff in six health districts in the West Midlands. 12% of managers and 17% of care staff had received induction training: 75% of care staff in private establishments, 32% of local authority care staff, 17% of voluntary sector care staff and 4% of health care staff had not attended any courses in the previous five years)
ii. McVilly KR. Residential staff: How they view their training and professional support. British Journal of Learning Disabilities 1997; 25: 18-25
(Type IV evidence - review of formal training courses available to staff working with clients with an intellectual disability. Both staff and managers of social care services felt that the training that they had received was inadequate in relation to that required for their job)
9h. Some training has been found to be effective in increasing staff knowledgei,ii and impacting on practiceiii,iv.
(Health gain notation – 2 "likely to be beneficial")
i. McKenzie K, Matheson E, Patrick S, et al. An evaluation of the impact of a one-day challenging behaviour course on the knowledge of health and social care staff working in learning disability services. Journal of Learning Disabilities 2000; 4(2): 153-165
(Type II evidence - randomised control study examining the impact of a one day training course on the knowledge of 59 health and social care staff, compared with a control group of 73 untrained staff. Training was found to significantly increase knowledge for up to one year)
ii. Berryman J, Evans IM, Kalbag A. The effects of training in non-aversive behaviour management on the attitudes & understanding of direct care staff. Journal of Behaviour Therapy and Experimental Psychiatry 1994; 25(3): 241-50
(Type III evidence - intervention study of the impact of two types of training on staff (n=83) attitudes and knowledge. Those trained in non-aversive techniques showed increased understanding of complexity of causes for challenging behaviour and skills based treatment approaches)
iii. Allen D, McDonald L, Dunn C, Doyle T. Changing care staff approaches to the prevention and management of aggressive behaviour in a residential treatment unit for persons with mental retardation & challenging behaviour. Research in Developmental Disabilities 1997; 18(2): 101-12
(Type III evidence - intervention study over a 5 year period which found clinically significant changes in terms of reduction in use of restraint, medication and in rates of staff and client injury)
iv. Taylor I, O'Reilly M, Lancioni G. An evaluation of an ongoing consultation model to train teachers to treat challenging behaviour. International Journal of Disability, Development and Education 1996; 43(3): 203-18
(Type III evidence - interventional study evaluating the impact of a psychologist giving ongoing consultation regarding functional assessment and adhering to behavioural principles to staff working with a client who exhibited high rates of self-injury. This led to a significant decrease in the client’s behaviour.)

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9i. Training has not always been found to be cost-effectivei or to have long-term benefitsi,ii. i. Ziarnik JP, Bernstein GS. A critical examination of the effect of inservice training on staff performance. Mental Retardation 1982; 20(3): 109-14
(Type V evidence - expert opinion based on a review of early literature in relation to effectiveness of staff training. Concludes that staff training alone is not an adequate solution to deficits in staff performance)
ii.
Cullen C. A Review of Some Important Issues in Research and Services for People with Learning Disabilities and Challenging Behaviour. 2000: Scottish Executive review of services for people with a learning disability. Edinburgh: Scottish Executive, 2000
(Type V evidence - expert opinion based on a literature review, concluding that staff training alone is not a sufficiently powerful factor to achieve enduring change)
9j. Evaluating the effectiveness of staff training is difficult. The outcome of training can be effected by a number of factors; the social, organisational and political context that the staff work ini (e.g. if changes in staff attitudes, knowledge and behaviour are not supported in the work environment they are unlikely to be maintained over time); staff characteristics (e.g. experience, skills and knowledge)ii; the perceived quality, relevance and applicability of the training itselfii. i. Harper DJ. Evaluating a training package for staff working with people with learning disabilities prior to hospital closure. The British Journal of Developmental Disabilities 1994; XL(1): 45-53
(Type V evidence - expert opinion based on a review of the literature)
ii. Landesman-Dwyer S, Knowles M. Ecological analysis of staff training in residential settings. In Hogg J, Mittler P (eds.) Staff Training in Mental Handicap. London: Croon Helm, 1987
(Type V evidence - expert opinion, presentation of models for the relationship between staff characteristics and behaviour, and the relationship between the quality and relevance of training to the effects of that training)
9k. It is important to establish clearly the type and nature of the training needs of the service in questioni,ii and to establish which goals the training is designed to meet and which outcome measures will be used to evaluate effectiveness. Five different types of outcome measures used in this field are outlinedii.
Subjective i.e. what staff report about the usefulness, validity, and quality of the training; Cognitive i.e. knowledge gain; Behavioural i.e. the impact of training on behaviour; Client centred i.e. the impact on clients; and Organisational i.e. the impact on the work organisation.
i. Cullen C. A Review of Some Important Issues in Research and Services for People with Learning Disabilities and Challenging Behaviour. 2000: Scottish Executive review of services for people with a learning disability. Edinburgh: Scottish Executive, 2000
(Type V evidence - expert opinion based on a literature review, concluding that staff training alone is not a sufficiently powerful factor to achieve enduring change)
ii. Ziarnik JP, Bernstein GS. A critical examination of the effect of inservice training on staff performance. Mental Retardation 1982; 20(3): 109-14
(Type V evidence - expert opinion based on a review of early literature)
9l. There is currently insufficient evidence to unequivocally establish the effectiveness of staff training alone in improving staff practice in managing challenging behaviour.
(Health gain notation – 4 "unknown")
 

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk