Friday, 29 June 2012

Who’s Challenging Who? Changing the hearts and minds of support staff working with individuals whose behaviour challenges

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Practice/Policy context

Several UK care scandals in the past two decades have identified that support staff working with individuals with a learning disability whose behaviour challenges can behave in ways that constitute abuse and maltreatment. The latest of these in 2011 focused on the BBC Panorama documentary about the Winterbourne View care home.

The latest scandal suggests that promises that “this can never happen again” have not been fulfilled. This is despite appropriate policy and commissioning guidance, and recommendations for best practice in working with people whose behaviour challenges.

Professor Richard Hastings (School of Psychology, Bangor University) has been carrying out research for more than 20 years focused on staff who work with individuals whose behaviour challenges. He argues that policies and guidance are too far removed from the day-to-day factors that influence staff behaviour towards those they support. Although Professor Hastings agrees that staff skills and knowledge in understanding and intervening with challenging behaviour are important, he also argues that two further dimensions are neglected. First, support staff experience their work with challenging behaviour as emotionally demanding. Second, staff attitudes towards individuals labelled as “challenging” need to be changed. Change is needed to address these two influences on support staff behaviour.

The Who’s Challenging Who project

Who’s Challenging Who (WCW) is an attitude change training package that has been developed over 18 months since January 2011 (pre-dating Winterbourne View). The development and pilot evaluation of WCW was funded by a Knowledge Transfer Partnership grant between Mencap and Bangor University. WCW involves a person with learning disability who has behaviour that challenges working with a person without disability as co-trainers for a half day workshop targeting health and social care support staff.

The WCW training curriculum was informed jointly by the experiences of the co-trainers with learning disability and by existing research evidence. The theory behind the WCW training is to provide multiple opportunities for direct contact with individuals whose behaviour challenges and contact with information about their experiences of services and being labelled as “challenging”. Small groups of support staff (up to 10) experience an intensive interactive session with the aim of increasing their empathy (what it is like to be in the shoes of individuals labelled as challenging), and changing their attitudes.

Contact theory (the theory behind WCW) has already been used successfully to inform attitude change and reduce stigma towards other excluded groups, such as individuals with mental health difficulties.

Who’s Challenging Who outcome data

Professor Hastings and colleagues have recently carried out a research evaluation of the WCW training package with 10 groups of staff (a total of 76 staff attended evaluation groups). Research measures were used to assess staff attitudes towards those whose behaviour challenges before the training course and after the WCW training. Outcomes measured were: staff empathy, staff similarity attitudes (beliefs about the similarity between people whose behaviour challenges and other people), empowerment attitudes (beliefs about people whose behaviour challenges being empowered to take control of their lives), and staff feelings of confidence in supporting individuals whose behaviour challenges.

Statistically significant changes pre-post WCW training were found for all four attitudinal dimensions. Although statistical change is important because it suggests a reliable positive change in the group of staff trained using WCW, it is also important to ask how large the training effect was. Using metrics called effect sizes, Professor Hastings and colleagues showed that the training effect was “moderate” or “medium” in size. What this means is that the attitude changes observed were clinically or practically meaningful, especially given that this was only a half day training. Thus, the data on WCW effectiveness are very encouraging.

What next?

WCW could be used as an attitude change intervention in learning disability services throughout the UK and internationally. WCW could be a part of the response to the Winterbourne View scandal. Evidence-based approaches to changing staff attitudes within services are sorely needed right now. WCW could be used in induction training, as a refresher/booster training for staff who have worked in health and social care for a long time, and/or alongside skills/knowledge-based training on challenging behaviour.

Of course, there are also opportunities for further research on the outcomes of WCW. In particular, a test of WCW against a control condition is needed. Feedback from individuals attending the pilot training also included the suggestion that WCW may be more powerful if co-delivered by an individual from the services within which staff work. This model could be explored in future research.

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