MENTAL HANDICAP VOL. 13 SEPTEMBER 1985

individuals with widely differing and c h a n g i n g serv ice n e e d s . E v e n i f mechanisms existed to enable consumer views to be sampled in order to ensure that what was being provided by statutory agencies matched consumer needs, services would have to be sufficiently flexible to allow for change at a pace that reflected current needs of an ever- changing population.

The results of the questionnaire, as well as highlighting approval of NIMROD, also identified short-falls in existing mental handicap services, such as advice on benefits and special allowances, short- term care, specialist services, and day care. Also, despite parents’ generally high levels of satisfaction, they considered many existing service components required improvement, including the social work, health visiting, and community nursing services which may be considered the cornerstone of domiciliary support services to families with a handicapped member. Early indications are that parents have found that NIMROD has provided them with more practical support than other existing services and that it is to NIMROD that they are more likely to turn for help with future problems.

The role of the client and family in the determination of the quality and quantity of mental handicap services is central in the issue of mental handicap service provision, although the importance of this role has not hitherto been acknowledged in a practical way by the planners and a d m i n i s t r a t o r s of s e r v i c e s . I t i s e n c o u r a g i n g t h a t , w i t h t h e implementation of the All Wales Strategy, plans for new patterns of service provision a r e n o w b e g i n n i n g t o i n c l u d e representation from consumers (Welsh Office, 1983; HMSO, 1985. Even so, there is still some way to go before consumers of mental handicap services will be afforded regular opportunities to make their needs known, rather than accepting the more traditional and passive role of recipients of services.

References HMSO. All Wales Advisory Panel on tht

Deve lopment of Services for Mentallj Handicapped People. Annual Report 1984. Cardiff Welsh Office, 1985.

Humphreys, S . , Lowe, K., Blunden, R. Long term evaluation of services for mentallj handicapped people in Cardiff: research methodology. Cardiff Mental handicap in Wales - Applied Research Unit, 1983.

Ward, L . People first. Developing services in tht community for people with mental handicap: i review of recent literature. Bristol: Bristol University, 1982.

Welsh Office. All Wales Strategy for tht Deve lopment of Services for Mentallj Handicapped People. Cardiff Welsh Office: 1983.

The full Research Report on which this article i: based may be obtained from Simone Humphrey5 at the address given.

rRAlNlNG STAFF in a large residential setting for people with mental handicaps Jim Wood Ian Berry Bill Cowell

SUMMARY. The article describes an approach to organising an in-service scheme :o provide direct care staff with skills in up-to-date teaching and handling techniques. Pspects of organisation and implementation are covered, and problems of naintenance and evaluation are included. An important benefit of the strategies mployed is the improved level of cooperation between two major disciplines towards he common purpose of resident care and progress.

Introduction The need for periodic changes in

philosophy and models of care for people who are mentally handicapped has been indicated in various Government reports and more recently in the revised 1982 syllabus for RNMH training. As the emphasis is on initial training, however, most staff working in hospitals were taught in line with the earlier medical model and they have limited access to the specific detail of the changes now expected of them. The need for inservice training of exis t ing s ta f f , bo th qual i f ied and unqualified, has been recognised (Mittler, 1981).

Training strategies vary but there are three important issues, in addition to content, that must be considered when p r e p a r i n g a t r a i n i n g p l a n : implementation, maintenance, and evaluation. The three are closely linked. How t ra in ing is implemented can influence the way it is maintained. Maintaining change is probably the most taxing area. Evaluation is necessary to monitor training and maintenance and allow judgements about effects to be made.

T h i s art icle outlines one way of implementing inservice training, and indicates how maintenance and evaluation can be attempted in a service setting.

Implementation strategy WHERE TO START

It is probably feasible to start with students undergoing initial training and to wait for ideas to permeate through the system. It would, however, take many

years for all the staff in a large organisation to be trained and the attitude changes noted by Moores and Grant (1976) could mean that some staff would lose their positive views as a result of contact with others holding different views.

The alternative is to work with existing staff so that groups be built up who know and understand the skills that newly qualified staff bring to the job and who can provide a setting where these skills can be used. C 0 N T E N T

Psychologists involved in staff training have two client groups to serve - staff and residents. Using a constructional approach to residents’ skill development by creating alternatives to inappropriate behaviours implies training staff in appropriate skills. The literature and courses available all p o i n t t o t h r e e main a reas where improvement in staff skills is required: precision teaching techniques to aid r e s i d e n t t r a i n i n g ; cons t ruc t iona l approaches to inappropriate resident behaviour by use of cont ingency management; and resident engagement in activity.

It must be decided whether training should be theoretically or practically based, reflect a principles to practice approach, or be general or specific in nature. The views of care staff must be considered - they are the practitioners, and so should be responsible for deciding on the particular methods to use with residents they know, such as the nursing process model of care for example. Content, therefore, needs to be directly applicable, providing staff with skills to

This article was written when all three authors were working at Leybourne Grange. JIM WOOD is now a Lecturer at Bromley College of Technology, Kent, IAN BERRY is a Principal Psychologist at Broughton Hospital, Nr. Chester, and BILL COWELL is the Director of Nursing Services at Leybourne Grange, West Malling, Kent.

0 1985 British Institute of Mental Handicap 97

MENTAL HANDICAP VOL. 13 SEPTEMBER 1985

use in a general way on their own initiative. Staff should not be expected to follow a “cook-book” approach to a very narrow range of resident needs.

Overall, a principles with practice approach appears to be necessary. The principles should include assessment, task selection and analysis, reinforcement, techniques of training, approaches to increasing/decreasing behaviours, and observation methods. Practice can be included by ensuring that staff develop and implement ac tua l individual programmes during training. COURSE ORGANISATION

Training was split into three main units, Teaching/Training, Contingency Management, and Room Management each consisting of six one hour sessions in which principles were introduced and discussed with associated practical tasks leading to development of an individual programme of work. A fourth unit covered more theoretical aspects. Training took place in the villas with staff attending during normal shift hours to avoid problems of release. This had the additional advantages of training groups of staff with a common fund of experience, and providing a mutual support system in a known environment after training. The intention was to “ ~ l ~ t ” the course content into the villa routine and this was achieved by holding weekly meetings according to working patterns. DELIVERY

Training was provided for 133 existing staff with various levels of responsibility (21 nursing officers, 24 ward managers, 5 staff nurses, 17 enrolled nurses, 64 nursing assistants, and 2 activity staff).

An early decision was made to include qualified and unqualified staff in the schedule, start ing with key senior personnel. Th i s gave senior staff knowledge and experience of what the training covered so that they could later advise more junior staff. It increased their commitment to the training and enabled them to give advice on the most suitable settings in which to commence as they were most aware of the needs of their staff and villas. I t also preserved their managerial role and allowed them to discuss the training being offered with reference to normal practice.

Subsequently training groups have included both trained and untrained staff with the advantages being that all villa staff are trained at the same time, it is easier to free a mixed group of staff for training, and it helps to develop a supportive framework within the everyday working situation.

Maintenance The early literature about staff training

is littered with examples of one-off approaches that were not sustained (Woods and Cullen, 1983). Staff often develop skills, then fail to use them. Plenty has been written as to possible reasons for

failing to maintain impetus - frequently the trainer loses contact either at the end of the course or once programme success is achieved.

I t has recently been realised that training does not occur in a vacuum but in an organisational context, and that change can be stifled if the system in which staff work is ignored. It is essential too for staff to have support through sustained contact with relevant practical advice. Training alone is a necessary but insufficient precursor to effecting change.

Adopting a systems view indicates that training, if it has impact, will inevitably lead to modifications in that system. It is the accommodation of such change by the organisation which can make or break it, and there must be realistic expectations of what t ra ining can achieve. These considerations necessitate a sympathetic approach to staff by those wishing to provide training and, importantly, a willingness and commitment to respond to staff initiatives. This can provide a foundation for initial development.

At Leybourne Grange one member of the training team devoted most of his time to the training and maintenance of skills developed by care staff, simultaneously helping senior nurses to sustain their role in the training.

The following strategies have been adopted to encourage maintenance and foster greater independence of care staff to continue implementing programmes. 1. During initial training and subsequently,

frequent contacts are made with villa staff to discuss individual work. Staff are encouraged to contact the psychologist teaching the course.

2. Discussion takes place with villa managers on likely ways of keeping things going. Meetings are held with all staff to discuss the outcome of training. Staff views on how to continue are sought. The use of a “goal planning” approach is considered most appropriate and the adoption of a nursing process model has facilitated its development.

3. A positive monitoring approach is adopted. At present this is informal, the person responsible for the staff training sustaining contact with villas and senior nurses. It is hoped that soon a more rationalised system will be adopted whereby programmes, their implementation, and reviews can be monitored regularly whilst still keeping open the channels of informal communication. This will allow for greater feedback which is so necessary to all staff working with people who are mentally handicapped.

4. A certificate is awarded for successful completion of each training unit . This increases staff motivation and commitment to complete the training and provides formal recognition of the effort they have made.

Evaluation Evaluation is essential in ventures of this

kind. It helps to identify strengths and weaknesses in the training. It allows examination of outcomes and methods of maintenance which assist the formation of judgements of worth. More importantly, evaluation can measure the practical implications of what has been done and help sensitise the training to the needs of

the client group served. Formal and informal means of evaluation occur and are complementary .

Evaluation must indicate whether staff and residents are benefitting from the scheme.

Residents should benefit from a planned, structured approach provided by trained staff. Results indicate that most residents’ individual programmes show some success within two to three weeks of staff training being undertaken, in skills ranging from washing, shaving, feeding and dressing, to using a symbol board, toys, drawing, cutting, and signing names. Many programmes have subsequently been revised to extend their skills, and other members of staff have become involved thereby increasing maintenance and generalisation of the skills learned.

It will be necessary to do some follow-up work to identify the skills acquired and maintained by the staff and how well residents perform in the long term as a result of staff intervention. Informal evaluation indicates that staff perceive the training as relevant and accept that it can be used and incorporated into their work routine. It adds interest to the job and helps build a team approach to resident care. It is also of interest to note the changed expectations of staff and the pleasure they receive by achieving success with residents. Ensuring commitment

The strategy described is summarised in Figure 1. It relies very much on the commitment of both care and psychology staff at senior level. Close consultation and cooperation between these professions is necessary in order that the training component is offered to care staff in the most relevant and acceptable way. This is applicable at all levels and involves time and compromise by both sides in order that staff in daily contact with residents can express practically the very real commitment they have to them. It is necessary for senior staff to agree course content, a time scale for relevant skills to be covered, the length of sessions, and the practical components. It is also important for psychology staff to convince direct care staff of their commitment and to avoid the adoption of a “here today - gone tomorrow” approach.

Commitment at senior level eases many potential difficulties. Senior nurses can retain control over introduction of training in the villas and explain the scheme to ward managers. Discussion about details then occurs with villa managers and villa staff.

At the direct care level, meetings, times, and groups are flexible. They are organised by villa managers with individual staff deciding who they work with, and what and how they teach. This helps to develop a personal commitment to the training programmes they put into practice. The staff trainer and other psychologists are readily available to discuss individual programmes. While

98 @ 1985 British Institute of Mental Handicap

MENTAL HANDICAP VOL. 13 SEPTEMBER 1985

staff a r e expected to comple te a programme within a reasonable time after a training session (usually one month), they are not expected to function as “learners” nor to complete work bit by bit or at set times. This is a reflection of shift patterns and other duties that are part of the job. Thus they retain responsibility for the practical and teaching components of the training.

Conclusion The scheme outlined is still in the early

stages of consolidation but has been operative long enough for a degree of confidence in the approach to have been acquired. The scheme has involved negotiation and compromise on detail, without sacrificing principles. An i m p o r t a n t f e a t u r e has been communication - a two-way process to keep relevant persons informed and involved.

The approach offers several advantages: senior care staff are aware of what is offered and are in a position to assist and retain responsibility; common ground between psychology and the care discipline is established; psychological involvement and the specialist nature of mental handicap care is increased; it helps narrow the gap between theory and practice, as well as between people at different levels in the hierarchy; it is skill based, thus having a direct appeal; training occurs in-situ; staff develop knowledge and expertise on more up-to-date

4 Discuss organisation and structure k-- Care! staff Psychology staff of scheme

I 1

b Meeddiscuss4 4 I

Senior nurses

1 (work groups)

I Staff trainer

Training

1 Develop, programme,

and teach

1 Re’iew -Villa managers I 1

Villa staff - Maintain staff skills

FIGURE 1. Implementing staff training

approaches; existing staff are trained in the skills that students in initial training receive, thus enhancing the opportunities for consistency and continuation of the skills learned in practice.

Probably the best summary would be to quote what some staff have said:-

“This is what I thought I had trained for and come here to do!” (qualified staff member); “I didn’t think it would, but it has made us work more as a team.” (unqualified assistant); “It makes the job much more interesting.” (both qualified and unqualified staff).

Acknowledgement Thanks are expressed to the residents

and staff of Leybourne Grange for allowing us to develop this work and for enthusiastically putting it into practice.

References Mittler, P. Strategies for manpower development

in the 1980’s. J. Pract. Approaches in Dev. Hand., 1981; 4: 3, 23-27.

Moores, B., Grant, G. W. B. Nurses expectations for accomplishment of Mentally Retarded Patients. Am. J . Ment. Defic., 1976; 80:6,644- 649.

Woods, P. A., Cullen, C. Determinants of staff behav iour in l o n g - t e r m care . Behav . Psychother., 1983; 11, 4-17.

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