Matthew N. I. Oliver, M.A.
Trisha T. Leimkuhl, B.A.
Gemma D. Skillman, Ph.D.
Department of Psychology, University of South Dakota
Direct-care paraprofessionals play an integral part in the community support for adults with mental retardation. Such paraprofessionals assume a variety of responsibilities including administering medications, assisting consumers with self-help needs, accompanying consumers to and from various community activities, and assisting consumers in the development of other daily adaptive behaviors. Additionally, paraprofessionals regularly face the responsibility of addressing challenging behavior and implementing behavior support programs (Aylward, Schloss, Alper, & Green, 1995). In order for staff to carry out their responsibilities in a manner that ensures optimal support quality, paraprofessionals need to be consistent, competent, highly motivated, and satisfied with their jobs. However, the potential negative effects of stress and burnout in this type of work for staff are numerous and can include increased client abuse, increased turn over (Aiken & Schloss, 1994), and the ineffective application of behavioral interventions (Knowles & Landesman, 1986; Morgan, 1990). Thus, ensuring that direct-care staff receive adequate training will likely reduce job-related stress and dissatisfaction and lead to better consumer support.
Hatton and Emerson (1993) reviewed several studies that focused on direct-care staff burnout and suggested it as being a reliable precursor to staff turnover. Indeed, Jacobson and Ackerman (1989) found the average direct-care paraprofessional annual turnover rate for the state of New York was 31% with a mean staff tenure of 2.8 years. Although stress and burnout in paraprofessional staff supporting persons with mental retardation have been surveyed (Aiken & Schloss, 1994), the needs of particular staff groups have not been greatly recognized. For example, it is not clear whether staff working in vocational settings experience similar stressors or respond to behavior-related stress in a similar manner as do staff working in residential settings. It is also not clear whether staff training needs vary substantially across work-place settings. Moreover, it is not clear whether paraprofessional staff supporting consumers with severe and profound developmental disabilities desire strategies and training that differ from staff working with higher functioning consumers.
Several studies have found training paraprofessionals to be beneficial. For example, one study found that staff training brought about an overall increase in social interaction between staff and consumers (Schepis & Reid, 1994); other studies have found that staff training improved adherence to correctly implementing behavioral support programs (Parsons & Reid, 1993; Shore, Iwata, Vollmer, Lerman, & Zarcone, 1995). Moreover, Schinke and Wong (1977) found that staff training significantly increased staff knowledge of behavioral principles, improved staff-rated evaluations of consumers, and improved job satisfaction. Nonetheless, in a study done by Christian, Snycerski, Singh, and Poling (1999), approximately one-third (31%) of direct-care staff working with persons who had mental retardation reported receiving inadequate training in the area of behavior management; moreover, they found that a significant number of direct-care staff desired additional training in behavior management skills (83%).
A number of programs for training direct-care paraprofessionals in the use of behavior support strategies have been developed (Gardner, 1973; Parsons & Reid, 1993; Shore, Iwata, Vollmer, Lerman, & Zarcone, 1995). Gardner (1973) identified several areas needing evaluation regarding direct-care staff including understanding behavioral principles behind interventions in addition to the skills needed to appropriately cope with job-related stress. Research has suggested (Browner et al., 1986) that aggressive behavior is one of the most significant sources of stress for direct-care staff. Unfortunately, excessive stress often acts a significant obstacle to paraprofessionals needing to effectively implement behavioral support strategies. For example, staff in an emotionally charged atmosphere frequently express biases and distortions in their conceptualizations of challenging behavior (Worchel & Cooper, 1983). Of particular concern is that staff under high levels of stress may begin to see their behaviors as irrelevant to consumers' behavior, which may result in paraprofessionals being less willing to consistently adhere to behavior support programs for consumers (Oliver & Skillman, 2002). Furthermore, once staff have formed an initial impression of a consumer's behavior, the impression can be difficult to change (Karan, Harrington, & Broday, 1993) because staff often act in ways that sustain their beliefs (Cooper & Baron, 1977). Unfortunately, consumers with more challenging behavior are more likely to be avoided and have less interaction with staff than consumers who do not (Hastings & Remington, 1994). Nonetheless, understanding the relationship between knowledge of behavior principles and stress due to challenging behavior may yield insight as to how staff stress might be minimized.
The purpose of this study is to survey direct-care paraprofessionals' ratings of various training needs, work-relevant behavior-related stressors, and job satisfaction. This study also seeks to compare ranked training need priorities across paraprofessionals' work-place settings. Finally, this study evaluates the hypothesis that paraprofessionals' knowledge of behavioral principles is related to their reported stress ratings and work satisfaction.
All respondents worked in one of two mid-sized Midwestern agencies that provided services specifically for adults with developmental disabilities. Participating agencies provided individual staff members survey packets with the invitation to participate. Participating staff voluntarily mailed their completed packets back to the authors. Participants were 93 (37%) staff from a potential pool of 250 community direct-care paraprofessionals working in residential and vocational settings. The residential setting included staff working with lower functioning (i.e., primarily consumers with severe to profound mental retardation) consumers in group homes as well as staff helping higher functioning (i.e., primarily consumers with mild to moderate mental retardation) consumers through assisted living support. The vocational setting involved staff working in either sheltered workshops or in specific community-based employment sites. Because paraprofessionals from both agencies did not differ on overall stress, satisfaction, training needs, and behavior knowledge, demographic information of participants from the two agencies are presented collectively (See Table 1).
Participants completed a survey with 14, 10, and 10 items regarding training needs, work-related behavioral stressors, and work satisfaction, respectively. Surveys were partially constructed from archival data collected at one of the sampled agencies. That is, items regarding behavioral stressors were constituted from commonly reported challenging behaviors (e.g., physical aggression, self-injurious behavior, self-isolation). These behaviors were rated on a 5-point Likert scale ranging from 1, "very stressful," to 5, "not stressful at all." Items regarding training needs and job satisfaction were constructed from information gathered during a training inservice in which staff were asked to list things for which they would like additional training and what they liked and disliked about working at the agency. Training needs were rated on a 6-point Likert scale ranging from 1, "strongly agree," to 6, "strongly disagree"; job satisfaction items were rated on a 7-point Likert scale ranging from 1, "very satisfied," to 7, "very unsatisfied." Staff also completed a survey on knowledge of behavioral principles adapted from the Knowledge of Behavioral Principles as Applied to Children (KBPAC; O'Dell, Tarler-Benlolo, & Flynn, 1979). Fifteen items were selected at random from this 50-item measure. Modifications were made to the items only to make the wording applicable to paraprofessionals supporting adults with mental retardation.
Descriptive statistics on training needs, behavior-related stress, and job satisfaction are presented in Tables 2 through 4. To evaluate training need differences across residential and vocational work-place settings, an analysis of variance (ANOVA) was computed; no differences were found. The training needs of residential staff were evaluated to assess whether training needs of paraprofessionals working with persons having more severe forms of mental retardation differed from those working with higher functioning individuals. An ANOVA indicated that residential staff supporting lower functioning consumers were more likely to desire training on adapting the physical environment to reduce problem behavior (F = 7.68, p< .01; M = 2.73, SD = 1.15 vs. M = 3.80, SD = 0.91) and on identifying behaviors to be changed than were staff supporting higher functioning individuals (F = 5.02, p< .03; M = 2.95, SD = 1.12 vs. M = 3.80, SD = 1.03). To evaluate the relationship between paraprofessionals' knowledge of behavioral principles and their perceived behavior-related stress and work satisfaction, paraprofessional knowledge of behavioral principles was regressed on staff stress and satisfaction. No significant relationships were found. Interestingly, paraprofessionals tended to have a weak understanding of behavioral principles; the average adapted scale score was 6.70 (SD = 2.33; Range 1 to 13) out of 15.
When training need items were assessed individually, staff ranked training regarding mental health issues, handling crisis situations, developmental disabilities, and using non-aversive behavioral interventions as being particularly desirable. While the interest in behavioral management is not surprising and is important, better awareness of mental health issues and developmental disabilities in general are also important. This is likely to benefit both staff and consumers in that heightening paraprofessional's awareness of how disabilities and mental health needs may affect consumers enables staff to act more diligently in providing support. Interestingly, agencies have not traditionally focused on this issue. Indeed, residential staff have often received little or no training regarding mental illness despite the fact that the coexistence of mental retardation and mental illness has been well-documented (Borthwick-Duffy, 1994; Jacobson, 1990; Nezu, Nezu, & Gill-Weiss, 1992). Moreover, although Thomas (1994) found staff members to be motivated and committed to providing quality services, they generally are unable to skillfully address the treatment needs of the dually diagnosed consumer.
When evaluating training need differences across work-place setting, no differences were found. However, when training needs of residential staff were evaluated, residential staff supporting lower functioning consumers, relative to staff supporting higher functioning consumers, were more likely to desire training on adapting the physical environment to prevent problem behavior and on identifying behaviors to be changed. This is interesting given the relative difficulty in assessing behavioral functions and in treating challenging behavior in adults with more severe mental retardation as opposed to their higher functioning counterparts. Moreover, given the common pervasiveness of impairment for persons with more severe forms of mental retardation, agencies may need to provide paraprofessionals with training on how to prioritize which behaviors to treat in order to optimize consumers' quality of life.
In addition to evaluating training needs of paraprofessionals, this study evaluated the relationship of behavior-related stress and job satisfaction with direct-care paraprofessionals' behavioral knowledge. The results suggest that paraprofessionals' knowledge of behavioral principles and their perceived behavior-related stress and work satisfaction are not related. It is important to note that paraprofessionals are likely to have limited understanding of behavioral principles which suggests that staff may be prone to inadvertently facilitate and maintain challenging behavior rather than prevent it. Nevertheless, paraprofessionals tended to implicitly emphasize the need to learn more about managing behavioral concerns.
The results of this study need to be considered in light of a number of limitations. First, although the 37% return rate of paraprofessionals supporting persons with mental retardation is comparable, if not higher than, similar field-based survey research, this may limit the generalizability of the results to other paraprofessionals in the community setting. Second, while no relationship was found between knowledge of behavioral principles and work-related stress, the stressors evaluated by the participants involved specific challenging behaviors and not other non-behavioral stressors that may be influenced by staff members' understanding of behavioral principles. Finally, inferences drawn from differences between working with higher and lower functioning consumers in the residential setting should be cautiously considered given the small sample size of staff working with consumers in assisted-living apartments (N = 10) than in group home facilities (N = 64).
Given our findings, we encourage community agencies supporting adults with mental retardation to take a progressive and continuous approach in improving their agency support systems. Several management styles have emerged that resonate with these values including Total Quality Management (TQM) and Continuous Quality Improvement. For example TQM is a leadership approach used by consumer-driven community agencies that identify and achieve quality outcomes. To do this, such agencies utilize systems thinking, continuous evaluation, and organization-wide participation (Sluyter, 1998).
Agencies are specifically encouraged to provide more information on mental health aspects of behavioral concerns and to evaluate the impact of paraprofessional trainings on staff behavior as well as consumer outcomes. Additionally, agencies should consider how to involve staff and consumers in policy development and support innovation. This can help reduce a top-down management approach which can lead to irrelevant policy while increasing the sense of affiliation staff members have with their agency philosophy and mission. Moreover, agencies would do well to include paraprofessionals when developing or selecting staff inservices, and thereby optimize the relevance of the presented information. Agencies might also consider developing a recognition plan to continuously reward employee efforts exerted toward collaboratively chosen support outcomes.
Taking a progressive and continuous approach to considering the training needs, stress, and satisfaction of direct-care paraprofessional staff is important for community agencies supporting persons with mental retardation. That is, effectively addressing direct-care paraprofessionals' training needs, work-related stress, and job satisfaction ultimately affects the quality of support agencies render to the consumers they serve. Essentially, agencies who use leadership to involve their direct-care staff in policy development, support innovation, and who recognize the efforts of their staff create a community context wherein all parties can benefit.
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Correspondence concerning this article should be addressed to Matthew Oliver (firstname.lastname@example.org), Department of Psychology, University of South Dakota, 414 E. Clark St., Vermillion, SD 57069. Portions of this paper were presented at the 2001 Annual Meeting of the American Association on Mental Retardation, Denver, CO.