Ann R. Poindexter, M.D.
Probably one of the most important factors in the development of successful programs for people with developmental disabilities and behavioral/psychiatric problems is the active presence of excellent direct support staff. A number of factors are associated with maintaining this factor, including recruitment, training, and retention.
Recruitment of suitable staff members is felt by many to be a major problem, along with being able to offer competitive pay scales. A number of factors other than pay can often be helpful. First, many agencies need to get away from the stereotype of youth being a necessity for employmentas well as male gender being an essential for working with individuals with significant behavior problems. Many older women are quite successful in dealing with aggressive males with dual diagnosis.)
Good employees are often a major recruitment asset if we ask them to tell others what they like about their jobs, and to recommend others. Some agencies offer employees a bonus if they recruit/recommend new staff members who stay for at least a specified period. Also, particularly in small towns and rural areas, getting the word out to groups that are interested in human rights/services, such as church and civic groups may result in good applicants (Larson & Hewitt, 2005). Background checks and random drug screens should be performed on all employees, without exception, no matter who refers them.Secondly, staff training programs are another essential factor in maintenance of an excellent direct support staff. The vowels of satisfactory staff training material include: (a) they should be easy to understand; (b) they should be interesting; (c) the recipients should have an opportunity to use the material; and (d) they should be up to date. Training should, of course, provide all regulatory agency-mandated training such as first aid, CPR, personnel policy issues, privacy issues, and similar topics. Issues such as overall causes of mental retardation, general information about dual diagnosis, and general information about positive behavioral supports must be included. Specific medical issues concerning the individuals being served should be included, such as information about epilepsy, diabetes, cerebral palsy, and sleep disorders. General psychiatric information, particularly concerning depression and anxiety disorders should be included, even if none of the persons being served has a formal diagnosis of this sort, primarily because these conditions are exceptionally common and often missed in this population. Medication information, particularly concerning medication side-effects, should be included, with particular attention to the medications being received by the persons being served. Also, staff members should be specifically asked about topics they feel they need to learn more about in order to work successfully with the individuals being served.
Several interesting new protocols for performance- and competency-based strategy for training staff in methods of carrying out behavior plans and providing supportive and corrective feedback regarding observed performance in carrying out a behavior plan were recently outlined by Reid (2004). Steps for training for carrying out plans include describing each procedure to be carried out and providing a concise, written summary of each procedure, physically demonstrating how to carry out each procedure (typically in a role-play situation), having the trainee practice carrying out the procedure, observing each trainees practice and providing supportive and corrective feedback, and repeating until the trainee demonstrates competence. After staff have been observed regarding performance in actually carrying out a behavior plan, Reid recommends that the feedback session be begun with a positive statement regarding the staff members overall performance and specification of the procedures within the behavior plan that were carried correctly. Then information should be given regarding procedures within the behavior plan that were carried out incorrectly (if applicable), and specific precise instructions should be given about how to correctly perform these procedures. The staff person should be asked if anything needs clarification regarding the feedback presented or if there are any questions. The staff person should be informed about when his/her performance in carrying out the plan will be observed again. The feedback session should be ended with an overall positive or encouraging statement regarding the performance in carrying out the plan.
In a related theme, Crisis Prevention Institute (2002) notes five steps in debriefing staff after a crisis situation has occurred: (a) Gather together as soon as its possible and practical, but after everyone is back in control and all incident reports have been written; (b) Establish the basic facts: What happened?; (c) talk about peoples actions and feelings; (d) decide what to do next; and (e) give each other support and respect.
The training tools just described are designed to be used in a hands-on situation, and are relatively time consuming, which some agencies feel is a problem. Retention of experienced direct support staff is a significant problem in all service programs for people with dual diagnosis, as discussed later in this article. While the training curriculum they describe involved communication skills rather than specific technical information, Smoot and Gonzales (1995) found, while evaluating cost-benefits of a staff training program designed to improve patient management skills and relive staff stress, that the trained unit had less staff turnover and staff members used less sick and annual leave than did the control unit.
Because of the scarcity of live training programs on clinical medical and psychiatric issues and the importance of day-to-day staff coverage issues, some type of self-directed instructional system may be of practical importance, particularly in community-based programs in rural areas. Piskurich (1993) defined self-directed learning as a training design in which trainees master packages of predetermined material, at their own pace, without the aid of an instructor. He noted that the strengths of self-directed learning include: (a) Availability when the training is needed, not when a class is being held; (b) Non- reliance on an instructor, which not only increases availability but decreases cost on-site implementation, so trainees dont waste time and money traveling, and (c) Consistency of presentation, since self-directed learning packages present the same information each time they are used. Piskurich further notes that advantages for trainees include availability when the trainee is ready, the trainee working at his/her own pace, individual choice of material, no surprises, immediate feedback and the provision of review and reference. Advantages for employers include multiple-site training, reduced meeting room cost, the ability to capture knowledge of subject matter experts, fewer trainers required, reduced trainer travel costs, the elimination of trainee travel costs, just-in-time training, down-time training, no training classes when busy, easier shift training, possibility of cross-training, training consistency, and less aggregate time spent.
Self-directed instructional programs may involve paper-and-pencil, computer-based, and/or audio-visual formats. (NADD has available a CD-ROM with 23 paper-and-pencil courses included, which can be obtained via the website (www.thenadd.org. [Poindexter, 2003]). Porter (1991) reported a study of three methods of continuing education for paramedics, lecture, videotape, and computer-assisted instruction, and compared their relative abilities to promote knowledge acquisition and retention. He also examined subject attitude toward each method initially and any changes in attitude immediately after and 60 days after the method. He found that although lecture was the preferred method, computer-assisted instruction was best able to impart knowledge and enhance participant knowledge retention. His study did not involve any comparison with written format other than computer-based.Various videotapes on a number of related topics are available from NADD as well as other sources. Objectives and quizzes could be readily developed for this type material, thus broadening self-directed instructional offerings as needed.
Another way to reinforce information in self-directed training materials is the provision of various crossword puzzles and word-search games dealing with the same topics as the training materials. An inexpensive program for rapid, easy-to-make puzzles, Puzzle Maker, is available from www.DiscoverySchool.com. This company markets its materials primarily to public school teachers, but, since the puzzles are made from any sort of word lists, they are readily adapted to staff training materials. A company called LearningWare Inc. (www.LearningWare.com) markets materials for development of computer games utilizing staff training materials, although these are relatively expensive. Agencies interested in developing these sorts of materials can view sample materials via the companys web-site. Self-directed instructional materials also often lend themselves to use by family members, advocates, and higher functioning clients themselves. When various games are used as part of the training this process can be markedly facilitated.
As far as retention of staff is concerned, anything to decrease staff turnover rates should be considered. Human service agencies may learn some things about decreasing staff turnover from the fast food industry, an area which competes for the army of people who are needed to fill entry-level positions. Dominos pizza has developed some interesting approaches to slowing down turnover (White, 2005). In a region in Jew Jersey four years ago, store managers were leaving every three to six months. Without a steady boss, workers there who answered phones, made pizzas, and delivered orders had a turnover rate as high as 300% a year! While average turnover for most large and midsize companies in general is about 10% to 15%, at fast-food chains, rates as high as 200% a year for hourly workers arent unusual.
Some fast-food companies are tackling the retention problem with a higher starting wage. Starbucks says it pays hourly store workers more than minimum wage, with the rate varying in different markets. The company says its turnover rate for such workers is 89% to 90%. They also claim to focus on friendly workplaces and good managers, and they feel that higher wages make a difference. Dominos has a different view, they are willing to try all sorts of tactics to retain hourly employees except paying them significantly more. Dominos feels that the way to decrease turnover is by focusing on store managers, hiring more selectively, coaching them on how to create better workplaces, and motivating them with the promise of stock options and promotions. Obviously high turnover is expensive. It costs money to recruit, hire, and train people, and undercuts service when inexperienced employees dont work as efficiently. They estimate that it costs the company about $2,500 each time an hourly store worker leaves and about $20,000 each time a store manager resigns. Dominos research showed that the most important factor in a stores success wasnt neighborhood demographics, packaging, or marketing, but the quality of its store manager. By 2004, the companys overall turnover had declined to 107%. Those of us in human services would do well to listen to successful companies of other types, even fast-food companies.
Hewitt, Larson, ONell, and Sauer (2005) describe an interesting, somewhat related approach which they describe as an intentional socialization process. They point out that orientation typically occurs in a new employees first week to month on the job, but socialization takes much longer. They recommend an immediate connection to a person in a similar job role or to a mentor, supporting networking opportunities, and encouragement of professionalization of direct support staff, as well as various welcoming and recognition activities.
When problems arise, which they will, supervisors shouldnt just cast blame, but involve staff in developing a plan to prevent recurrence. The strengths of staffthe good things they doshould be reinforced consistently and often. Support staff should be involved in the development of all treatment programs, including the reasons for various treatment modalities. The major importance of staff in the success of treatment programs should always be emphasized. Staff supervision should be positive, but not, of course, predictable. Listening to staff is one of the most important tasks of a supervisor.
Crisis Prevention Institute. (2002). Staff debriefing strategies. Brookfield, WI: Author (www.crisisprevention.com).
Hewitt, A. S., Larson, S. A., ONell, S. N., & Sauer, J. K. (2005). Chapter 5: Orientation, socialization, networking, and professionalization. In S. A. Larson & A. S. Hewlitt (Eds.), Staff recruitment, retention, and training strategies (pp. 105-1230). Baltimore, MD: Paul H. Brookes.
Larson, S. A. & Hewitt, A. S. (2005). Chapter 2: Recruiting direct support professionals. In S. A. Larson & A. S. Hewlitt (Eds.), Staff recruitment, retention, and training strategies (pp. 21-40). Baltimore, MD: Paul H. Brookes.
Piskurich, G. M. (1993). Self-directed learning: A practical guide to design, development, and implementation. San Francisco, CA: Jossey-Bass.
Poindexter, A. R. (2003). Self-directed instructional courses (CD-ROM). Kingston, NY: NADD Press.
Porter, R. S. (1991). Efficacy of computer-assisted instruction in the continuing education of paramedics. Annals of Emergency Medicine, 20, 380-384.
Reid, D. H. (2004). Training and supervising direct support personnel to carry out behavioral procedures. In J. L. Matson, R. B. Laud, & M. L. Matson, Behavior modification for persons with developmental disabilities: Empirically supported treatments. Kingston, NY: NADD Press.
Smoot, S. L. & Gonzales, J. L. (1995). Cost-effective communication skills training for state hospital employees. Psychiatric Services, 46, 819-822.
White, E. (2005, Feb. 17). To keep employees, Dominos decides its not all about pay. Wall Street Journal, p.A1.