Self Determination Tools for Direct Support Staff - Phase II Report
Elizabeth J. Thorin , Ph.D., Principal Investigator
R44-HD38635-03 Phase II
Project Period: 09/01/2001-08/31/2003
Program Title: Self Determination Tools for Direct Support Staff: Respect, Choice, Decision, Family
Summary
The idea behind Self-Determination Tools for Direct Support Staff was to provide direct-service workers with an understanding of the significance of self-determination for those they support, as well as practical techniques for promoting self-determination during day-to-day activities.
Through a research grant from the National Institute of Mental Health, an IRIS Media research and development team, along with expert consultants, gathered data, developed a video program and tested the effectiveness of the program
The Self-Determination Tools for Direct Support Staff materials were evaluated by 191 direct support staff working in northwest residential and vocational facilities. Participants were randomly assigned to one of two groups: an intervention group that watched our video and the contrast group that watched a video previously produced by the Principal Investigator. Members of this group also read selected articles on self-determination. Click here for a description of the intervention program .
To assess the programs, participants wrote brief responses to 29 video vignettes presenting common problematic situations encountered in the field. Both groups completed this assessment as a pre-post test. Participants in the intervention group improved their scores on this test significantly more than participants in the contrast group. Participants in both groups also completed a user satisfaction questionnaire. People in the intervention group said that the information they received from the video was more helpful, meaningful and practical. Everyone in the intervention group said they would recommend these materials to other direct support staff.
Project Aims
The purpose of this project was to deliver innovative content in the form of a video-based training package for direct support workers on the concepts and practices of promoting self-determination for the people they support. In Phase I of this project, we developed and evaluated a video that educated viewers about six essential components to promoting self-determination: developing respectful relationships, supporting choice, encouraging new experiences, promoting informed decision-making, planning for the future, and including the family. In Phase II, we completed a set of four videos and a user guide that provide detailed information and practice activities on all six components of supporting self-determination. Phase II activities included:
- Developing content for four instructional videos
- Evaluating the content using focus groups and expert review
- Developing four video treatments incorporating feedback
- Conducting additional focus groups to review the treatment
- Writing four video scripts
- Reviewing video scripts by experts; revising and refining
- Producing four professional videos and a user guide
- Developing assessment tools, including assessment video vignettes, for an evaluation study
- Evaluating the effectiveness of the training materials using a randomized two-group pre-post design
Research Results and Significance
Description of Task Activities
Develop content for four instructional videos.
Content for the video programs were derived from published and unpublished resources, previous research activities of the Principal Investigator, and feedback received in Phase I from focus group participants and consultants. The Principal Investigator developed a 4 page narrative description of content to be addressed in each of the four videos: Developing Respectful Relationships, Supporting Choice while Encouraging New Experiences, Promoting Informed Decision-Making, and Planning for the Future; Working with Families. The Scriptwriter and Principal Investigator then developed an outline of the content, including information on the importance and relevance of each topic as well as specific components of the skill being addressed.
Evaluate the content using focus groups and expert review.
The first focus group was held at IRIS Media offices with very experienced direct support staff. As the Principal Investigator and Scriptwriter presented the proposed content, the participants indicated relevance by providing examples from their own experience, and provided cautions about the presentation of some material given the realities of the direct support staff role. A focus group of self-advocates was held during the statewide Oregon Developmental Disabilities Inservice. The Principal Investigator and Scriptwriter learned about the things that good staff and bad staff do and don't do to support self-determination. The examples from both groups proved very useful in the development of the video script as well as the assessment materials. It was decided that expert review of the treatment rather than the script would be more effective (see #4).
Develop four video treatments incorporating feedback.
The Scriptwriter and Principal Investigator developed a model for presenting information in each of the videos: showing an introductory vignette of a negative example of the content, and then showing all the ways that the behaviors could be improved. For example, the video on developing respectful relationships would begin with a vignette showing poor communication and disrespect and how that affects a relationship. Good communication skills such as listening, asking questions, and sharing information are then modeled, with very different outcomes. Treatments were developed for each of the four videos.
Conduct additional focus groups to review the treatment.
Three focus groups, one of parents, one of self-advocates, and one of direct support staff were held in Kent , Washington , to review the treatments. Parents talked about the range of direct staff interactions with their adult child, from being a nanny and doing everything for him or her, to staff who say "it's your choice" to someone who may not know the options or may not have had experience making good choices. Parents felt their role was to oversee the supports their child gets and to be kept informed. Self-advocates like staff who give them good advice and support them to do the things they want to do, not what staff want them to do. Prompts and reminders are okay if done respectfully in a relationship built on trust. Direct support staff also noted that those they work with have lives filled with disrespect, and staff need to model appropriate interactions for community members. Staff are always walking a line between being a friend and being paid staff, between setting high standards for those they work with and letting them just be who they are, between encouraging choice and protecting health and safety.
In addition, two national experts on self-determination for people with disabilities reviewed and commented on the treatment. Michael Wehmeyer, Ph.D., and Michael Ward, Ph.D., provided feedback on the definition of self-determination used for the project, and offered suggestions for clarifying language used when talking about choice-making. The treatment for working with families was considered respectful of family desires while balancing the self-determination goals of the person with a disability.
Write four video scripts.
As the Scriptwriter began incorporating the feedback from focus groups and consultants into video scripts, the project was enhanced by the addition of a Research Assistant who had previously been a direct support staff person. Her involvement in script review meetings with the Scriptwriter and Principal Investigator resulted in the conceptualization of 3 forms of interactions between direct support staff and those they serve: the smotherer, the slacker, and the ally. The smotherer does everything for the individual, the slacker says "it's their choice" and provides little support, and the ally does everything just right. The Scriptwriter used these three types to exemplify the range of possible staff/individual exchanges in a concrete manner that is easy to remember and learn from.
- Expert review of video scripts; revise and refine.
- Dr. Michael Ward reviewed the script, making recommendations about language that helped clarify the message being conveyed. The Principal Investigator?s concerns about the amount of narration in the script (she would be the one on camera reciting it) led to a recommendation by the Media Producer/Director and Scriptwriter that each video include a co-narrator who was a person with cognitive disabilities. Thus, final edits to the script involved dividing the narration between the co-hosts, a process that resulted in clearer language and a more dynamic exchange of information.
Produce four professional videos and a user guide.
The Media Producer led the production of the four videos. Additional members of the production team included a Production Coordinator, Camera Operator, Audio Recordist, and Gaffer. This team was responsible for casting, scouting and coordinating locations, scheduling, and shooting the video sequences. The program was shot on a professional digital video format, DVCAM, using a full lighting and grip package available to ensure the highest quality product. Dramatized sequences were shot on location in an effort to provide a realistic context.
The production used experienced actors recruited from a professional talent pool in Eugene and Portland . In many cases, persons with developmental and other disabilities were recruited to portray models and actors in the program. Many of these actors were identified through the network of the Principal Investigator and the Media Producer, including PHAME Inc. (Pacific Handicapped Artists, Musicians, and Entertainers Inc.). The Principal Investigator's longstanding work in the area and her activities with such groups as The Arc and People First, helped provide access to many individuals. The production team also made a concerted effort to recruit a diverse group of actors to ensure that the program reflect a broad diversity of race, ethnicity, gender, and disability.
Post-production was completed at IRIS's studio, where the program was edited on a professional non-linear digital editing system. Graphics, illustrations and animations were composed using a combination of programs that include Adobe PhotoShop, Adobe Illustrator, Adobe AfterEffects, Ultimatte, and Boris FX. Audio post-production included recording of voice narration, mixing and sweetening. Original music, used as intro and segues, was composed and added to the sound track.
The Instructional Designer, in addition to reviewing scripts and performing the role of executive producer on the videos, was responsible for producing the manual and executing the cover and package design.
Develop assessment tools for an evaluation study.
Three outcome measures were proposed for this project: the Content Questionnaire (CONT), the What Would You Do (WWYD) and the Behavioral Outcome Measure (BOM). Activities related to these tasks are described below.
Content Questionnaire. This was to be a short test, made up of multiple choice and true/false items, to assess whether subjects improved their understanding of the basic concepts of self-determination pre-post intervention. An initial pool of 30 items was developed and an examination of face validity was conducted. Forty direct support staff were recruited during a statewide conference to complete the questionnaire and provide written comments on the language and concepts. Based on item frequencies of correct answers and the written comments, 20 items were eliminated. Ten direct support staff, also recruited during a conference, participated in a test of item difficulty on the remaining items. Of the ten questions, seven were answered correctly by 50% or more of these subjects. At this point, a decision was made, on the recommendation of the Research Methodologist, to cease further develop of this instrument. Simultaneous work on the WWYD was yielding much more promising results for that instrument as an outcome measure.
What Would You Do? This instrument was envisioned as a series of brief (under 1 minute each) video-vignettes dramatizing realistic problematic situations between direct support staff and people with developmental disabilities ending with asking the question "What would you do?" Development of this instrument began with the writing of 34 brief (one to two sentences) descriptions of situations that were likely to be encountered by direct care staff. Twelve direct support staff recruited during a state wide conference participated in a face validity examination. Participants read the vignettes and wrote brief answers; a group discussion, led by the Principal Investigator and the Media Developer followed this activity. During the discussion, it became clear that responses to the situations varied depending on whether the staff thought the person with DD had a guardian. Instructions for responding to the WWYD were modified to include that all adults portrayed in the vignettes were acting as their own guardians. An analysis of the written answers revealed that some of the questions dealt with identical issues. Thus, the original list of 34 situations was cut by 5, to 29 items, for an examination of item difficulty. In addition, project staff decided that dramatic portrayals of the vignettes weren't necessary; instead, non-speaking dramatic sequences were filmed with a voice-over to read a description of the situation and ask the question, "What would you do?"
The 29 video vignettes were produced in order to conduct the item difficulty test. Twenty direct support workers attending a local developmental disabilities conference were recruited to participate in the item difficulty administration. Based on the results of that test, 24 items were retained for the final version of the test.
Test retest reliability of the WWYD was established by recruiting 23 direct support workers to complete the test with three days between administrations. While this period did not mimic the period to be used in the intervention, that short of a time period between administrations could have had the effect of yielding an artificially high reliability coefficient. The test retest Pearson correlation on the total score was .77. A paired t-test revealed that scores significantly decreased between the two administrations (T1 mean=17.8 (s.d. 6.9); T2 mean=14.8 (s.d. 1.6); t(22)=2.98, p=.007).
Behavioral Outcome Measure. This instrument was originally planned as a measure much like the WWYD, but to be used as a 30 day follow up phone interview to measure changes in behavior between staff in the intervention groups. Initial plans were to develop 32 one-sentence descriptions of common problematic situations encountered in the field. Staff would report their response to that situation if it had occurred in the past 30 days. In the course of developing the content for the BOM a decision was made to identify typical problem areas instead of developing hypothetical field situations. The six problem areas derived from the WWYD were a) unrealistic/inappropriate ambitions/desires, b) risks to health and safety, c) control issues, d) personal appearance/hygiene, e) client boredom, f) conflicts of morals/ethics, and g) interpersonal problems and/or disappointments. Direct support staff were asked if they'd experienced any recent events in that area and if so, what was their response to the situation. As the item problem areas were derived from an instrument on which both face validity and item difficulty analyses had been conducted, a decision was made to forego these activities with the BOM. We also decided against conducting test-retest assessments. The instrument asks staff to think back over the last 30 days and to describe situations related to the issues that they had dealt with in those 30 days. If we re-administered the instrument with even one intervening day it was likely staff might describe either different situations or new situations that had arisen in the 24 hours between administrations. Thus the final form of the instrument consisted of six questions asking about responses to situations where these issues were in play, and 3 other questions 1) asking if staff had, after considering a specific action they?d taken, thought later about how they might have handled a situation differently, 2) asking if their behavior had been influenced by the intervention, and 3) soliciting general comments about the materials.
Coding Procedures.
Both the WWYD and the BOM elicit open-ended answers. To score these instruments, codes were developed and assessors were trained. For the WWYD, we developed a code which assigned scores of 0, 1 or 2 to an answer depending on the extent to which that answer was supportive of self-determination. Three assessors were trained using a coding manual containing definitions of the coding categories, and examples of answers to each question which would qualify for a particular score. Coders first trained for approximately 90 minutes a week for 6 weeks by reading background material, watching the intervention material, participating in group discussions of the concepts of self-determination, and twice writing their own answers to the WWYD. Following that initial training period, written answers on the WWYD from the face validity activity were used as initial training materials. Sets of questions were assigned to pairs of coders; answers were scored separately by each coder and discrepancies were resolved by group discussion and consensus. The Principal Investigator participated in these initial training meetings and discussions. Coding reliability was calculated by scoring the number of items coders agreed on before consensus discussions. The reliability agreement scores from the face validity answers ranged from 31% to 93% with an average of 58% agreement. Similarly, written answers from the test-retest administrations were also used as training material. Reliability agreement scores ranged from 58% to 100% with an average of 77% agreement. All answers to both the item difficulty and test-retest items were scored by consensus.
To check for reliability on the outcome answers we used a different procedure. Sets of answers were coded separately by pairs of coders, the coding supervisor identified discrepancies, and those discrepancies were resolved by the Principal Investigator. Both coders and the Principal Investigator were kept blind to condition; dummy identification numbers were assigned to each set of answers so that neither condition nor time of administration (pre/post test) could be discerned. 167 sets of answers (approximately 50%) were checked for reliability; the Pearson correlation on the item-by-item agreement score between sets of coders was .71. Six sets of answers were identified as outliers; discrepancies between coders ranged, on those set of answers, from 13 to 16 points, while the range of discrepancies on the other 161 answer sets ranged from 0 to 12. The Pearson correlation between coders, without outliers, was .77.
We originally planned to code answers to the BOM questions in the same manner as we coded the WWYD. It became clear during the course of administering this instrument, however, that we couldn?t follow similar procedures. Some subjects provided more information than others; some situations rarely occurred. In some situations it was clear that staff were following a previously established behavior plan and weren't free to make their own choices about how to deal with a situation. For all these reasons, we decided to code all sets of answers using a consensus procedure with two coders. Each coder read each set of answers and applied one code to each set (0,1,2) which reflected how well that subject supported self-determination. The two coders then met to compare answers and arrive at a consensus when they didn?t agree. Initial agreement before consensus ranged from 53% to 88% with an average of 71%.
Evaluate the effectiveness of the training materials using a randomized two-group pre-post design.
We originally planned to conduct the field study as in-service presentations at state and regional conferences. Due to region-wide budget difficulties, all in-service conferences were cancelled. In order to maintain as closely as possible the conditions of the original plan, we conducted in-service-like presentations in four locations: Eugene , Salem and Portland, Oregon and Seattle, Washington . 191 direct support workers were recruited to participate. Subjects were recruited using several methods: through flyers sent to organizations and to people from our database who had previously indicated an interest in participating in a research project, by hiring a recruiter for the Seattle area, and by personal contacts of IRIS staff. Sessions were scheduled to take place over two days in each location; approximately 50 direct support workers attended each session over the course of the two days. Each session lasted approximately four hours.
At each session, subjects met in two separate rooms. All subjects first completed a brief demographics questionnaire and the WWYD. Following the WWYD, subjects in the Intervention Group viewed the Supporting Self Determination videos. Subjects in the Control Group watched a 17 minute videotape, "Whose Decision is it Anyway: Service Providers Supporting Self-Determination" and were given a set of readings that were planned to take approximately 45 minutes to read: The Ecology of Self-Determination by Abery and Stancliffe (Chapter 7 from Self-Determination Across the Life Span by Sands and Wehmeyer), A Vision of What Can Be (Chapter 2 from An Affirmation of Community by Nerney and Crowley), and Sharing Power and a System of Support by Smull. Following administration of the materials, all subjects completed the WWYD and a brief consumer satisfaction questionnaire. Approximately one month following the session, each subject was called to complete the BOM. All calls were audio-taped and transcribed; answers were coded following procedures described above.
Sample Demographics.
There were no significant differences between the groups on demographic variables.
Table 1 - Sample Demographics
|
Intervention (n=92)
|
Control (n=99)
|
|||
| Mean | s.d. | Mean | s.d. | |
| Age | 37.2 | 11.5 | 35.3 | 11.2 |
| Gender | ||||
| Male | 23% | 29% | ||
| Female | 77% | 71% | ||
|
Educational Background |
||||
| H.S. Diploma | 25% | 16% | ||
| Some college | 44% | 53% | ||
| BA/BS | 23% | 27% | ||
| Some grad work | 3% | 1% | ||
| Graduate degree | 4% | 3% | ||
| Previous Training on Self Determination | ||||
| Yes | 69% | 73% | ||
| Ethnicity | ||||
| Hispanic | 4% | 4% | ||
| Non-Hispanic | 96% | 96% | ||
| Race | ||||
| Caucasian | 70% | 77% | ||
| African American | 14% | 9% | ||
| American Indian | 3% | 3% | ||
| Asian | 3% | 3% | ||
| Mixed | 5% | 4% | ||
| Other | 3% | 3% | ||
| Type of Workplace | ||||
| Vocational | 29% | 21% | ||
| Residential | 66% | 66% | ||
| Recreational | 4% | 2% | ||
| Other | 3% | 8% | ||
| Type of Work | ||||
| Direct Support | 60% | 52% | ||
| Management | 7% | 7% | ||
| Support & Management | 33% | 41% | ||
| Experience in DD Field | ||||
| 0-6 months | 6% | |||
| 6 mo - 1 year | 11% | 6% | ||
| 1-2 years | 12% | 7% | ||
| 2-3 years | 19% | 16% | ||
| over 3 years | 59% | 65% | ||
Outcomes.
The mean score for the "What Would You Do? over all items was used as the outcome measure. There was a significant Group by Time interaction effect (F(1,189)=39.6, p=.000) on pre/post test scores on the WWYD (see Table 2).
Table 2 - WWYD Means
|
Intervention (n=99)
|
Control (n=92)
|
|||
| Mean | s.d. | Mean | s.d. | |
| Pre Test | .37 | .25 | .30 | .22 |
| Post Test | .79 | .40 | .38 | .29 |
173 subjects completed the Behavioral Outcome Measure, administered by phone approximately one month following the WWYD post test. Of these 173, 27 were not scored for a variety of reasons: the audio recording failed, subjects didn't answer any of the questions and/or subjects answered only one question and/or answers were not relevant. Repeated measures MANOVA with polynomial contrasts was conducted to examine whether changes observed between baseline and post test scores maintained over time, as reflected on BOM scores. Significant differences were found on the main effects of Group (F(1,142)=14.4, p=.00) and Time (F(2,141)=59, p=.00) and on the Group by Time interaction effect (F(2,141)=29, p=.00). Inspection of the univariate ANOVAs for the Group by Time interaction revealed that only the quadratic effect was significant (F(1,142)=28, p=.00). Table 3 shows the means and standard deviations for all three scores.
Table 3 - WWYD and BOM Scores
|
Intervention (n=73)
|
Control (n=71)
|
|||
| Mean | s.d. | Mean | s.d. | |
| WWYD T1 | .38 | .26 | .32 | .23 |
| WWYD T2 | .80 | .41 | .39 | .30 |
| BOM | .64 | .59 | .51 | .58 |
It is also noteworthy that only 47% of the subjects in the Control Group were rated as 1 (Somewhat supportive of self-determination) on the BOM , while 60% of the subjects in the Intervention Group were rated as 1 (Chi square(1)=2.5, p=.10).
Since both groups watched a video tape on self determination, consumer satisfaction scores (on a five point scale) related to the video could be compared between groups. There was no difference on how much of the information was new to subjects in both groups. However, on every question related to satisfaction with the video, subjects in the Intervention group reported significantly higher levels than subjects in the Control group. Table 4 presents data from these questions.
Table 4 - Consumer Satisfaction Data
|
Intervention
|
Control
|
|||
| Mean | s.d. | Mean | s.d. | |
| How much of the information was new to you? | 2.5 | .87 | 2.6 | .92 |
| How much did the video help you understand self determination? | 4.4 | .70 | 3.8 | .92* |
| How practical/useful was the information? | 4.3 | .81 | 3.6 | 1.0* |
| Rate the overall quality of the video | 4.3 | .67 | 3.5 | .81* |
| * p<.001 | ||||
88% of subjects in the Intervention group reported they would do something different after viewing the video while only 71% of the Control group said they would do something different. This difference was statistically significant ( Chi Square (1)=7.8, p<.005). All subjects in the Intervention group said they would recommend the video to other direct support staff while only 87% of those in the Control group would ( Chi Square (1)=12.8, p<.005).
Discussion.
The product of this project is a set of five videotapes called "Self-Determination Tools for Direct Support Staff": Developing Respectful Relationships, Encouraging Choice-Making and New Experiences, Promoting Informed Decision-Making, Planning for the Future and Working with Families, and What Would You Do? A companion viewer guide includes an overview of the video programs, a summary description of the three styles of support, and an analysis of responses to each of the 24 vignettes in the What Would You Do? videotape.
One significant outcome of this project was the development of a mnemonic to aid staff in understanding and practicing the support of self-determination. By considering the three staff roles of ally, smotherer and slacker direct support staff can examine and alter their own behaviors to the benefit of the self-determination of those they support. Staff have been overheard telling each other "Don't be a smotherer now".
The significant results obtained through the field-testing of the materials are even more noteworthy when considering the experience the subjects already had with self-determination; approximately 70% of the sample were not only familiar with the term self-determination but had actually received training in self-determination. It can be a difficult concept to master (there is no universally accepted definition) and even more difficult to translate into behaviors and activities that are relevant to one's daily work. This product has successfully done that. Although both the intervention and control groups rated "a little" of the information as new to them, the intervention considered the information to help them "quite a bit " of derstanding how to support self-determination.
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