Systematic Article Review
The first study to be reviewed was conducted by Lowe et al. Lowes study focused on the training of staff to implement positive behavior support. Previous studies had shown that positive behavioral support was the preferred mode of service by patients with specialized needs. However, health institutions had few members of their staff equipped to provide such support. Lowe et al. wanted to address this disparity by providing introductory training to the staff members in general rather than equipping only specialist servers of the staff with comprehensive training.
The researchers remained relevant when they decided to test the depth of knowledge retained by the trainees and the impact that the training had on their attitudes. The researchers further checked for long-term effects of the training by gauging the knowledge and changed attitude of the trainees one year after the conduct of the training. These questions helped to assess the efficacy of the training conducted.
A quasi-experimental design was adopted by distinguishing between registered and unregistered members of the staff who underwent training. Members of the registered staff were perceived as qualified nurses while members of the unregistered staff were perceived as unqualified nurses. The design was high in internal validity because it provided a baseline measure for knowledge and attitude. The participants were asked to complete the questionnaires prior to training proper.
Overall there were three assessment points to consider (1) prior to training (2) directly after training and (3) one year after training. It was only with regard to the last that the internal validity of the study was threatened. The period of time without monitoring and supervision from the researchers allowed the participants to come in contact with members of the other group. It would have been difficult to control for external factors or to attribute changes to the mere passing of time.
The study was also high in external validity for nurses of the age-range focused on in the study. Lowe et al. were able to differentiate nurses between those who received prior training on the material and those who had not. This makes the results generalizable to both groups. However, the study might not have taken into consideration the recent growth in demand of nurses. This has caused schools in recent years to be more rigid in their training in order to produce graduates with a competitive advantage over other job applicants. The findings for the knowledge scores of registered nurses may therefore not be applicable anymore.
The dependent variable in the study was the training received by the nurses. The independent variable was the treatment that the nurses offered to patients with severely challenging behavior. The independent variable was operationalized in terms of knowledge and changed attitude of the staff. This could have been operationalized in a more effective way if patient feedback had been assessed as well. The study revealed that the training improved knowledge and perceived confidence of the staff members. However, the long-term effect of the training was minimal and not statistically significant.
McClean et al. directed their research to the assessment of Person Focused Training as a service delivery mode to persons with severe challenging behavior. In this study it is also accepted that positive behavioral support is acknowledged as the most effective method of caring for individuals with severe challenging behaviors. To address the problem of actualizing positive behavioral support in the practice of health care staff, McClean et al. propose that a person-by-person adaptation of the method be implemented. This would take into consideration the individual differences of patients thereby promoting personal improvement.
The study was a non-experimental design although in the analysis of data the nature of the patients behavioral problems were categorized as were the nature of the treatment facilities availed of. The study was high in internal validity because it provided a baseline mark for the condition of the patients and the practice of the caregivers. The period of time prior to the application of the independent variable was sufficient to gauge the pre-test condition. Thus, changes subsequent to the introduction of Person Focused Training could be attributed to the training.
The research is also high in external validity because of the wide sampling that was conducted thereby covering a vast range of severe challenging behavior and platforms for treatment introduction. Moreover, the extended period of time throughout which data was periodically and systematically collected allowed for the tracking of changes in the dependent variables. The effects of extraneous variables were minimized and controlled for through the extended period of data collection.
The independent variable in this case was the manner in implementing positive behavioral support. The dependent variable was the condition of the patient. The researchers operationalized the dependent variable by introducing positive behavioral support in a case-per-case basis and taking into account the peculiarities of each patients case. The dependent variable was operationalized by assessing reductions in patients target behaviors.
The results of the research showed that Person Focused Training had significant effects on reduction of target behaviors. Moreover, the training sustained changed behavior over an extended period of time. However, a problem is encountered in the replication of effective methods that were used by the caregivers.
The Person Focused Training should have been further qualified in terms of actual techniques and actions taken by the caregivers in the classes of severe challenging behavior encountered. The lack of analysis in this regard could have introduced extraneous variables which could have better accounted for the improvements of behavior. The deeper analysis of the case-by-case treatment in Person Focused Training would be a good subject of future research.
The third article to be reviewed deals with pyramidal training of staff in order to promote skill-acquisition by all caregivers within the health care institution. The goal of the research was to reduce client behavior targets by improving the skills of the health care staff. This was conducted by employing an experimental design wherein patient progress was noted at varied times. In one case the behavior of the patient and of the staff member was noted every time the staff member administered a particular training session. In the second case, progress was taken note of all throughout the day thereby accounting for the daily behavior of the patient and the behavior of the different staff members assigned to him during the course of the days shifts. For the third group the assessment was conducted only after completion of supervisor training.
The experiment employed a multiple baseline design. The independent variable was the method of training and the dependent variable was the change in behavior in clients and staff members. The method of training was sufficiently operationalized with a method outlined for supervisor training and for supervisor communication of the training to subordinates. The dependent variable was operationalized using different sets of indicators for the various groups in the study. This did not present problems because of the nature of treatment implementation in these groups.
Two baselines were adopted in this study. The first baseline was collected from the staff members and the patients during a treatment and generalization session. The second baseline was obtained prior to the training of supervisors. Upon the initialization of the exhaustive training program, measurements were not collected by the researchers. However, upon completion of the training, the collection of data was resumed.
The research reflected a high degree of internal validity because of the contrast given by the three sets of experimental groups. The first two groups reflected current practices of the facility and as such tracked the improvements that those practices provided. The third group tracked the improvements that could be achieved if the training program were implemented. The use of multiple baselines ensured that the comparisons made between the groups were parallel. The utilization of a single baseline would not have ensured such parallelism in comparisons.
The research was rather limited in its generalizability because it focused on only a small range of behaviors to be reduced and treated. The efficacy of the training might not be evidence considering the number and variety of client cases prevalent in health care institutions. The effectiveness of the model may not be evidenced when it is used to teach the whole array of behaviors to be treated and addressed. Another problem would be the population size of the study. The population studied was rather small. The results might not be produced if a health care institution employing several hundreds of staff members were to adopt it. Taking into consideration the manpower needed to make the training effective, it may be inconvenient or impractical for large health care facilities to adopt this mode of training.
The study showed that the implementation of treatment procedures improved as a result of the pyramidal training employed. The improvement was evidenced by significant improvement in staff implementation as well as improvement in reduction of client target behaviors. The pyramidal technique of communicating skills employed by Shore et al. required a labor-extensive program. This would transfer many of the staff from client treatment to training thereby producing an imbalance in services while staff members undergo and facilitate training.
The fourth and final article to be reviewed involves the implementation of a 3-day training for treating challenging behavior. The goal of the research was to reduce negative emotional reactions and promote self-efficacy of staff members confronted with challenging behaviors. The research also aimed to improve the causal beliefs of staff members regarding challenging behavior.
The research employed a non-experimental design. The design was low in internal validity because of the nature of the collection of data. The questionnaires were sent and collected by post. The threat of social interactions with other practitioners or with other training programs was not controlled for. Baselines were obtained in the study. This increased the likelihood of internal validity. Questionnaires were filled out prior to the 3-day training and once again filled out 3 months after the 3-day training. While the pre-test was sufficient to mark out baseline, the 3 month period opened the opportunity for contamination of the effect of the 3-day training. It is well to note the absence of control conditions to ensure that the changes observed in the 3-day training group was attributable to the training.
The research is high in external validity because it tested a sample of staff members across a wide range of demographic categorizations. The diversity of the practice and personal background of the participants ensured that the research population was representative of the general population at large. However, the low level of internal validity made the research findings doubtful.
The results showed that changes in causal belief and negative emotional responses were not present. However, there was a significant improvement in self-efficacy and confidence of the staff members. The independent variable in the study was the training process and the dependent variable were the self-efficacy of staff members, their causal beliefs and their negative emotional responses. The operationalization of both the independent and dependent variables were sufficient and replicable. However, there was a problem in the manner of operationalizing self-efficacy in that it was largely self-report. The opinion of supervising staff members and the progress of the patients should also have been looked into. This failure to adequately operationalize the dependent variable also contributed to the low internal validity of the study.
Critical Analysis
The four articles that were reviewed all focused on the improvement of services and staff member skills directed towards the treatment of severe challenging behavior. The four articles studied the effectiveness of different training programs that could be utilized for this purpose. Lowes study showed the importance of having all staff members retain skills in treating challenging behavior.
It is noted however that in Lowes design there was a failure to assess the staff members skills in terms of patient progress. This was similar to Tierneys study because the improvement of skills was assessed only based on self-report data given by the staff members. The studies of McClean and Shore on the other hand assessed improvement through the reflected reduction of target behaviors in patients. This provided a more objective measurement of staff member improvement and treatment application.
It is also observed that in Lowe and McCleans designs there was no qualification on the training provided to the staff members. The actual practice of the training was therefore not capable of being reviewed nor could an objective assessment of the actual implementation of the skills be conducted. In Shore and Tierneys studies the training was discussed in detail to ensure that the skills practiced could be identified and assessed. Although in Tierney no such assessment was conducted thereby weakening the study design.
Conclusion
The studies reveal the need to conduct training of staff members in order to improve self-efficacy and in order to lessen negative emotional responses to challenging behaviors. In order to ensure that training is communicated into patient progress then the training should be personal and extensive in nature. Introductory training may improve short-term treatment but will not be retained by staff members in the long-term. Also, a Person Focused Training is effective in promoting staff member understanding and empathy for patients. Person Focused Training coupled with a pyramidal or 3-day training would promote reduction in target behavior as well as reduction of staff member negative emotional response.
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