Who's Challenging Whom: A cluster randomised controlled trial to test the effectiveness of a staff training intervention to improve support staff attitudes and empathy towards adults with learning disability and challenging behaviours

Introduction

The behaviours and attitudes of support staff can trigger the challenging behaviours of people with learning disabilities, or make these challenging behaviours worse. A systematic review of staff training literature in learning disability settings identified no existing evidence-based training course to increase empathy and to change support staff attitudes towards those with challenging behaviour. Meta-syntheses of existing qualitative research on the experiences of people with learning disability and their carers also identified the need for training for staff focused on empathy and attitude change.

Who’s Challenging Who? (WCW) is a training intervention aiming to improve staff understanding of the experiences of people with learning disabilities whose behaviour was described as challenging (i.e., staff empathy) and staff attitudes towards this group.

WcW is not a training course about academic or practice perspectives on ‘challenging behaviour’, but is entirely focused on what people with learning disabilities want to communicate about their experience of challenging behaviour.

Objectives

The primary aim of this research was to assess the effectiveness of the WCW staff training course to increase the empathy towards people with challenging behaviours of social care staff working in residential settings for people with a learning disability, compared with a waiting list control group, using a cluster randomised controlled (RCT) design.

Methods

A RCT of 118 residential settings for people with learning disability and challenging behaviour, allocated to receive WCW or to be offered WCW 5–6 months later, was carried out between 2015 and 2017. WCW was co-produced with people with learning disability and delivered by people with learning disability.

The training course, lasting half a day, was delivered by people with learning disability. Staff empathy, attitudinal, and work wellbeing outcomes were measured (two from each setting, total 236 staff), and recorded incidents of challenging behaviour and the use of restrictive intervention practices were measured for each residential setting.

Outcomes were assessed at baseline (before randomisation) and at 6 and 20 weeks post-randomisation. A nested qualitative study focused on interviews with 13 staff who attended WCW training and with all four WCW trainers (including those with learning disability).

Findings

• The Who’s Challenging Who staff training intervention led to improvements in some secondary outcomes (staff attitudes, and work motivation) but no statistically significant effect for the primary outcome (staff empathy), or setting outcomes (recorded incidents of challenging behaviour or use of restrictive practices such as restraint).
• The direct use of the experience of people with learning disabilities was perceived as strength of WCW (by staff and by trainers).
• Practitioners should work with people with learning disabilities to co-design and deliver training for  staff as a part of workforce strategies developed in response to the Transforming Care Policy Programme and similar initiatives.
• The selection and training of people with learning disabilities, their role in co-producing WCW, and their success in delivering the training to a high standard are other unique contributions of this study.

Resources

Videos

A series of short videos about the trainers’ experiences of being involved in the WCW project – https://bit.ly/2Ixx2EN

Easy read summaries

Why did we need this research? (PDF)
Easy read summary of the research (PDF)

Policy briefing

Who’s Challenging Who: Evaluation of an intervention to improve staff empathy towards adults with learning disabilities and behaviour that challenges (PDF)

Journal papers

Flynn S, Hastings RP, Gillespie D, McNamara R, Randell E (2019) Trainer and support staff experiences of engaging with the Who’s Challenging Who? challenging behaviour training course, Journal of Intellectual Disabilities, Online First.

Flynn S, Hastings R, McNamara R, Gillespie D, Randell E, Richards L, Taylor Z (2019) “Who’s Challenging Who?: a co-produced approach for training staff in learning disability services about challenging behaviour”, Tizard Learning Disability Review.

Flynn S, Hastings RP, Gillespie D, McNamara R, Randell E (2018) Is the amount of exposure to aggressive challenging behaviour related to staff work-related well-being in intellectual disability services? Evidence from a clustered research design, Research in Developmental Disabilities, 81, 155-161.

Hastings RP, Gillespie D, Flynn S, McNamara R, Taylor Z, Knight R, Randell E, Richards L, Moody G, Mitchell A, Przybylak P, Williams B, Hunt P (2018) Co-produced training to improve support staff attitudes and empathy towards adults with intellectual disability and behaviours that challenge: A cluster randomised controlled trial of the Who’s Challenging Who? intervention, Journal of Intellectual Disability Research, 62, 9, 798-813.

Richards L, Williams B, Przybylak P, Flynn S (2018) The experiences of people with learning disabilities in co-produced challenging behaviour training, Learning Disability Practice, 21, 4, 28-35.

Randell E, Hastings RP, McNamara R, Knight R, Gillespie D, Taylor Z (2017) Effectiveness of the ‘Who’s Challenging Who’ support staff training intervention to improve attitudes and empathy towards adults with intellectual disability and challenging behaviours: study protocol for a cluster randomised controlled trial, Trials, 18, 1, 460.

Related publications

• A cluster randomised controlled trial to test "Who’s Challenging Who"
  ( https://www.sscr.nihr.ac.uk/wp-content/uploads/RF64.pdf )