As long as I can remember there have been demands by intellectual disability services for more staff. In some quarters there seems to be an unquestioning belief that services can only be improved in this way. Their rationale is simple: only services with ample staff can deliver individualised programmes that will enhance the independence and quality of life of people with intellectual disabilities. However, there is a belief within some government circles and among certain sections of the public that pumping more resources into services has not led to any appreciable improvement in service availability or quality. They believe that the time has come to take stock of our health service and to review how it operates. Who is right?
Some years ago I examined the literature with regard to staffing ratios for residential services. I found that in the 1960s and early 1970s several studies were conducted by health authorities to try and determine what the optimal staffing ratios should be in residential services for people with intellectual disabilities. Dr Norma Raynes, an eminent British researcher, reviewed these studies and concluded that the literature provided no clear answers. Put another way, the widely held belief that increased staffing levels lead to better conditions for people living in care is not substantiated. Numerous writers and research studies bear witness to this reality.
Sharon Landesman, reporting on a large, well-controlled study in the USA (where staffing levels had been quadrupled), found no evidence to indicate that changes in staffing ratios resulted in improvements for people living in care. In her study no worthwhile changes in residents’ behaviour were observed when people with significant intellectual disabilities were moved from a large institution to small domestic bungalows within the grounds of an institution. The only changes that were observed for people in the new setting were that they spent more time alone, more time rocking in their chairs and that they watched more TV. Robert Schalock and his colleagues’ study found that residents reported a decrease in their quality of life when staffing levels increased. In a study I conducted a few years ago, increased staffing levels were significantly associated, in many instances, with decreases in choices, autonomy and opportunities for people with intellectual disabilities who moved from a large residential centre to other settings.
Increasing staffing levels, even by very substantial amounts, may lead to no appreciable worthwhile change in the experiences of people with intellectual disabilities or even to a definite disimprovement in their quality of life. It is not difficult to see how this can happen. Consider the following scenario.
Margaret is a 37-year-old woman with a moderate intellectual disability who has lived in a small residential unit with five others for the past ten years. Up until three years ago there was one staff member on duty on the unit at any time. Margaret took pride in helping staff clean the unit and prepare meals. She enjoyed going shopping, meeting people and each evening she particularly looked forward to the chat and cup of tea they all had after they had finished their meal. Overall, Margaret seemed content and she felt that her contributions were appreciated. However, once staffing levels increased, the atmosphere on the unit changed. Staff spend much more of their time together, cleaning the unit, deciding on what they will cook or where they will go. They also have a lot of private meetings, where they discuss Margaret and the other residents. She and the other residents are not consulted much and they dislike it when staff ask them to leave the room while they have meetings or write reports. Margaret feels that she is not needed by staff anymore. She is often sad and angry now, and frequently has disagreements with the other people she lives with and with staff. At Margaret’s last person-centred planning meeting staff spent a lot of time talking about her ‘depression’ and her need to move to a unit with higher staffing levels that could better manage her behavioural problems.
In contrast to the above, there are several studies that testify to the considerable benefits of increased staffing levels for people with intellectual disabilities. For example, almost all studies that have investigated the effects of moving people from institutions to community houses, usually necessitating the employment of additional staff, have shown that community living results in a better quality of life for people with intellectual disabilities. Similar outcomes are typically found in studies that compare traditional vocational training with supported employment schemes.
In brief, the evidence about staffing levels is varied. Adequate staffing levels are needed to deliver quality services; however simply increasing the number of staff in a service will not guarantee better services. It can in some instances make matters worse. This finding will come as no surprise to people who work in services for people with intellectual disabilities. Most staff know that the most crucial factor determining the quality of life of people in residential care is what staff actually do and how they relate to individuals with an intellectual disability. While staffing levels are important, any search for a link between staffing ratios and quality of care is doomed if it does not involve an examination of staff behaviour.
Accordingly, in recent years several investigators have turned their attention to examining what variables and practices influence staff behaviour, in the hope that this information will help deliver better services. Areas of enquiry have included; staff conditions, types of training, staffing arrangements, quality assurance systems, organisational climate, stress levels, staff turnover, etc. The information provided by some of these studies has been helpful in developing guidelines for good practice. For example, we have learned that a small group of residents receive more individual attention when there is one, or on occasions, two staff on duty. When staffing levels increase beyond this point, the amount of individual attention residents receive tends to decrease.
There is, however one area that I believe is of primary importance in determining how staff behave, which in turn affects the type of service people in care receive. This is the area of service values and priorities. In my experience it is often necessary to draw a distinction between the ‘formal’ and the ‘actual’ values and priorities of a service.
Most services in Ireland for people with disabilities have policy documents that outline their formal values and service priorities. Most of these are exemplary documents. They usually express an aspiration to provide person-centred services that will enable each person with a disability to live as independent and as satisfying a life as possible within their community and to make a significant contribution to the enrichment of society. Recognition is typically given to family participation, the rights of individuals to be involved in decisions concerning themselves and to be treated with respect. However, in practice there can be a difference between what a service aspires to and what is encouraged. Consider the following example.
Pauline, an enthusiastic house parent, was attracted to a service because of its exemplary client-focussed policy statement and within months of her arrival she had managed to considerably enhance the quality of life of the five people she worked with in the community house. She helped two individuals find part-time jobs in a supermarket and a local pub. She established a small community ironing service in the house and raised funds to purchase a glasshouse where residents grew and sold bedding plants. Those in the house soon made many new contacts and friends and the house became a hive of activity with locals dropping in on a regular basis. They used their modest income for outings to the cinema and the local restaurant. Pauline’s efforts were much appreciated by the people with intellectual disabilities and their relatives. However, she soon discovered that clinically clean surroundings, tight budget management and an intolerance for risk taking, were the actual values and priorities that existed within the service and that her endeavours were largely ignored or misunderstood by her manager. In essence, Pauline discovered that there was a difference in this service between its formal and actual values and priorities.
On her manager’s first visit to the house she reprimanded Pauline for not having the washing-up done by 10-30 am and gave her a demonstration on how to clean the base of the windows with a toothbrush. Over the next few months Pauline learned that visits to the cinema or meals out were regarded as an unnecessary expense and that a budget surplus at the end of the month was considered as good housekeeping. Minor risk-taking, such as residents going to the local shop unaccompanied was considered irresponsible. It was made clear that if an accident occurred she would be held accountable. Her manager seldom showed any interest in the pursuits and activities of the people living in the house, apart from enquiring about health problems.
Within a year it was clear to Pauline what the service expected from her. She became disillusioned and left. Her manager, however, was held in high regard by senior personnel in the service and the service was regarded as a ‘model service’ by the local health board who proudly showed visitors around their community houses.
The above example highlights how the values and priorities held by influential people at the top can influence staff behaviour and the experiences of residents. This happens because staff, regardless of their own values and priorities, find that their behaviour is shaped by their managers through praise, recognition, reprimands or simply being ignored. Those who reflect the actual, rather than the formal, values and priorities of the system get promoted and in turn shape the behaviours of others. Over a period of time the type of service people experience will reflect the actual priorities of those in charge—tight budget control, immaculately clean houses and a lack of calculated risk taking—rather than those stated in their exemplary policy document.
Good budgeting and clean surroundings are naturally important, but they are hardly the primary reasons why a service exists. In my experience, staff quickly learn to focus on the actual values that operate within a service and frequently treat policy documents with scepticism. If we want to provide quality services then it is important that the values a service aspires to are those that operate in practice. If increased staffing levels do not result in improved services, then we need to examine the actual values and priorities that operate within the system.