Exploring links between expressed emotion, challenging behaviour and burnout in learning disability frontline staff. Emma Mc Donnell

Aim of Study: 1. Replicate previous research findings that there is a relationship between high burnout (BO) and high expressed emotion(EE) in frontline staff working in the area of intellectual disability. 2. Determine if level of training in challenging behaviour (CB) management effects attributions made by staff of the causes of CB 3. Examine whether attribution style can predict high levels of EE in staff and therefore also create a link to a relationship to high BO

Expressed Emotion Measures emotional climate of the family:  Hostility  Criticism  Emotional over-involvement (Vaughan & Leff, 1976)

Expressed Emotion & Intellectual Disabilities Research indicates that frontline staff can display high levels of expressed emotion (EE) as they typically spend large amounts of time with the same groups of clients leading to similar levels of high EE as those of family carers. (Weigel et al. 2006; Stanhope & Solomon, 2007; Dennis & Leach, 2007).

Challenging Behaviour Rates of CB in the intellectual disability population vary from between  10% as indicated by Lowe et als Welsh study (2007)  28% in Mc Clean & Walsh’s Irish study (1995)

Attribution Theory The fundamental attribution error posits that people are more likely to make personality based attributions for causes of behaviour rather than attribute behaviour to situational factors. (Weigel et al. 2006)

Attribution Theory & Frontline Staff  Staff attitudes to causes of CB have indicated that staff beliefs about the cause of CB affect the way in which they interact with clients presenting with such behaviour (Tierney et al. 2007)  Staff have been noted to have elevated EE scores towards clients who they perceive as having more control over their CB (Weigel et al. 2006)

Staff Burnout  Emotional exhaustion  Depersonalisation  Personal accomplishment (Maslach et al, 1996)

Method & Materials Participants (N=221): 108 completed surveys  Staff who had worked with at least one client whose behaviour they perceived as challenging for a minimum of a year were included in the analysis. Materials:  Lime Survey, an open source survey application, was used to create an online survey which was hosted on the intranet server

Measures: 1. Demographic information 2. Checklist of Challenging Behaviour CCB (Harris et al. 1994) 3. Challenging Behaviour Attributions Scale CHABA (Hastings, 1997) 4. Level of Expressed Emotion (LEE) Scale Carer Version (Kararian et al. 1990) 5. Maslach Burnout Inventory Human Services Survey MBI-HSS (Maslach & Jackson, 1996)

Results: Demographics Gender mix of participantsAge range of participants

Highest Level of Staff Formal Education Attainment: Education LevelFrequency % Junior Certificate10.5% Leaving Certificate63.2% Certificate147.5.% Diploma2915.4% Degree % Masters126.4% Doctorate10.5% TotalN=186

Staff Participation Levels in Types of Challenging Behaviour Courses and Frequency: Type of CB courseFrequency% Challenging Behaviour 3 Day Course % TIPS4319.5% Mark % Studio % Total: N= 221

Expressed Emotion Scores:

Staff Burnout Scores:

Logistic Regression Analysis:1 Estimating factors that influence high/low EE A logistic regression analysis was used to predict the probability of high EE scores in staff being linked with elevated BO scores in one of its three domains: - Emotional exhaustion, - Depersonalisation - Personal Accomplishment.  The results indicate that high EE predicts high emotional exhaustion.  Staff that are presenting with emotional exhaustion are more likely to have elevated EE scores.  The coefficient on the emotional exhaustion variable is positive and significant at p=.012

Logistic Regression Analysis:2 The same model was also used to calculate which of the three attribution dimensions of the CHABA scale would be correlated to staff with high EE scores.  Internal / external  Controllable / uncontrollable  Stable / unstable  The coefficient on the internal variable was positive and significant p=.049  This indicates that staff who have high EE scores are eight times more likely to be making internal attributions.

Discussion: EE & CB Training  High EE was evident in 51.85% of staff in this study, this appears to be within the limits found in other studies that range from 31% to 66% (Dennis & Leach, 2007; Langdon et al. 2007).  No significant difference was found between the EE scores of trained versus untrained staff in the area of CB. This is contrary to previous research that suggests that less formally trained staff have higher EE scores (Dennis & Leach, 2007; Van Humbeeck et al. 2001).

Discussion: Attribution style & EE  Results indicate that staff with elevated EE scores are eight times more likely to be making internal attributions for causes of CB in clients.  This result corresponds very positively to previous research in the area which suggests a link between internal attribution of client CB by staff is correlated to high EE scores in staff (Tierney et al. 2007; Sharrock et al. 1990; Weigel et al. 2006).

Discussion: EE & Staff Burnout  This study corresponds with previous research suggesting that high levels of some elements of BO are present in frontline staff and that this can be linked to high EE scores.  This study corroborates the finding of a link between elevated EE scores and high scores on the BO measure in a much greater sample  n=108 versus n=10. (Dennis & Leach, 2007)

Discussion: Effects of Staff Burnout  The results of this study indicate a strong link between internal attributional style of staff towards clients CB, consequently elevated EE scores developing in these individuals and leading to BO in the area of emotional exhaustion.  The effect of BO on intellectual disability services is large with higher rates of absenteeism, staff turnover and low morale leading to a more stressful working environment (Dennis & Leach, 2007).

Limitations: Approximately 10% of frontline staff completed the survey, however there was a skew in the sample with the majority of participants in their 20’s or 30’s:  The benefit of using a method that greatly increases numbers of participants outweighs the slightly skewed nature of the sample.  The anonymity afforded by this methodology does have its benefits with participants more likely to respond honestly about a sensitive work area.

Future Research:  CB training courses: no significant effect found in the low versus high EE groups with regard to the effect of CB training.  The results indicate that present CB management training had little effect on staff attributions.  As staff attributions to the internal causes of CB can now be demonstrated to predict high EE scores the impact of improving training to shift staff beliefs towards external attributions should warrant further research.

Conclusion: Lowering EE environments has a two-fold effect with both staff and client benefitting from a more positive interaction. Ultimately improving the training and support provided to staff working in with challenging behaviour in the area of intellectual disability improves the quality of care and the quality of life for service-user.