Setting up inpatient behavioral treatment programs: The staff needs assessment

Behavioral Interventions, Vol. 9, No. I , 1-12 (1994)

SETTING UP INPATIENT BEHAVIORAL TREATMENT PROGRAMS: THE STAFF NEEDS ASSESSMENT

Patrick W. Corrigan, E. Paul Holmes and Daniel Luchins University of Chicago, Pritzker School of Medicine

Joseph Parks and Abdul Basit Tinley Park Mental Health Center & University of Chicago, Pritzker School of Medicine

Ethel DeLaney Tinley Park Mental Health Center

Donna Kayton-Weinberg Illinois School of Professional Psychology

Despite the success that behavior therapy has demonstrated in treating severely mentally ill adults, widespread impact of behavioral treatments on this population has been limited because the staff of many inpatient settings do not routinely utilize these strategies. Surveying staff regarding their perception of programatic and organizational needs is proposed as a valuable first step for selecting behavioral strategies to be introduced in these settings. Goldfried and D’Zurilla (1969) developed a behavioral assessment survey that is especially useful for identifying staff needs vis-ri-vis behavioral rehabilitation. Using these strategies, survey questions addressed five problem areas: Administrative, Staff, Patient, Resource, and Programatic. Results using this survey with 40 clinicians on the extended care unit of a state hospital showed that staff members had greatest concern with the Patient Problem Area (i.e., aversive patient behaviors that are not sufficiently addressed by treatment plans). Further analyses showed staff members were interested in addressing Patient concerns using incentive procedures. The needs assessment in this study not only provided useful information that might be generalized to other treatment settings, but also showcased a reliable survey approach that program developers might implement prior to designing training curricula for behaviorally naive staff in inpatient settings.

Behaviorally-based treatments, when used with medication management, significantly enhance the quality of care for many severely mentally ill adults. The effects of various behavioral strategies have been repeatedly validated on this population including social skills training (Bellack, Hersen, & Turner, 1976; Wallace & Liberman, 1985), token economies (Ayllon & Azrin, 1968; Paul & Lentz, 1977), behavior family management (Anderson, Reiss, & Hogarty,

Address correspondence to: Patrick W. Corrigan, Psy.D., University of Chicago Center for Psychiatric Rehabi- litation, 7230 Arbor Drive, Chicago, IL 60477, USA

10724M47~94/010001-12$11.00 0 1994 by John Wiley & Sons, Ltd.

2 P. W. Corrigan et al.

1986; Falloon, Boyd, & McGill, 1984), and cognitive rehabilitation (Brenner, Hodel, Roder, & Corrigan, 1992; Spring & Ravdin, 1992). These interventions have had significant impact on the course of severe psychiatric disorders; e.g., patients participating in social skills training studies have significantly diminished symptoms and rate of relapse (Hogarty et a/., 1986, 1991; Wallace & Liberman, 1985) and have improved social functioning (Brown & Munford, 1983; Fecteau & Duffy, 1986).

Despite these successes, the impact of behavior therapy on treatment of severe mental illness, outside highly structured research settings, has been surprisingly muted. Several barriers have been identified which impede the introduction and day-to-day implementation of behavioral innovations at typical inpatient settings; central among these is the lack of line level staff with sufficient training to implement quality behavioral programs (Backer, Kuehnel, & Liberman, 1986; Corrigan, MacKain, & Liberman, in press; Cullari & Ferguson, 1981). To resolve this problem, clinical investigators have developed and evaluated training programs that teach rehabilitation skills to the administrators and clinicians charged with treating these patients. Studies on staff training programs have shown that trainees are able to competently learn and use rehabilitation skills, and that they in turn are able to train colleagues at their mental health center to use these skills (Eckman, Liberman, Phipps, & Blair, 1990; Rogers, Cohen, Danley, Hutchinson, & Anthony, 1986; Wallace, Liberman, MacKain, Black- well, & Eckman, 1992). Moreover, patients participating in modules taught by trained staff significantly increase their skills repertoire.

There are limitations to staff training programs, however, which may be understood by extrapolating similar criticisms that have been made about social skills training programs for patients; i.e., the content of some training programs are not relevant to the real life needs of patients (or staff). For example, should staff members be taught behavior family management strategies when the team is more interested in manipulating incentives that control patient behaviors. Clinical investigators interested in patient populations have shown that this problem can be diminished by surveying patient samples regarding the nature of their interpersonal problems (Corrigan & Holmes, in press; Goldsmith & McFall, 1975). Similar surveys could be developed for staff and their treatment programs.

Identifying staff priorities for program development is an important first step in staff training. The needs assessment informs consultants about which treatment methods should be the initial focus of training. Beginning with this focus will enhance the relationship between training consultant and staff members. Moreover, staff members are more likely to adopt and maintain strategies that are relevant to their perceptions of unit needs. Line level clinicians are

Staff needs assessment 3

more likely to have successful treatment interactions with patients when adopt- ing meaningful interventions.

Because we seek to understand how (and if, behavioral rehabilitation programs meet staff work-related needs, Goldfried and D’Zurilla’s (1 969) “Behavior Analytic” method was adapted to survey staff regarding their perception of programmatic and institutional needs. This method utilizes a stepwise strategy for surveying subjects regarding their perceptions of common interpersonalprob- Zems and includes 3 phases as modified for this study:

1. Problem identification: Staff members are asked to list programatic needs relevant to patient care (e.g., What do patients do on the unit that keeps them from being discharged?);

2. Problem Validation: Items generated for the first step are evaluated by the group to consensually determine whether each situation is actually viewed as problematic and therefore should be addressed; and

3. Solution Enumeration: Staff members are asked for effective responses to consensually identified needs (e.g., What could staff members on the unit do differently that might address this need?). The list of responses helps program developers understand what the unit has tried, or is open to attempting, in dealing with programatic needs.

Readers familiar with the Behavioral Analytic method will note the change in terminology for purposes of this study as well as the consensual validation phase focusing on problem situations rather than solutions to reflect our keener interest in programatic needs. Adaption of Goldfried and D’Zurilla’s strategies meets several recommendations for improving the methodological rigor of staff survey research (Cogswell & Stubblefield, 1988; Royse & Drude, 1982). The strategy incorporates a consensual confirmation phase to assure validity of responses. Problem situations identified in the survey readily suggest change strategies that might be implemented to affect these situations.

METHODS

Hospital administrators at Tinley Park Mental Health Center (TPMHC) con- tracted with faculty of the University of Chicago Center for Psychiatric Rehabili- tation to develop a state-of-the-art behavioral rehabilitation program for their Extended Care Unit (ECU). TPMHC is a state owned and operated inpatient facility in the south suburbs of Chicago. Like many state hospitals, the majority of patients at TPMHC ( N = 235) suffer acute exacerbations of their psychiatric illness; hence, treatment for these patients was oriented towards facilitating


rapid remission of symptoms and reentry into the community. TPMHC also had 120 beds on the ECU dedicated to long-term treatment. ECU patients typically had a chronic history of severe mental illness with repeated admissions and few skills to sustain community life; average length of stay for these patients exceeded 15 months.

Needs assessment All ECU clinical staff were instructed by their director to attend 1 of 4 group

meetings where staff members “will be surveyed regarding your opinions about needs for changing the program to improve patient care.” Multiple meetings were conducted so that staff members could cover unit duties while peers attended the meetings; from 7 to 15 staff members attended each one. The needs assessment was conducted in 3 phases corresponding to Goldfried and D’Zurilla’s steps. In the first phase, Problem Identification, staff members were instructed to complete a pencil-and-paper measure comprising 15 open-ended questions regarding their perceptions of programatic needs related to patient care; these questions are listed in Table 1. Questions represented 5 problem areas that had been identified in previous staff surveys: (1) Administrative, bureaucratic red tape that interfered with clinical practice; (2) Staff, problems related to staff attitudes; (3) Patient, aversive patient behaviors that are not sufficiently addressed by treatment plans; (4) Resources, lack of funds, equipment, space, or staff to implement treatment properly; and (5) Program, current intervention strategies that do not meet treatment goals (Corrigan, Kwartarini, & Pramana, 1992; Emerson & Emerson, 1987).

Responses were compiled by 2 independent raters to form the checklist for the second phase of the needs assessment, Problem Validation. At a subsequent meeting, survey participants were told to check off programatic and institutional needs from this list that they believed to be germane to ECU patient care. The top 25% of needs endorsed most frequently by the combined sample were transformed into open-ended questions for the Solution Enumeration phase of the assessment. Subjects’ opinions about effective coping responses to these situations were then solicited using a second, open-ended, written survey. Staff members also completed a short demographic survey.

RESULTS

Forty staff members completed the needs assessment; this represented 7 1.5% of the a.m. and p.m. shifts on the ECU. The sample was 50% female with

StafSneeds assessment 5

TABLE 1. Open-ended questions in the problem identification phase of the survey by problem area.

The first question is general. Where can our consultation be of most help?

Administrative Do administrators and supervisors provide sufficient support for your treatment programs? Are administrators and supervisors available to meet with staff members? Are sufficient continuing education opportunities available?

Staff Do your colleagues share interest in the treatment programs you want to conduct? Are there leaders on the units to conduct appropriate treatments? Does the staff have the necessary know-how to conduct treatments?

Patient Do patients have any problems that are not addressed well by current treatments on the unit? Do your patients have any problems with aggression currently not well treated by your

Do your patients have any problems with inactivity currently not well treated by your programs? Do your patients have any problems with not complying with treatment programs? Do you have any problems with family members?

Resources Are there sufficient resources to conduct treatment programs? If not, what would you need? Do you have enough time to conduct the treatments you want?

programs?

Program Are any patient problems due to gaps in unit programing?

an average age of 45.2 years (SD = 8.6). Thirty percent of the sample was single, 51.3% was married, and 17.9% was widowed or separated. The sample had, on average, completed 18.8 years of education (SD = 7.5). Subjects were divided into 3 job groups: nursing staff (i.e., nurses, mental health technicians, and mental health specialists) comprised 60.0% of the sample, clinical staff (i.e., social workers, activity therapists, psychiatrists, and psychologists) comprised 32.5%, and administrators comprised 7.5%. Staff reported that 52.5% worked a.m. shifts and 47.5% worked p.m. The staff was 41.7% African American, 33.3% White, 16.7% Hispanic, and 8.3% Asian. Interestingly, neither quantity nor quality of responses differed significantly across any staff demographic vari- able.

Problem identification Two independent raters reviewed staff members’ responses to the written

survey and identified 57 responses; interrater agreement was high (0.94). These responses are listed in Table 2.


TABLE 2. The 57 Items generated in response to the problem identification phase per problem area.

Administrative 1. Staff are not asked to give suggestions when programatic changes are considered 3. The system discourages creativity 4. Negotiating the system tends to undermine initiative and motivation 5. The program lacks an overall unifying agenda; each discipline has its own interests first 8. Program changes are poorly communicated to direct-care Staff

17. Administrative policy places patient rights over staff safety 22. Administration is more concerned about documentation than patient care 27. Some administrators’ approach to motivating staff is aversive

Stag 10. Danger of secondary smoke is a problem 1 I . A significant amount of staff time is spent on paperwork 15. Staff lack a working knowledge of behavioral management 16. Job title limits the degree of involvement with patients 18. Staff lack motivation to conduct treatment 19. Criteria for admission to restraint room is not consistent among staff 21. There is a lack of staff to carry out treatment 25. Staff have to be more concerned about complying with policy and their own safety than

31. Some staff are not concerned about the patients’ well-being 34. There is a lack of clearly defined treatment goals and expectations 52. Detailed staff are not familiar with unit patients or unit treatment approach 57. There is a lack of access to continuing education opportunities for all staff

their patients’ needs

Patient 6. Patients are bored 9. One of the few behaviors the patients enjoy is smoking

14. Patients are not given enough opportunity to interact with their treatment team 20. Aggressive patients are not medicated properly 23. Numerous patients do not comply with treatment plans (i.e., refuse mediation) 24. Current treatment programs do not address patient behavior problems 26. Patients do not take responsibility for their personal hygiene and grooming 29. Patients are misdiagnosed 33. Medication alone does not solve the problems of aggression 35. Problems patients get more attention than inactive patients 36. Patients and their Fdmilies do not have access to areas for private visiting 38. Some patients do not want to be discharged from the hospital 39. Patients are not interested in treatment programs 40. Presence of organic brain disordered and developmentally delayed patients require alternative

interventions to those the psychiatric unit provides 42. Patients respond to limit setting by threats and verbal abuse 51. A significant proportion of the patients remain inactive during the day 56. Many patients do not adhere to unit rules (Le., smoke in undesignated areas)

StafSneeds assessment 7

TABLE 2. Contd.

Resource 30. There is a lack of funds to maintain quality of care 43. There is a lack of equipment for activities 37. There is a lack of space to carry out activities 44. Patients do not have adequate clothing, underwear and grooming supplies 46. There is a lack of sufficient staff to provide treatment 49. There is a lack of adequate medical care

Program 2. Treatment interventions do not take into consideration the degree of variance between high

7. There is no organized treatment for alcohol and drug abusers and low functioning patients

12. Patients lack adequate discharge planning and linkage to community services 13. Current treatment programs do not address symptoms like apathy, blunted affect and social

28. There are not sufficient structured activities for patients 32. There is a lack of adequate number of structured activities for patients during the evening

41. There is inadequate focus on skill building in preparation for community living 45. There is a lack of treatment interventions that promote acquisition of independent living

47. Patients are not provided adequate medical care 48. There is insufficient interventions focused at diminishing aggression 50. New treatment interventions are implemented with little consistency 53. New treatment interventions are dropped without giving adequate time to assess their effecti-

54. Communication of appropriate and inappropriate behavior is inconsistent 55. Groum are too big for staff to Drovide adequate structure

withdrawal

shift

skills

veness

Numbers preceding items correspond with random position in checklist administered to subjects in this study.

Problem validation The 40 staff members were then asked to check each item from the list of

57 responses that “you consider a need or problem that should be addressed in order to facilitate improvements on your unit.” An Endorsement Index was determined for each problem area (i.e., number of items comprising the problem area endorsed by the subject divided by total items comprising the problem area) to determine which problem areas were of greatest concern to subjects. The mean and standard deviation of these indices are listed in Table 3 . Findings from a repeated measures ANOVA showed that rate of item endorsement significantly differed across problem areas (F(4,156) = 4.30, p < .003). Post hoc, matched pairs t-tests suggested that staff members reported significantly greater concern (p < .05) with items from the Patient Problem Area than any other problem area.


TABLE 3. Means and standard deviations of endorsement index for the 5 problem areas.

Endorsement index

Administrative

Staff

Patient

Resource

Program

O.6Oa (0.30) 0.56”

(0.32) 0.75b

0.63a (0.31) 0.6Ia

(0.25)

(0.21 j

Standard deviations are included parenthetically. the mean of endorsement indices with different super- scripts differ significantly (p < .05).

TABLE 4. Frequency of individual item endorsements.

Item Itern frequencies

Administrative

Staff

Patient -patients d o not comply with treatment plans (i.e., refuse medication) -some patients d o not want to be discharged from the hospital

Resource -lack of funds to maintain quality of care -patients d o not have adequate clothing, underwear, and grooming

-lack of sufficient staff to provide treatment

Program -medication alone does not solve problems of aggression

82.5 87.5

80.0

supplies 80.0 85.0

87.5

The frequency of endorsement of the 57 individual responses was determined to identify specific issues within the 5 problem areas that were of most concern to staff members. Only a few responses were endorsed by more than 80% of staff members and are listed in Table 4. Most of these items were from the Patient and Resource Problem Areas. Note that, in terms of the Patient Problem Area, staff members were concerned about compliance with treatment plans and the inability to control patient aggression. Similarly, in terms of the Resource, staff members were concerned about a lack of funds to implement procedures.

Stuff needs assessment 9

TABLE 5. Staff identified solutions to improving patient problems.

Solution Number of staffmembers endorsing item

Use some sort of reward More contact with staff Use grounds passes Token economy Communicate expectations Make groups interesting Appropriate medications Gain their trust Compliment appropriate behavior Money management Get more agreeable patients More one to one therapy Change staff+2’s negative attitudes Increase cooperation between patients and staff Use problem solving interventions Smaller groups Encourage interaction Use work programs

14 6 4 4 3 3 3 2 2 2 2 2 2 2 2 2 2 2

Solution enumeration Two independent raters reviewed staff recommendations regarding how to

handle needs. Interrater reliability was 0.91. One hundred and one suggestions were made across the 5 problem areas: 18 for Administrative, 15 for Staff, 54 for patient, 8 for Resources, and 6 for Prograrnatic.* Because the Patient Problem Area was found to be endorsed most frequently during the Problem Identification and Validation phases, staff solutions specific to this issue were further analyzed to inform consultants about strategies that should be included in the initial training sessions. At least 2 staff members independently identified 18 of these solutions for improving patients’ behaviors. (See Table 5.) More than a quarter of the sample recommended some sort of reward system. How- ever, less than 10% of the staff were aware of or recommended using a token economy for this purpose.

DISCUSSION

Staff perceptions regarding programatic needs must be assessed to design training curricula and identify organizational strategies that enhance program development. In this study, Goldfried and D’Zurilla’s Behavioral Analytic

* Copies of the list of 101 solutions may be obtained by writing to the authors.


Method was used to survey staff perceptions, organizing specific questions into 5 problem areas: Administrative, Staff, Patient, Resource, and Programatic. Results of a survey on 40 clinicians suggested that staff members had significant concerns about all of the 5 problem areas and more than 50% of items in each problem area were endorsed by staff members. The priority of problem areas is of particular interest in this study, however. Which problem area do staff members find most relevant to their concerns about running a treatment unit? Staff members in this study identified the Patient Problem Area as most important. Therefore, program innovators need to begin training and consultation efforts by addressing patient-related problems.

Knowing what problem area to focus does not suggest what intervention strategies to teach staff members. Consultants might train staff on social skills training, incentive therapies, or behavior family management to address patients’ problems. Biases may lead consultants to focus on treatment strategies they believe to be important based on their treatment experiences. For example, we believed that skills training was an important treatment approach to teach all staff members. However, the solution enumeration phase provides information regarding intervention strategies that stuflrnernbers endorse as relevant. Participants in this study endorsed incentive therapies as most important to them. Therefore, despite our natural inclinations, we began staff training with a discussion of incentive therapies.

Specific problem areas and solutions identified in this study may reflect the content of the open-ended questions that anchored the survey. Questions in this study were based on problem factors identified in previous comprehensive surveys of staff samples (Corrigan et ul., 1992; Emerson & Emerson, 1987). Different factors might yield different survey questions; needs assessors might select questions depending on the problem areas of interest to them. The study was also limited because a Solution Validation phase was not included in the design (i.e., a final step in the survey in which staff members rate how helpful each solution might be for their unit). This phase, originally included in the Goldfried and D’Zurilla survey method, was not incorporated into this study because of concern that staff members would not complete a long and intensive survey procedure. Future studies should consider the cost-benefit of including a Solution Validation phase to determine the relative priority of solutions identified by staff members.

Perhaps the greatest value of this study lies in showcasing the Behavioral Analytic Method as an assessment strategy for surveying staff needs. Program developers may benefit from transferring specific findings from this survey to their treatment settings (keeping in mind that generalization is limited by the similarity of samples). Alternately, they might adopt this survey approach for

StufSneeds assessment 11

determining the specific needs of staff members in hospitals of interest to them. Program developers armed with this information are more likely to make training decisions that are particularly relevant for their treatment milieu. The worth of staff needs assessment will ultimately be tested in a study incorporating a 2 group experimental design in which consultants in the first group use findings from a needs assessment to develop and implement a staff training program while the second group uses a standard curriculum for training. Effects on staff, and ultimately on unit programing and patient problems, should be better for the former group if needs assessment has a beneficial effect on staff training.

ACKNOWLEDGEMENTS

We would like to thank the staff of the Tinley Park Extended Care Units for their cooperation in this study. We also appreciate the help of Stan McCracken, Brett Buican, and Ilana Addis. This study was made possible in part by a grant from the Illinois Department of Mental Health and Developmental Disabilities. Address correspondence to Patrick Corrigan, Psy.D., University of Chicago, Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, IL 60477.

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Documents

Setting up inpatient behavioral treatment programs: The staff needs assessment