Paraprofessionals' awareness of possible ethical violations related to supporting consumers with mental retardation was evaluated. Eighty-one paraprofessionals from residential programs for adults with mental retardation responded to 10 vignettes describing hypothetical ethical violations. Results suggest that paraprofessionals recognized and recommended appropriate courses of action in response to ethical violations. When results were compared to a similar study in an inpatient psychiatric setting (Dracy & Yutrzenka, 1997), findings indicated that paraprofessionals supporting persons with mental retardation were more conservative in their responses to ethical violations than were paraprofessionals supporting persons with mental illness.
Editor in charge: Phil Ferguson
The body of literature on the ethical conduct of direct-care paraprofessional staff members supporting persons with mental retardation in residential, outpatient, or inpatient settings is notably limited. Yet, it is traditionally the direct-care staff members—not professional staff members—who have the greatest amount of consistent contact with consumers in these settings. Research evaluating paraprofessionals' understanding of ethics and their behavior is especially important given the current health care trends of increased rates of deprofessionalization, increased paraprofessional staff members responsibilities, and greater staff members and consumer stress in human service and health care environments (Sturmey & Stiles, 1996). Research on ethics and paraprofessional behavior is also important due to its implications for reducing consumer abuse (Thomas, 1994). Although prohibitive abuse and neglect statutes exist, as do codes of ethics espoused by state and national associations (e.g., American Association on Mental Retardation [AAMR], The ARC), such laws and codes are often insufficiently comprehensive and specific to guide paraprofessionals who provide day-to-day support to consumers with mental retardation (Marchetti & McCartney, 1990; Thomas, 1994). Alarmingly, health care administrators have sometimes considered staff members training, where topics such as recognizing unethical behaviors and learning correct procedures for reporting ethical violations can be addressed, one of the first areas to cut when budgets are limited (Berman, 1994). Dracy and Yutrzenka (1997) warned that if paraprofessionals continue to work under increasingly strenuous conditions with less training and less supervision, the quality of ethical care is likely to suffer.
Research in which investigators evaluate the ethical awareness and conduct of paraprofessionals within residential community settings supporting consumers with mental retardation is particularly needed. This is due to both the unique needs of individuals with mental retardation and the unique context of the community setting. For example, persons with mental retardation are more vulnerable to abuse and neglect than are their peers without disabilities (Lumley & Miltenberger, 1997; Marchetti & McCartney, 1990). Relative to adults without disabilities, adults with mental retardation are more likely to have a curtailed knowledge base for making informed decisions, limited understanding regarding laws against abuse, severely impaired communication, and fewer adaptive behavior skills (Weisstub & Arboleda-Florez, 1997). Furthermore, several authors have noted the ethical complexities of appropriate relational boundaries that paraprofessional staff members experience in residential community settings relative to more traditional hospital settings (Curtis & Hodge, 1995; Lambert & Davidson, 1999; Perkins, Hudson, Gray, & Stewart, 1998). For example, in contrast to the briefer relationships common in inpatient psychiatric hospital settings, where paraprofessionals tend to work with individuals solely in the hospital setting anywhere from a few days to a few weeks at a time, community residential care staff members are typically heavily involved in multiple areas of the consumers' personal lives, including family relationships, employment, finances, and friendships for much longer periods of time (i.e., months to years). Consequently, when community-based paraprofessionals are expected to assume and experience extensive role overlap, ethical boundaries between staff members and consumers in residential settings may become blurred (Lambert & Davidson, 1999; Perkins et al., 1998). Because boundaries are likely to be less clear due to role overlap, and because persons with mental retardation are vulnerable to ethical violations, the probability that residential paraprofessional staff members will dismiss ethical violations may be elevated. However, though conceptually conceivable, it is not empirically clear whether the amount of role overlap experienced by residential staff members actually renders their responses to ethical violations different from those of other paraprofessionals in other (i.e., inpatient) settings.
In view of the challenges facing residential staff members working with consumers who have mental retardation, the inadequacies of codified ethical standards, and the limited attention paid to staff members training in ethics, a strong potential exists for unrecognized, under-reported, or unreported ethical violations to occur. The present study was designed to explore direct-care paraprofessionals' awareness of and responses to ethical issues in the contexts of hypothetical ethical violations. More specifically, we hypothesized that residential direct-care staff members working with individuals who have mental retardation would accurately distinguish between mild, moderate, and high levels of severity of ethical violations in the vignettes presented. In addition, we hypothesized that this recognition of severity would be reflected in the types of actions staff members would take in response to these hypothetical violations. Finally, because we had access to Dracy and Yutrzenka's (1997) data that examined similar hypotheses with paraprofessionals working in an inpatient psychiatric hospital, we compared the two groups to explore whether differences in the work setting would contribute to different patterns of responses. We hypothesized that staff members supporting persons with mental retardation would respond differently to hypothetical ethical violations than would staff members supporting persons with mental illness, given the potential for greater ambiguity in staff member–consumer relationships in the community setting.
Participants were solicited from a potential pool of 247 paraprofessional direct-care staff members working in two residential settings supporting individuals with mental retardation. Both agencies were located in the same rural region of the Midwestern United States. Sixty survey packets were sent to one agency and 187 to the other. Seventeen and 64 participants, respectively, returned their packets, yielding 28% and 34% agency response rates. That is, 81 of the 247 (33%) potential respondents returned completed surveys. To determine whether combining the samples of staff members supporting persons with mental retardation would be appropriate, we conducted a preliminary analysis evaluating possible demographic difference between the samples. Although the samples differed in education, χ2(3, N = 80) = 11.19, p < .01, age, t(1, 76) =−3.23, p < .002, and overall work experience with persons with mental retardation, t(1, 78) =−3.07, p < .003, they did not differ in terms of gender, race, work setting (i.e., group home/assisted living), or shift worked. A follow-up analysis found that participant education, age, and work experience were not related to residential paraprofessionals' responses to the ethical violations; hence, the samples are considered collectively in the following analyses.
Dracy and Yutrzenka's (1997) comparison paraprofessional sample was collected from a mid-sized public psychiatric inpatient hospital located in the same region from which the present sample originated. Their sample consisted of 85 out of 222 potential direct-care staff members (38%). Table 1 summarizes demographic data about the residential and inpatient samples.
The survey used for the current study was essentially identical to the survey form used by Dracy and Yutrzenka (1997) but was adapted for paraprofessionals working in residential programs supporting individuals with mental retardation. In developing the original survey, Dracy and Yutrzenka reviewed probable ethical violations that had occurred within a psychiatric inpatient setting and conducted a pilot survey with 16 mental health paraprofessionals to validate their choices for ethical violations included in their vignettes. Results of the pilot test suggested that the survey was easy to understand. Categorization of seventy level for each hypothetical ethical violation was based on concomitant implications for continued employment if staff members persons committed a particular violation on the job. Mild severity violations were those for which staff members would receive three written warnings prior to termination. Moderate severity violations were those for which staff members could be fired after receiving one or two written warnings. Finally, high severity violations were those for which staff members would be fired without receiving written warnings.
The survey used in the present study consisted of three sections. The first section included demographic items (i.e., gender, ethnicity, age, and level of education) and items reflecting the participants' work history and current job description. The second section included 10 vignettes, each containing a different hypothetical ethical violation of mild, moderate, or high severity (see Appendix A). In this section, only minor changes were made from Dracy and Yutrzenka's (1997) survey. For example, the word patient was changed to consumer to reflect the terminology currently used to describe individuals with disabilities in residential programs. The level of severity for each vignette in the earlier and current study was judged to be roughly consistent by professionals in the field of mental retardation. A selection of possible responses to the violation (e.g., ignore violation, confront the staff member's peer, inform immediate supervisor, and inform someone above the immediate supervisor) followed each of the vignettes. Participants were instructed to indicate how likely they were to respond to each of the specified options on a 6-point Likert scale ranging from 1 (always) to 6 (never). The third section of the survey included items relevant to how paraprofessionals perceive their own abilities to recognize and respond to potential ethical violations. Wording changes similar to those made in the second section were also made in the third section. Moreover, two items were added inquiring about any formal training participants had received specific to recognizing and responding to consumer abuse.
Program directors of each prospective agency were first contacted and invited to have their agencies and their direct-care staff members participate in this study. Once permission was obtained, program directors were sent a survey packet for each eligible staff member. Survey packets were distributed to individual staff members by residential managers, who were also instructed to ask residential direct-care staff members to return the completed survey within 2 weeks of receipt. Staff members were informed in a cover letter that participation was voluntary and anonymous and that they could return their survey directly to the researchers in the self-addressed, stamped envelope included with the survey packet.
Responses to Ethical Violations
To evaluate whether paraprofessionals working in residential programs with individuals who have mental retardation recognize and differentiate between examples of hypothetical ethical violations varying in severity, a 3 (levels of severity) × 4 (responses to situation) within-subjects multivariate analysis of variance (MANOVA) was computed. Results indicated an overall severity by response interaction, Wilks' lambda = .151, F(6, 65) = 61.05, p < .001. The overall analysis was followed by four one-way repeated-measures analyses of variance (ANOVAs) in order to evaluate the relationship between the four response options across levels of violation severity. Results indicated that the likelihood of residential staff members ignoring the violation, F(2, 152) = 64.12, p < .001, confronting a peer staff member, F(2, 148) = 21.69, p < .001, reporting the violation to their supervisor, F(2, 150) = 121.79, p < .001, and reporting the violation to someone above their supervisor, F(2, 144) = 141.82, p < .001, all significantly varied with differing levels of violation severity.
The results of a priori pairwise comparisons between mild and moderate severity categories and between moderate and high severity categories for each of the four possible response choices are shown in Table 2. As predicted, paraprofessionals supporting persons with mental retardation were less likely to ignore ethical violations of high severity than those of less severity. Staff members were also more likely to report ethical violations to their supervisors or to persons above their immediate supervisor when ethical violations were of higher severity. Residential paraprofessionals did not differ in the likelihood of confronting peers for mild and moderate ethical violations. However, contrary to expectations, staff members were less likely to confront peers for ethical violations of high severity than for violations of mild or moderate severity.
The main effects of violation severity and response to violations were also evaluated. The main effect for severity was significant, F(2, 69) = 46.69, p < .001. Pairwise comparisons indicated that mild, moderate, and high (Ms = 3.46, standard deviation [SD]= .06, 3.17 [.06], and 2.99 [.07], respectively) levels of severity differed from each other beyond the .05 level. The main effect for response was also significant, F(3, 68) = 555.15, p < .001. Pairwise comparisons indicated that all responses (e.g., ignore, confront, contact supervisor, and go above supervisor (Ms = 5.54 [SD = .08], 2.33 , 1.86 [.09], and 3.10 [.13], respectively) differed from each other beyond the .05 level.
To determine whether paraprofessionals supporting persons with mental retardation responded differently to hypothetical ethical dilemmas than did those supporting persons with mental illness, a mixed-subjects MANOVA was computed. This allowed for the exploratory evaluation of any interactions of paraprofessional setting, ethical severity, and responses to hypothetical ethical dilemmas. Results indicated a significant overall Setting × Response × Severity interaction, Wilks' Lambda = .794, F(6, 139) = 6.00, p < .001. Although no significant interaction was found between setting and severity, a significant Setting × Response, Wilks' Lambda = .807, F(3, 142) = 11.30, p < .001, interaction was found, indicating that paraprofessional staff members supporting individuals with mental retardation responded differently to ethical violations than did staff members supporting individuals with mental illness. This suggested that although both groups share the general trend of being more likely to report ethical violations as severity increases, there are some differences in the groups' response patterns.
To understand the differences in response patterns across paraprofessional groups, we computed univariate comparisons. Results suggest that residential staff members working with adult consumers who have mental retardation are generally more conservative than are staff members working in psychiatric inpatient settings. That is, in comparison to staff members supporting persons with mental illness, staff members supporting persons with mental retardation rated themselves as less likely to ignore ethical violations of varying severity (Ms = 5.24 [SD = .08] and 5.54 [.08], respectively), F(1, 151) = 7.28, p < .01. Although there was no significant difference between groups for confronting a peer over an ethical violation, staff members supporting persons with mental retardation rated themselves, F(1, 155) = 27.40, p < .001, as being more likely to report ethical violations to their immediate supervisors than did staff members supporting persons with mental illness (Ms = 1.86 [SD = .09] and 2.60 [.09], respectively). Finally, staff members supporting persons with mental retardation rated themselves as more likely to report ethical violations to someone above their immediate supervisor than did staff members supporting persons with mental illness (Ms = 3.10 [SD = .13] and 3.91 [.13], respectively), F(1, 148) = 19.14, p < .001.
An exploratory analysis of responses to questions about personal knowledge and skill level relating to ethical issues indicated that nearly all of the staff members supporting persons with mental retardation perceived themselves as adequately skilled to recognize and report consumer abuse. More specifically, 75 of the residential staff members (93%) reported having received formal training in how to recognize potential ethical violations involved in working with individuals who have mental retardation. In addition, 74 of the residential staff members (91%) reported receiving training regarding how to respond to work-related ethical violations. Nonetheless, 42 (53%) of the residential staff members desired more training regarding ethical conduct and interventions. This finding was similar to Dracy and Yutrzenka's (1997) finding that 43 staff members supporting persons with mental illness (55%) desired more ethics-related training.
A one-way ANOVA was conducted to explore whether these samples differed in their ratings of confidence in their abilities to recognize consumer/patient abuse. Results indicated that staff members supporting persons with mental retardation felt more confident in their ability to recognize abuse than did staff members supporting persons with mental illness (Ms = 1.7 [SD] = .59 and 2.3 [1.22]), F(1, 163) = 15.32, p <.001. A second one-way ANOVA indicated that staff members supporting persons with mental retardation also felt more confident in reporting abuse according to their agency's policies than did staff members supporting persons with mental illness (Ms = 1.6 [SD = .79] and 2.6 [1.23], respectively), F(1, 163) = 34.90, p < .001.
The results of this study supported the hypothesis that residentially based direct-care staff members working with consumers who have mental retardation would accurately distinguish between mild, moderate, and high levels of severity of ethical violations in the vignettes presented. Results also supported the hypothesis that recognition of severity would be reflected in the types of actions staff members would take in response to these hypothetical violations. As predicted, residential paraprofessionals indicated that they would be more likely to report ethical violations of greater severity than those of less severity. Paraprofessionals supporting persons with mental retardation also reported a greater willingness to approach their immediate supervisors than someone above their supervisors when ethical violations occurred. Moreover, paraprofessionals indicated that they would be less likely to confront a peer when violation severity was high then when it was of moderate or mild severity. These last two findings are not necessarily problematic for agencies. Administrators are likely to prefer that ethical violations are first brought to the attention of paraprofessionals' immediate supervisor than a person above that supervisor. Furthermore, following the chain-of-command principle, agencies are likely to prefer having the supervisors of paraprofessionals deal with ethical violations rather than fellow staff members.
We were also interested in exploring patterns of responses between staff members supporting persons with mental retardation (present study) and paraprofessional staff members working in an inpatient psychiatric hospital (Dracy & Yutrzenka, 1997) to evaluate whether potential differences in work settings would contribute to different patterns of responses. We hypothesized that staff members supporting persons with mental retardation would respond differently to hypothetical ethical violations than would staff members supporting persons with mental illness, given the potential for greater ambiguity in staff member–consumer relationships in community residential settings. The results of this comparison suggest that staff members supporting persons with mental retardation were, however, more conservative than inpatient staff members on all responses except for confronting peers over an ethical violation. That is, residential staff members supporting persons with mental retardation were less likely to ignore ethical violations and more likely to report violations to their immediate supervisors or to someone above their supervisors than were inpatient staff members supporting persons with mental illness, regardless of violation severity. We note, however, that even though these effects were statistically significant, the mean difference between groups might not be large enough to warrant clear differences in practice. For example, in the case of reporting violations to the immediate supervisor, the statistically significant difference between both groups is only .07 of a unit different on a 6-point Likert scale, where both group means are between the response options of likely and very likely.
The results of the current study also suggest that staff members supporting persons with mental retardation are more confident in their awareness of consumer abuse than are staff members supporting persons with mental illness. These findings are consistent with similar findings reported by Garmen, Corrigan, Norris, and Bachard (1997), who found that residential staff members working with those with developmental disabilities felt more confident in their training than did other community and inpatient staff members working with persons who had mental illness. Because residential consumers are especially vulnerable to abuse by staff members (Lumley & Miltenberger, 1997; Marchetti & McCartney, 1990; Weisstub & Arboleda-Florez, 1997), it may be that residential agencies supporting adults with mental retardation offer more training or have more explicit policies regarding ethical issues in order to mitigate the probability of consumer abuse. If this is so, such training or policies may have affected the responses of residential paraprofessionals working with consumers. Research clarifying the relationship between moderating variables of role-overlap and ethical care is needed.
Although in this study we sought to evaluate paraprofessionals' awareness and responses to ethical violations, it is not clear whether staff members' ratings were influenced more by a personal sense of ethical behavior or by prescribed agency policies and procedures. It is probable that both are at play. Because laws do not cover a vast number of issues that staff members deal with in supporting consumers, and because codes of ethics are typically aspirational, paraprofessionals may rely on their own personal values or on specific agency policies when legal statutes and ethical codes are too general or vague. Although it is difficult to determine the specific reasons why a staff member would act in an ethical manner (e.g., to save their job, to act out of a sense of ethics), it is, nonetheless, imperative that program administrators carefully consider potential ethical dilemmas faced by their staff members and provide policy accordingly to guard against staff members infringing on the rights of consumers. Indeed, program administrators have the obligation to provide training on specific ethical concerns and to teach ethical principles of nonmaleficence and beneficence (see Thomas, 1994). We were encouraged to find that direct-care paraprofessionals are interested in learning more about ethical concerns and how to address them.
The results of this study need to be considered in the context of a number of the study's limitations. First, findings from comparing the residential and inpatient samples should be interpreted cautiously given that the samples differed diagnostically. That is, because one sample represented paraprofessionals supporting adults with mental retardation and the other represented paraprofessionals supporting adults with some type of mental illness, making clear interpretations regarding the impact of setting on paraprofessionals' responses to ethical dilemmas is difficult. Second, although the 33% return rate of paraprofessionals supporting persons with mental retardation is comparable to, if not slightly higher than, similar field-based survey research, this may limit the generalizability of the results to other paraprofessionals in residential settings. It is possible that the sample is biased in the direction of staff members who are more interested in, concerned about, or experienced with ethical concerns. Third, because the data were collected through a survey of hypothetical ethical dilemmas, information regarding direct experience with these potential violations and subsequent actions taken are not available. It is also possible that the selection of ethical violations may not represent the actual range of ethical dilemmas faced by residential staff members supporting persons with mental retardation. Fourth, the extent to which the reported responses reflect actual behavior of paraprofessional staff members is not clear. That is, what staff members say they would do may differ from what they actually would do if these hypothetical situations occurred in their work settings. Finally, although vignette severity scaling was rated and established by a panel of direct-care paraprofessionals and administrators, vignettes were written in such a way that their severity could be ambiguous. For example, one vignette regards treating a consumer more roughly than necessary, which, though rated as mildly severe, could potentially be rated as a highly severe ethical violation.
Although paraprofessional staff members appear to recognize and respond accordingly to hypothetical ethical violations, further research evaluating their ethical conduct is needed. Because paraprofessional staff members supporting persons with mental retardation were found to respond more conservatively to ethical violations than did inpatient staff members working in a psychiatric setting, it is still not clear whether the ethical conduct of paraprofessionals may suffer due to role overlap, or if it does, what possible factors mediate the role overlap experienced by residential paraprofessionals working with consumers. Essentially, such findings would be important to agency administrators for developing training policies for agencies supporting persons with mental retardation.
NOTE: The level of severity of the behavior depicted in the vignettes was mild for Items 1, 6, and 8; moderate for Items 4, 7, 9 and 10; and high for Items 2, 3 and 5.
Vignettes of Hypothetical Situations Involving Ethical Violations of Varying
You are aware that a peer has been addressing a consumer by a name other than what the consumer has asked to be addressed by (e.g., The consumer has asked to be addressed as Mr. Doe, but your peer instead addresses him as John).
You are aware that a peer has hit, kicked, or slapped a consumer.
You are aware that a peer has stolen a consumer's money or belongings.
You are aware that a peer has not been providing care that is in the best interest of the consumer (e.g., the peer has not insured that a consumer is dressed appropriately for weather conditions or has not provided care mandated by a treatment plan).
You are aware that a peer has made physical sexual contact with a consumer.
You are aware that a peer has criticized a consumer in a nonconstructive manner.
You are aware that a peer has directed sexual remarks toward a consumer.
You are aware that a peer uses rougher than necessary techniques when handling consumers.
You are aware that a peer has been teasing or belittling a consumer.
You are aware that a peer has threatened a consumer.
Authors: Matthew N. I. Oliver, MA, Graduate Student ( firstname.lastname@example.org), Barbara A. Yutrzenka, PhD, Professor and the Director of Clinical Training, Department of Psychology, 414 E. Clark St., University of South Dakota, Vermillion, SD 57069. Pat L. Redinius, MA, Training Director, UAP, University of South Dakota School of Medicine