Training needs and current status of training for direct support staff were identified in one southeastern state. Data sources were (a) direct support staff, (b) administrators of direct support staff, and (c) consumers with developmental disabilities. Stratified sampling was used to gather data from 108 administrators and 170 direct support staff utilizing mail surveys and from 179 focus group participants (56 administrators, 53 direct support staff, and 70 consumers). Findings suggest that direct support staff recognized the needs (a) for additional training on Community Support Skill Standards; (b) to develop a comprehensive, cost-efficient statewide system for training direct support staff; and (c) to develop the role of direct support staff into a valued profession.
The challenge with finding, keeping, and training direct support staff has been identified in several national policy efforts, including the Developmental Disability Act of 2000 (Title III, §204) and the New Freedom Initiative (Centers for Medicare and Medicaid Services, 2002). Challenges regarding direct support staff recruitment, compensation, and turnover have been documented since the inception of community supports for people with disabilities (American Network of Community Options and Resources, 2001; Heneman & Schutt, 2001; Hewitt & Lakin, 2001; Lakin & Bruininks, 1981; Larson, Lakin, & Hewitt, in press). The ability to find, train, and keep direct support staff is one of the biggest barriers to continued efforts to expand community services as well as the ability to sustain current community supports (American Network, 2001; California State Auditor, 1999; Colorado Department of Human Services, 2000; Hewitt & Lakin, 2001; Hewitt, Larson, & Lakin, 2000; Lakin & Hewitt, 2000).
Although direct support staff members provide one of the most important sources of support in the lives of people with developmental disabilities and their families, the disability field has contributed little beyond entry level orientation training to prepare, retain, or assist with developing meaningful career paths for these employees (Taylor, 1998). Although most states require training related to health and safety issues (e.g., first aid, CPR), little training is provided on how to assist individuals with developmental disabilities to lead productive, self-directed lives in which they are fully included in their communities (Jaskulski & Ebenstein, 1996). Unfortunately, the expectations placed upon direct support staff related to community supports for people with developmental disabilities far exceed the training and support provided to develop essential knowledge, skills, and attitudes needed to meet these expectations. This disconnect between high expectations, limited preparation, and skill training for direct support staff contributes to high burnout and turnover rates in this industry (Hewitt & O'Nell, 1998).
The overwhelming majority of direct support staff training is provided by employers at the beginning of employment. The typical training plan includes a 40-hour orientation on regulatory-driven or prescribed topics and annual reviews on specific topics such as emergency procedures, rights, maltreatment, and other similar topics. Because of the prescriptive and regulatory-driven nature of staff development in the field of developmental disabilities, many direct support staff report that they are not motivated by training. They dread it and are often not challenged by the training they receive (Hewitt, 1998). In addition, employees who are new to the field report that their training is overwhelming and that they have difficulty remembering what they have been told during their training experiences (Hewitt, 1998). Although employees come to new jobs with vastly different experiences, the training they receive is typically “one size fits all.” As a result, training is rarely competency-based (Hewitt & Larson, 1994; O'Nell & Hewitt, in press).
Competency-based training is designed to deliver training to people based on the specific outcomes desired and the specific gaps in knowledge, skills, and attitudes necessary to achieve those outcomes. Unfortunately, few efforts have been made to determine the knowledge, skills, and attitudes required of direct support staff working in the field of community human services. Most research that has been conducted has been focused on how a specific training program or intervention has resulted in a specific desired behavioral change in employees (Hewitt, 1998; Lattimore, Stephens, Favell, & Risley, 1984; Parsons, Reid, & Green, 1993). For example, following a specific training session on increasing choice-making by people with developmental disabilities, the frequency of choice-making opportunities increased (Miller, 1991). Although these studies lend support to the effectiveness of direct support staff training, they do not assist in identifying the global set of skills required by effective direct support staff.
In an effort to identify the set of necessary skills needed by direct support staff providing community services, Taylor, Bradley, and Warren (1996) conducted a comprehensive and national job analysis of the direct support worker role. This job analysis was developed using a modified “Developing a Curriculum”—DACUM (1990) process. The DACUM model leads current well-performing workers through a series of structured activities to define the major competencies and work activities demanded on their jobs and to associate the skills, knowledge, and attributes most critical to success on the job. In addition, in the DACUM process, workers define their role and discuss important trends and values shaping their roles. Five DACUM workshops were held that included over 100 participants. The competencies, skills, attributes, vision, and role definitions developed by these groups were then synthesized and validated through a national survey process. As a result of this study, the Community Support Skill Standards were developed. These standards identify 12 competency areas and related skill standard statements that define desired competencies for direct support staff. The competency areas define broad areas of functional responsibility for direct support staff, whereas the more than 144 skill standard statements describe a set of job functions related to the associated competency area and are intended to provide a comprehensive description of the job functions that fall under each competency area. These standards represent the first comprehensive description of the competencies, skills, and attributes required of direct support staff who work in community human service settings.
Hewitt (1998) used a similar job analysis research design to validate the Community Support Skill Standards within community residential services for people with developmental disabilities. She found that although these standards defined competencies and skills that are absolutely necessary for direct support staff in this field, there were additional required competencies in the areas of home living skills and development of social and relationship skills. Although the Community Support Skill Standards are being used in many states, little published research exists using these standards to identify potential training needs. Therefore, our primary purpose in this study was to use the Community Support Skill Standards competency areas as a framework to examine the training needs of direct support staff from the perspective of direct support staff, administrators, and people with developmental disabilities who receive services. In addition, information was gathered to identify current characteristics of training programs for direct support staff.
We conducted this study to determine the training needs and current status of training programs for direct support staff within a southeastern state. Direct support staff were defined as employees who are paid, working part- or full-time, and spending the majority of their time in “hands on” direct service to individuals with disabilities. Data were collected using multiple sources and methods. The sources were direct support staff, administrators of direct support staff, and individuals with developmental disabilities who receive services (consumers). Mail surveys were used to collect data from direct support staff and administrators. Focus groups were conducted to gather data from consumers, administrators, and direct support staff regarding training needs. The data-collection procedures, the identification of the target population, and the development of a sampling frame are discussed below.
We developed a written survey to measure (a) the training needs for direct support staff, (b) employment information, and (c) demographic information. The training needs section was based on the broad competency areas and skill standards reported in the Community Support Skill Standards (Taylor et al., 1996). We determined that it was important to use subscales related to competencies that were already established and verified through research to be relevant and essential skills for direct support staff. The 12 subscales for assessing their needs in this study were based on the 12 competencies areas defined in the Community Support Skill Standards: Consumer Empowerment; Communication; Assessment; Community Service and Networking; Facilitation of Services; Community Living Skills and Support; Education, Training, and Self-Development; Advocacy; Vocational Education and Career Support; Crisis Intervention; Organizational Participation; and Documentation. All the subscales had adequate reliability coefficients, ranging from .76 to .99. Content validity was examined by having nine experts in the field review the training needs items. Their feedback was used to make minor modifications to the instrument. Field testing occurred with administrators and direct support staff, and again minor modifications were made following the field test.
The administrators were instructed to rate the training needs items according to the following question: “Do direct support staff need knowledge and/or skills in the following areas?” Ratings were made using a 5-point scale, ranging from not at all (1) to very much (5). Items were averaged for each subscale and a score reported. We modified the direct support staff survey to examine whether direct support staff had received training on a particular competency/skill and whether they wanted training in a specific area. Direct support staff responded with a no (0) or yes (1) for each item.
We identified 1,092 agencies/organizations as employers of direct support staff in the state. To ensure adequate representation from the different regions of the state (i.e., Mountain, Central Piedmont, Piedmont, and Coastal) and types of agencies (i.e., residential, vocational, respite, and multiple service providers), we divided the sample into subpopulations or stratums according to the region and type of agency. Proportional random sampling with each subpopulation was conducted. We mailed 372 surveys to administrators. A snowball-sampling technique (Schutt, 1999) was used to recruit direct support staff survey participants. Respondents to the administrators' survey were asked to distribute surveys to their direct support staff employees; 788 surveys were provided to the agencies that agreed to distribute direct support staff surveys. Surveys were returned by 181 direct support staff (23.0% return rate) and 108 administrators (29.0%).
Focus groups were conducted across the state with administrators, direct support staff, and consumers. The purpose of these groups was to gather in-depth information regarding direct support staff training needs. We used purposive sampling to select focus group participants. By asking agencies that were randomly chosen from the stratified sampling frame to identify participants, we identified groups of administrators, direct support staff, and consumers.
In both the direct support staff and administrator focus groups, participants were asked, “What do you think are the most important training needs for direct support staff?” In the consumer focus groups, participants were asked, “What do people who provide direct services to you need training in? In other words, what do they need to know about or need to know how to do?” In addition, they were asked, “Do these services meet your expectations? Why or why not?”
The number of focus groups conducted was determined by the saturation of themes across groups. When we determined through coding and analysis of obtained data that the same themes were being repeated without new themes emerging, the focus groups were discontinued. To ensure trustworthiness of the themes, two members of the research team independently examined and coded the responses and developed themes from each focus group. Then they compared themes and came to a consensus concerning the emerging themes.
The average age of direct support staff respondents was 37. Most direct support staff participants were female (82%), European American (54%) or African American (39%), and not married (53%). Most direct support staff had a bachelor's degree (32%) or had attended some college (31%). The average direct support staff respondent had worked 4 years in their current position and planned to work 8 more years in their current job. About half of the respondents had taken a course in mental retardation. Approximately 15% of the respondents were currently enrolled in vocational/technical school or college, and 37% of the respondents had attended a conference within the last year.
The average age of administrator respondents was 44. Most administrators were European American (71%) females (56%) with a bachelor's degree or higher (68%). The average administrator respondent had worked 8 years in the current agency and had worked 15 years in services for individuals with developmental disabilities. The areas supervised by the administrators were vocational (31%), residential (19%), multiple areas (17%), personal assistant (6%), in-house support (4%), and respite (3%). Only 56% of the administrators reported taking a course on mental retardation or a course concerning working with people with disabilities.
Training Needs Identified by Direct Support Staff Respondents
The percentage of direct support staff who indicated that they had either received training or wanted training in each of the Community Support Skill Standards is summarized in Table 1. At least 50% of them had received training on a topic related to all 12 training competency areas, with the largest percentage having received training in Documentation, Communication, and Facilitation of Services. The areas with the lowest percentage of staff receiving training included Advocacy, Community Service and Networking, and Vocational Education and Career Support.
At least 60% of direct support staff reported that they wanted additional training on topics across all 12 competency areas; the most frequently identified areas were Crisis Intervention; Education, Training, and Self-Development; Advocacy; and Community Living Skills and Support. The least frequently reported areas in which respondents wanted additional training were Assessment and Consumer Empowerment.
Training Needs Identified by Administrators
Table 2 summarizes the knowledge and/or skills needed by direct support staff as reported by administrators. Results of identified training needs from the administrators' survey indicated that all 12 Community Support Skill Standards competency areas were rated above a 3.5 (on a 1 to 5 scale) in terms of the direct support staff needing knowledge and/or skills. The highest rated competency areas were Documentation, Crisis Intervention, and Communication. The lowest rated competency areas were Community Service and Networking and Advocacy.
The similarities and differences between training needs as identified by direct support staff and administrators are reported in Table 3. Administrators ranked Documentation and Communication as the most needed direct support staff training areas, and direct support staff indicated that Documentation and Communication were the top two areas in which they had received training. However, in considering the most important training areas needed, direct support staff indicated that Crisis Intervention and Advocacy were their top training needs, whereas administrators ranked Crisis Intervention as the third most important training need and Advocacy as the 11th most important training need.
All administrators indicated having difficulty finding training opportunities for direct support staff. The most frequently cited problems were finding resources to provide staffing in the agency during training activities (52%) and finding reasonably priced conferences, courses, or workshops (49%). Administrators indicated that 80% of their agencies provided “in-house” direct support staff training; 64% indicated having a budget, but only 22% indicated that their training budget was adequate. Reported training budgets ranged from $0 up to $200,000 (median = $5,000). As a result of inadequate training budgets, administrators indicated that 64% of their agencies provided newly hired direct support staff with less than one week of training, with 25% providing only 1 to 8 hours of training for new direct support staff.
Focus Group Participants
There were 9 administrator focus groups with 56 participants, 8 direct support staff focus groups with 53 participants, and 12 consumer focus groups with 70 participants. In the focus groups for direct support staff, the participants were predominantly European American (60%) females (64%) who were married (70%). Similarly, in the focus groups for administrators, the participants were mostly married (64%) European American (64%) females (64%). In the consumer focus groups, most participants were unmarried (96%) and European American (77%), with equal numbers of males and females.
Focus Group Training Themes
Four themes emerged from the direct support staff focus groups: health and safety, training and instruction, awareness of consumers' needs, and self-preservation. Within the health and safety theme, direct support staff members reported specific training needs in the areas of infectious diseases, safety of staff and consumers, cardiopulmonary resuscitation (CPR) and first aid, and medication. Topics in the training and instruction theme included implementation of goals and knowledge of specific disabilities (especially mental illness). Advocating for consumers' rights was the major topic for awareness of consumers' needs. Under the self-preservation theme, direct support staff members reported that crisis intervention and personal protection, as well as stress management, were important topics about which they wanted further training.
Similar themes emerged from the administrators' focus groups. For the health, safety, and behavior management theme, administrators reported that direct support staff need training in writing and implementing behavior management plans, positive behavior intervention strategies, and administering medication. Training and instruction topics included overall knowledge of developmental disabilities, clients' rights and confidentiality, and methods of instruction/teaching clients with developmental disabilities. Administrators reported that direct support staff needed to be aware of consumers' needs by providing consumers with choices, treating them as equals and with respect, and understanding the needs of people with developmental disabilities.
Three themes emerged from the consumer focus groups concerning direct support staff training needs: (a) health, safety, and behavior management; (b) training and instructional issues; and (c) awareness of consumer needs. For the health, safety, and behavior management theme, consumers stated that direct support staff need skills in CPR and first aid, administering medication, and teaching consumers to manage their own behavior. For issues in training and instruction, consumers stated that direct support staff need to understand how different people learn and gain knowledge of methods for communicating with consumers. The final theme, awareness of consumer needs, focused on the poor attitude that some direct support staff have towards consumers, the lack of understanding that direct support staff have concerning disabilities, and lack of understanding of consumer capabilities.
The results of this study are limited by a number of considerations. First, because the direct support staff training needs were only identified in one southeastern state, generalizing these findings to other states is tenuous. Second, the return rates for direct support staff and administrator written surveys were 23.0% and 29.0%, respectively. Therefore, findings may not actually reflect the total population of direct support staff and administrators' perceptions of these training needs. Next, the demographic makeup and average tenure of the direct support staff sample members may not be reflective of national trends for this group (e.g., average tenure of 4 years in their current position). Efforts to increase the validation of these findings occurred through stratified sampling of focus group participants and the comparison of findings by the research methods used. Replication of studies similar to this one are needed to increase generalizability of findings. Finally, the fact that the direct support staff survey was scored on a 2-point scale and the administrator's survey on a 5-point scale restricted the variance found in the overall direct support staff scores and weakened comparisons with administrators' scores. A 2-point scale was used for direct support staff because they were asked to answer two questions about each competency (i.e., if they had received training and if they wanted training). This 2-point scale allowed a shorter form to be completed. Thus, in attempting to increase response rate, variability was limited. However, we were still able to make comparisons using ranked data.
Results of this study indicate that direct support staff recognize the need for training. More than 60% indicated that they wanted more training on topics within the Community Support Skill Standards competency areas. In addition, results from the administrator, direct support staff, and consumer focus groups identified four additional areas of training needs: health and safety, training and instruction issues, awareness of customer needs, and direct support staff self-preservation skills (e.g., crisis intervention, personal protection, and stress management).
Although administrators rated all Community Support Skill Standards competency areas as important, they focused mostly on two training areas: Documentation and Communication. In addition, there was a discrepancy between what direct support staff and administrators viewed as critical areas for training. Although administrators viewed Curriculum and Development as priority training areas, direct support staff viewed Crisis Intervention; Education, Training, and Self-Development; Advocacy; and Community Living Skills and Support as priority areas. This difference in perspective could be due to limited training budgets and the need to ensure that these topics are covered for agency licensing/regulation–compliance. However, it is important to recognize that employees are more motivated to learn about things they think they need to know. Also, these data suggest that direct support staff are trained on topics that administrators view as a priority. Although training on basic orientation level topics is critical and often required through statute or policy and basic skills (such as documentation, first aid, and emergency procedures) are important, they are not sufficient. If they only receive basic, orientation level training, direct support staff are not equipped to meet their job responsibilities and service recipient/family expectations. Because of the difficulty organizations have in delivering even basic training to employees, it is not surprising that direct support staff indicate the need for additional training.
Therefore, if change related to training, selection, and practice is going to occur, it is likely that administrators will need to view the change as being important and valued. This change will require additional resources beyond just buy-in and commitment. If the community human services industry places demands on direct support staff that require comprehensive competency development, then training programs will need to go beyond meeting minimal orientation and regulatory requirements. For example, although direct support staff identified advocacy as the competency area in which they received the least amount of training, this ranked as one of the top three areas in which they wanted training. Administrators showed low priority for advocacy as an area of training need for direct support staff. Yet, within the field in practical day-to-day life for people with limited family involvement and/or limited consultation and self-advocacy skills, the direct support staff often serves as the primary advocate. They are also instrumental in assisting individuals with intellectual and developmental disabilities to access and become involved in self-advocacy movements and are also key facilitators of self-determination and empowerment for the people they support. These findings suggest that targeted training in this content area is likely needed for direct support staff who support people with intellectual disabilities/developmental disabilities. Although necessary, basic orientation programs do not meet these training needs.
About half of the agencies responding to this study (52%) indicated that they had difficulty finding ways to provide coverage for staff members when they attended training, and a similar percentage (49%) reported that finding money to support training activities was a challenge. The median agency budget for training activities was $5,000; only 22% of the agencies indicated that this amount was adequate. Given this situation, it appears that there is a need to develop a comprehensive, cohesive, and cost-efficient statewide system for training direct support staff.
There are a number of possible solutions to these training problems. Cost-efficient training needs to be made available across an entire state. Organizations with budgets of $5,000 for training cannot begin to effectively train their workforce. Pre-service, recognized, and subsidized programs should be developed to train people to become direct support employees. It is not reasonable to think that employers are ever going to meet the training demands within their organizations given current budget limitations, high rates of direct support employee turnover, and increased vacancies in direct support positions. Without a more educated and stable workforce, organizations will most likely not be able to move beyond the provision of basic orientation for their employees. Efforts to reduce turnover and vacancy rates as well as improve the entry level skills of direct support staff must be made.
Solutions to the training challenges faced by employers of direct support staff will also require a coordinated system of low-cost training, including conferences, workshops, and college/university coursework. In addition, individually accessed learning modules could be developed and made available via web-based instruction, printed training manuals, and audio- and videotaped packages. Instructional modules and/or college coursework delivered through this coordinated system should be developed based on the Community Support Skills Standards and the focus group themes of health/ safety, training/instruction, awareness of consumer needs, and self-preservation skills, thus ensuring that direct support staff are being trained on validated and comprehensively identified competency and skill needs.
The possibility of developing credentialing and apprenticeship programs for direct support staff should be considered. Such programs would offer the opportunity for direct support staff to obtain advanced level training beyond their orientation. These programs should be designed to develop specific skill sets and include incentives for direct support staff to complete them. Credentialing and apprenticeship could be required for a certain percentage of direct support staff, with reimbursement rates being higher in service settings that employ a certain percentage of credentialed direct support employees, thus providing a mechanism for increasing salaries and improving retention. Offering these types of programs also creates a mechanism through which direct support staff can relocate without having to repeat training.
Finally, organizations should discontinue the practice of providing isolated internal training. Although every organization is unique and operates on its own mission and vision, many training topics are routine and cross all organizations (e.g., emergency procedures, introduction to developmental disabilities, first aid). Organizations certainly must continue training and orienting direct support staff to understand and implement their mission and vision, but they also need to rethink how they provide other basic training and orientation. Given the small training budgets and the routine need to provide orientation and basic training to the ever-revolving group of new employees, organizations must create efficient use of resources by collaborating. Coalitions should be formed to provide joint training across communities and provider organizations. Not only does this facilitate cost efficiency, it will also provide direct support employees the opportunity to network with others in their profession.
This project was funded at 25% by the University of North Carolina Charlotte and at 75% by the North Carolina Council on Developmental Disabilities and the funds it receives through P.L. 104–183, the Developmental Disabilities Assistance and Bill of Rights Act of 1996.
Authors: David W. Test, PhD, Professor (firstname.lastname@example.org), Claudia Flowers, PhD, Associate Professor, and Jill Solow, MEd, Project Coordinator, College of Education, Special Education Program, 9201, The University of North Carolina at Charlotte, Charlotte, NC 28223. Amy Hewitt, PhD, Research Associate, University of Minnesota, Institute on Community Integration, 107 PT H, 150 Pillsbury Dr., SE, Minneapolis, MN 55455