Descriptive Analysis of a Staff Injury-Reduction Intervention in a Human Services Setting for Children and Youth With Intellectual and Developmental Disabilities

Abstract

Clinical safety is a dominant concern for human services organizations serving people with intellectual and developmental disabilities (IDD) and high-risk challenging behaviors. This article is a descriptive analysis of components that comprised an injury-reduction intervention among direct-care staff at a specialized school. Using a behavior-based safety approach, intervention was associated with fewer staff injuries and more weeks without injury reports. The article focuses on systems-level strategies and recommendations for future research and practice.

Keywords

injury reduction behavioral safety human services organizations

Direct-care staff within human services organizations (HSOs) for people with intellectual and developmental disabilities (IDD) are sometimes injured on the job (Spreat, Lipinski, Hill, & Halpin, 1986; Williams, 2009). For example, staff may sustain injuries when they implement a physical intervention procedure (e.g., response blocking, manual restraint) or carry out instructional and behavior support plans (BSPs). Scratches, bruises, and lacerations are just some of the possible injuries. Of note, the potential for injury creates an at-risk and unsafe work environment. There is also a financial burden to HSOs due to injury-incurred workers’ compensation claims (Lennox, 2007) as well as the cost of filling vacancies that result from staff absences.

Despite the critical concerns about staff injuries, few data-based prevention and reduction projects have been published. Sanders (2009) described a multicomponent program for reducing physical restraint and associated staff injuries at a HSO for children and adults with IDD. Implemented over a 4-year period, the program emphasized (a) staff training, (b) alternatives to physical restraint, (c) increased supervision by senior management personnel, and (d) systematic review of restraint utilization. This program effectively reduced physical restraint, staff injuries, and injury-related costs during the 4-year period. Summarizing the results, Sanders highlighted the components of building staff and management support for an injury-reduction initiative, intensifying training efforts, and routinely reviewing progress.

Singh et al. (2009) also described a comprehensive staff training program that targeted use of physical restraint in four group homes serving 20 adults with IDD. The program included 12 mindfulness training sessions in which staff learned meditation methods and exercises to enhance a state of mindfulness during routine interactions with the people in their care. The initial training was supplemented with additional mindfulness practice instructions and support. Singh et al. reported that relative to a baseline phase, the staff training program was associated with less frequent applications of physical restraint and injuries to staff and peers during a 35-week evaluation period.

Two single-case studies evaluated staff-worn protective equipment to reduce injuries caused by child aggression. In the case of a child with autism, Urban, Luiselli, Child, and Parenteau (2011) had staff wear shoulder-to-wrist padded sleeves and baseball caps to protect their arms and scalp respectively. As revealed in a multiple baseline design, the equipment reduced but did not eliminate injury; however, injury severity to arms and scalp decreased significantly when staff wore the padded sleeves and baseball caps. The second study, by Lin, Luiselli, Gilligan, and Dacosta (2012), found that staff was able to eliminate serious hand-scratch injuries from a child with autism by wearing commercially manufactured batters gloves. The results of these studies suggest that staff-worn protective equipment may be a reasonable approach to injury control within a comprehensive clinical safety program. However, as reported by Parenteau, Luiselli, and Keeley (2013), staff-worn protective equipment may also occasion increased risk of injury to nonprotected areas of the body.

As defined by the discipline of behavior-based safety (BBS; Geller, 2005), analyzing the context of occupational injuries is a critical first step toward reducing and preventing them. BBS relies on objective measurement of injury indices (type, frequency, severity) and contributory antecedent and consequence influences. As a systems-level intervention, BBS embraces empirically supported practices including but not limited to environmental modifications, stimulus control, incident monitoring, and positive reinforcement of performance improvement. Comprehensive process and outcome evaluation are other customary features of BBS.

The present article, representing a pilot project informed by BBS, describes a staff injury-reduction intervention in a HSO for children and youth with IDD. My focus is to explain the primary components of the intervention as they relate to similar, large-scale injury-reduction exemplars (Sanders 2009; Singh et al., 2009) and inform other possible approaches within agencies concerned about injury risk and prevention. The article also includes illustrative data from the two-phase pilot project that (a) documented and analyzed the clinical context of staff injury data (Phase I) and (b) implemented an injury-reduction plan (Phase II). This descriptive analysis of a staff injury-reduction intervention is intended to promote further research into the necessary components of clinical safety plans within HSOs serving people with IDD and high-risk challenging behavior (Luiselli, 2011).

Method

Participants and Setting

The participants were approximately 220 direct-care staff at a day and residential school serving children and youth with IDD (6-20 years old), primarily autism and pervasive developmental disorder. Before employment at the school, the participants completed several training courses devoted to applied behavior analysis (ABA), physical management, mandated reporting, health care (first aid, cardiopulmonary resuscitation [CPR], medication administration), and related topics. Further “on-the-job” training was provided through routine clinical supervision, case review meetings, and program conferences. All participants were trained additionally in the injury documentation and reporting procedures described below. It should be noted that before employment, the participants were fully appraised about the severity of problem behaviors encountered at the school and that injuries were possible when working with such a difficult student population.

During the evaluation period, there were 120 to 130 students in attendance each day. Both day and residential students comprised 18 classrooms at the school, and the residential students lived in 8 community-based group homes. The majority of students had been referred to the school because they displayed high-risk challenging behaviors (e.g., aggression, self-injury, property destruction, tantrum outbursts, pica) that prevented them from receiving educational services in less restrictive settings. During their assignments to classrooms and group homes, the participants were responsible for implementing students’ individualized educational programs (IEPs) and BSPs, conducting instruction, organizing activities, recording data, and managing crisis situations.

Other details about the school include the assignment of five clinical directors (PhD and MA level) to collaborate with the participants in writing students’ IEPs and BSPs. The clinical directors were assisted by other supervisors and administrators responsible for monitoring the effects of these plans, revising procedures, and training the participants. There was typically a 3-staff-to-7-student ratio within the classrooms and group homes at the school.

Measurement

Participants were required to complete, sign, and submit to the school’s Human Resources (HR) Department an Accident Report (AR) form within 24 hr of being injured by a student. The employee information section of the form included basic demographic and work-shift details. The section for injury information had the participants record the date, time, and setting (classroom, group home, community) of the injury. This section also had the participants indicate the type of injury (e.g., bite, scratch, abrasion), the respective body location, and whether medical treatment was needed. A final section of the form allowed the participants to write additional information about the circumstances of the injury, if warranted. As noted, participants signed the AR form and submitted it to the HR Department.

For the purpose of the project evaluation, the primary dependent measure was the frequency of bite and nonbite injuries the participants reported each week. These data were gathered from the completed AR forms that were submitted to the HR Department. A bite injury was defined as tissue damage to any part of the body caused by a student making teeth-to-skin contact. A nonbite injury was defined as tissue damage to any part of the body caused by a punch, scratch, grab, head-butt, or hair pull from a student. The classification of tissue-damaging and bite/nonbite injuries was specified on the AR form before the project had begun and remained the same thereafter.

Procedures

Phase I

Pre-intervention (20 weeks)

Before intervention, the participants documented and reported injuries as per required protocol. Administrative personnel at the school conferred with the participants about their injuries, reviewed the AR forms with them, and ensured that proper medical treatment was administered as needed. The participants implemented procedures with students according to the IEPs and BSPs as well as the physical management methods they had been trained to use. And as described previously, clinical directors and their assistants supervised implementation of these plans, conducted review meetings, and made program decisions based on their evaluations. However, the clinical directors and school administrators did not design or introduce a comprehensive strategy for reducing staff injuries.

The objective of Phase I was analyzing the preintervention injury data before designing an injury-reduction intervention plan. Figure 1 shows that among the participants who submitted AR forms, 68% sustained a single injury. As for student behaviors, depicted in Figure 2, bites and hits accounted for 76% of injuries. Further analysis, presented in Figure 3, revealed that four students were responsible for 60% of injuries. Finally, Figure 4 documents that the clinical context associated with injury was not detailed in the AR form 33.3% of the time.

Figure 1.

Percentage of participants receiving 1, 2, and 3 injuries.

Figure 2.

Percentage of injuries caused by student behaviors.

Figure 3.

Percentage of injuries caused by individual students.

Figure 4.

Percentage of injuries with identified clinical context.

Summarizing the preintervention data, there were relatively few participants who sustained multiple injuries. This outcome suggested that intensified training should be considered for participants who were susceptible to repeated injury. The finding that most injuries were caused by bites and hits which were inflicted principally by four students indicated detailed review of their BSPs and possible procedural modifications. Although the clinical context of injuries could be extracted from the AR form, this information was lacking one third of the time. Accordingly, it was necessary to gather more relevant clinical data that could inform decisions about intervention.

Phase II

Intervention (44 weeks)

The author supervised intervention planning by assembling a clinical safety committee at the school, which included the program director, five clinical directors, assistants, and several school administrators. This committee convened weekly to coordinate and evaluate intervention across the classrooms and group homes.

There were four primary components of the systems-level intervention plan:

1. Clinical Incident Report Form. A new measurement tool, the Clinical Incident Report Form, was added to the AR form to identify more clearly the conditions associated with injuries. Shown in Figure 5, the form had participants enter injury and related information but additionally describe the context in which the injury was sustained. For example, there were sections in the form that allowed participants to verify and describe whether they were injured by a student when conducting instruction, intervening physically, implementing a BSP, responding to a crisis event, and similar situations. Also, a designated supervisor reviewed the completed form with participants, “debriefed” the incident, and wrote a narrative note about the injury. The Clinical Incident Report Form was filled out simultaneously with the AR form and subsequently routed to the author for further analysis.

2. Focus on High-Risk Students. Intervention planning and focus centered on the four students who caused the most frequent injuries, as well as other students responsible for more than one reported injury. The clinical safety committee supervised implementation of several strategies that targeted this segment of the student population:

Each student’s BSP was reviewed to ensure that all procedures were formulated based on functional behavioral assessments (Cipani & Schock, 2011) that considered antecedent and consequence sources of control. In particular, these reviews concentrated on environmental “triggers” for problem behaviors that were associated with injuries and methods to prevent them. The clinical directors at the school were responsible for revising the BSPs and training participants accordingly. In illustration, the clinical directors may have revised the BSP by eliminating, adding, or changing procedures that were not in place during Phase I or appeared contraindicated for the purpose of injury reduction.

The clinical safety committee conducted a detailed analysis of any physical intervention procedures that comprised a student’s BSP, for example, response blocking, guided compliance, and manual restraint. These procedures were scrutinized with the participants, checking on their application of proper technique. In some cases, modified procedures were introduced to better protect participants during their physical interactions with students. Although these issues were sometimes addressed in Phase I, they were emphasized and reviewed more critically in Phase II.

Having the participants wear protective equipment such as arm guards (Urban et al., 2011) and padded gloves (Lin et al., 2012), which were not in effect during Phase I, was considered as another injury prevention strategy. Decisions about protective equipment were made on a risk-benefit analysis. That is, the potential advantages of staff wearing protective equipment had to be balanced against possible negative outcomes such as a student displaying novel injury-provoking behaviors directed at a nonprotected area of the body (Parenteau et al., 2013). Judgments about protective equipment were also based on range-of-motion restriction, appearance, and acceptability by the participants.

3. Implementation Integrity and Coordination. Clinical directors conducted implementation integrity observations during their routine supervision of participants. These observations were intended to document accurate application of all BSP components during scheduled activities with students. The clinical directors referenced each student’s BSP as an intervention integrity guide, recording procedures that staff implemented accurately and inaccurately. An additional objective was ensuring proper BSP implementation across classroom and group-home settings. Cross-setting implementation integrity was addressed through observations, staff meetings, and in situ performance feedback from the clinical directors to staff (Codding, Feinberg, Dunn, & Pace, 2005).

4. Continuous Clinical Quality Improvement. As noted previously, the author chaired a clinical safety committee, which met weekly to review intervention data for the high-risk students and performance improvement objectives schoolwide. Relevant data were distributed to committee members as graphic feedback to guide decision making. Results were also conveyed to the school’s HR Department. The review of injury data, procedural adjustments, and outcome dissemination were considered components of a continuous clinical quality improvement plan that has been recommended for HSOs (Luiselli & Russo, 2005).

Figure 5.

Clinical incident report form.

In summary, the primary components of the systems-level intervention applied in Phase II differed from conditions in Phase I by emphasizing supervision, participant training, and BSP modifications that specifically targeted injury reduction and prevention. In particular, Phase II (a) added more refined analysis of injury data, context, and circumstances, (b) highlighted BSP revisions of students causing the most frequent injuries, (c) concentrated clinical supervision on injury prevention alternatives, and (d) reported outcome to a school committee that was responsible for coordinating intervention.

Results

Figure 6 presents the number of bite injuries each week and Figure 7 presents the number of nonbite injuries each week that the participants reported during preintervention and intervention phases. For both injury types, frequencies decreased during intervention. Referencing Figure 8, average bite injuries were 1.4 per week during pre-intervention (range = 0-6) and 0.61 per week during intervention (range = 0-5). For nonbite injuries, the average was 1.2 per week during pre-intervention (range = 0-5) and 0.75 per week during intervention (range = 0-3). We further analyzed the percentage of weeks without a reported injury. Bite injuries did not occur in 45% of weeks during pre-intervention and 64% of weeks during intervention. Nonbite injuries were absent in 25% of weeks during pre-intervention and in 50% of weeks during intervention.

Figure 6.

Number of bite injuries each week.

Figure 7.

Number of nonbite injuries each week.

Figure 8.

Average weekly frequency of bite and nonbite injuries.

Discussion

Injuries to direct-care staff at a specialized school for children and adolescents with IDD decreased following a systems-level, BBS intervention. These results, although not definitive, are encouraging given the limited research on staff injury reduction and prevention within HSOs (Sanders, 2009). Indeed, the setting for the project included many students who had serious challenging behaviors and posed injury risk to the participants. Similar youth services programs would likely have the same risk potential. Accordingly, organizations must explore strategies and comprehensive models for improving clinical safety which include some, all, or variants of the components described in this article.

The injury prevention and reduction project began by analyzing preintervention data to isolate variables that could inform the direction and design of an intervention plan. Key findings from the analysis were that several students caused the majority of injuries, additional detail about the clinical context of injuries was needed, and there should be continuous monitoring of intervention effectiveness. Formation of a schoolwide clinical safety committee proved essential for coordinating intervention implementation, with emphasis on (a) designing clinically sensitive recording methods (the Clinical Incident Report Form), (b) revising students’ BSPs, (c) intensifying participant training, and (d) building intervention implementation integrity assessment within routine clinical supervision.

Limitations of the project were largely a function of the target problem and the applied setting where it was conducted. For example, as a quasi-experimental evaluation, the project did not have sufficient rigor to control for internal validity. However, it would have been ethically irresponsible to temporarily withdraw intervention as an experimental manipulation, possibly increasing injury to the participants. One option in this regard would have been a multiple baseline design across participants, classrooms, and group homes. And yet, this design is also questionable because it would have delayed intervention that was required organization-wide.

Other concerns are that the project did not document attrition and addition of participants over the 64-week evaluation period. Of course, a changing direct-care staff census is common within HSOs. Similarly, there were some changes to the student population that were not accounted for in the aggregate data. Notably, however, the four students causing the most injuries were constant throughout the project.

The components outlined in this article, in light of other similar projects (Sanders, 2009), demonstrate the utility of behavior incident analysis for designing comprehensive clinical safety programs, reducing injuries to staff, and creating safer habilitation and living environments. Clearly, more research in this area is needed to identify effective procedures that can be adopted by HSOs. For example, the present project relied heavily on staff training and comprehensive clinical supervision. As noted, the participants received general preservice training but additionally, on-the-job guidance and direction that specifically addressed injury reduction and prevention. Accordingly, HSOs must be committed to building administrative support for such resources because large-scale efforts, similar to the one presented in this report, are likely to have the greatest impact on clinical safety.

It is difficult to isolate the singular contribution of the components in this BBS intervention, but several implications and recommendations appear noteworthy. First, direct-care staff must be able to reliably document the conditions that are associated with injuries. These data must also include the injury-provoking behaviors and associated circumstances. In particular, HSOs must have experienced clinicians capable of analyzing the data and making decisions about intervention tactics.

Concerning staff training, HSOs must be keenly aware of building a multitiered system that incorporates several modalities such as didactic instruction, behavior rehearsal, and in vivo performance feedback. Ideally, training should be competency based, emphasizing the skills required by direct-care staff to implement procedures that will effectively reduce and safeguard against injuries.

Yet another essential consideration is that it may be difficult to manage all of the influences that account for staff injuries. A further constraint, as revealed in this project, is that eliminating injuries is unlikely when serving high-risk and behaviorally challenging children, adolescents, and adults, particularly when physical intervention is mandated (Luiselli, 2011). Nonetheless, it is imperative that professionals continue to design and evaluate systems-focused, injury-reduction interventions that will promote safe practices among IDD practitioners and the people they serve.

Footnotes

Acknowledgements

Thanks to Stephanie Child, Kate Gilligan, Blake Grider, Andrea Markowski, Hanna Rue, and Shanon Tomassone for their contributions to this project.

Author’s Note

This project was conducted at the May Center for Child Development, Randolph, MA 02368.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

James K. Luiselli, EdD, ABPP, BCBA-D, is senior vice president for applied research, clinical training, and peer review at May Institute, Randolph, Massachusetts. He is also director of training for the institute’s predoctoral internship and postdoctoral fellowship programs in clinical psychology. Among his publications are 10 books and more than 300 book chapters and journal articles. His interests include applied behavior analysis, clinical behavior therapy, performance enhancement, and sport psychology.

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