Person-centered planning on the front-line: exploring practice frameworks of direct support staff in community programs for individuals with intellectual and developmental disabilities

Background: The Department of Health and Human Services estimates that by 2020 the number of direct support professionals (DSPs) needed to meet the care of the projected increase of 1.4 million individuals with intellectual and developmental disabilities (ID/DD) will rise sharply to approximately 1.2 million full-time employees. A long acknowledged challenge of the ID/DD field is how to hire, retain, and train DSPs to carry out the person-centered plans (PCPs) in a way that improves clients’ quality of life and supports increases in their levels of independence. Literature has shown the importance of DSP practice behaviors as they relate to client outcomes, and the skills, knowledge, and values that are necessary to carry out person-centered plans. To date, there have been few studies focused exclusively on how DSPs understand, interpret, and put into daily practice these same skills, knowledge, and values. This study examines the ways in which individuals who are employed as DSPs in congregate or group home settings for individuals with ID/DD perceive and approach practice decisions within a framework of person-centered planning. Theory: The theoretical framework developed in this study combined a critical realist ontology with recognition theory, interbehavioral psychology, and street-level bureaucracy to envision the multiple generative mechanisms that may influence a DSP’s daily decision making. These daily decisions, and the attitudes, opinions, and viewpoints that reinforce them, require a fairly sophisticated understanding of the types of practice behaviors that encompass choice and autonomy. This study used the framework above in conjunction with the existing literature to explore the habitual practice behaviors of DSPs as viewed from a critical realist perspective to determine what types of “real level” variables (i.e., levels of recognition, paternalism, self-referential decision-making, agency policy and resources influence, and group home culture) are expressed by DSPs as significant “actual level” or activating factors in their day-to-day use of discretion at the “empirical level” of service provision. Methods: Primary data were collected in a mixed method fashion from in-person interviews and the application of Q methodology to elicit consensus viewpoints from 30 DSPs working in two ID/DD support organizations in New Jersey. This was accomplished through the development of 48 statements (i.e., Fisherian concourse) which represented the six areas introduced above which participants sorted according to their own subjective view on what areas were most influential to their daily practice. All participant sorts were analyzed in PQmethod, using the sequential application of three sets of statistical procedures: 1) correlation, 2) factor analysis and 3) the computation of factor scores. The quantitative data analysis was followed by a qualitative analysis in which the factors were interpreted using the post-sort interviews and theoretical considerations to allow participant voices to provide meaning to the statistical results Key Findings: The results of the factor analysis and qualitative thematic analysis revealed five factors explaining 60% of the variance among the individual Q sorts. The five factors showed consensus on how DSPs carried out their work in the following ways: (1) Focus on recognition and agency policy; (2) focus on barriers to work; (3) focus on being a role model; (4) focus on self-referential thinking; and (5) focus on pushing back against agency policy. Implications: The theoretical framework, methodology, and findings of this research highlight the critical need to envision person-centered plans and their implementation as a process generated by various mechanisms at the micro, mezzo and macro levels which culminates in the DSP/client relationship. The five factors that arose from the qualitative and quantitative analyses reflect how DSPs manage their discretion on the job in the context of person-centered plans (factors 1, 3 and 4) and how structural level mechanisms (factors 2 and 5) can hinder DSP’s ability to do their work. Recognition theory and its operationalization of recognition into three areas of self, rights, and community worth was found to resonate strongly with most DSPs that participated in this study and could be a theoretical tool useful to adding context and philosophical grounding for the implementation of person-centered planning. Substantial support for viewing DSPs as street-level bureaucrats was also found among these respondents, adding insight into how policy at the macro level is interpreted by groups of program staff at the mezzo level and put into practice at the micro level of DSP to client interaction.Ph.D.Includes bibliographical referencesby Kyle R. Cale