Employees
’ experiences of education and knowledge
in intellectual disability practice
Sylvia Olsson and Christine Gustafsson
Department of School of Health Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden
Abstract
Background:The value of support, service, and care in intellectual disability (ID) practice is linked to the competence of the pro-fessional caregivers. The quality of work is affected by the level of education of healthcare employees involved.
Specific Aims:This study aimed to collect data on how employees perceive their education and training in ID practice and how educational programs prepare them for their working environment.
Methods:We used a quantitative approach to investigate how employees reflect on their knowledge about ID and other
disabil-ities and the sources of such knowledge. A total of 262 employees engaged in ID practice completed an online survey.
Findings:The results indicated that education significantly influenced the participants’ knowledge level, and highly specific edu-cation (i.e., workplace training) can substitute for work experience in ID practice. The authors conclude that all workplaces should examine their employees’ skills regularly from the viewpoint of fulfilling the needs of people with ID.
Discussion:Based on the results, it can be concluded that employees in ID practice need specific knowledge through workplace training (i.e., through hands-on practice at the workplace). Competence development in the form of workplace training is needed to upskill the staff and possibly increases employees’ participation at work.
Keywords: disability, education, intellectual disability, intellectual disability practice, workplace training
Introduction
In intellectual disability (ID) practice in Sweden, a generalist movement has emerged from vocational and educational per-spectives. Different forms of vocational education for general care and nursing existed in the 19th and 20th centuries. How-ever, traditionally, ID practice in municipal social care has been overlooked and barely supported with training. In the provision of care and support for people with ID, caregivers play a pivotal role. Qian, Tichá, Larson, Stancliffe, and Wuorio (2015) found that when individuals receive more assistance from staff, they spend more time participating in meaningful activities. Employees play a central role in mediating the use of opportuni-ties by people with ID (Mansell & Elliott, 2001). They have the authority to decide whether the doors should be locked or open, when all should eat dinner, and access materials and activities (Mansell & Beadle-Brown, 2012). Moreover, employees shape the behavior of persons with ID through the responses and sup-port they provide (Beadle-Brown et al., 2016). Modern ID prac-tice in Sweden requires that employees should not only have certain educational qualifications but also be skilled at respect-ing their clients’ needs and adherrespect-ing to regulations. The extent to which a person with ID is involved in daily life is an outcome
of the interactions between the individual’s characteristics, employees, and the group home environment (Qian et al., 2015). It is important to consider employees’ experiences of supporting people in a discussion of the situation of people with ID (Lord, Field, & Smith, 2017). However, employees do not receive adequate training or guidance on how to support the people they serve. They often provide support on their own or alongside their coworkers, who may lack adequate preparation or experience as well (Mansell & Beadle-Brown, 2012).
Many adults with ID need support in daily life. In Sweden, adults with ID can live either in a private home with support from a personal assistant or in a group home. A group home is a unique housing setting in which each resident lives in a private and perma-nent apartment and shares spaces with other residents, such as the common kitchen, dining, and living rooms (SFS, 1993, p. 584). Thus, a group home is different from an institution. The provision of support to persons with ID for participating in activities effec-tively enhances their quality of life (Beadle-Brown, Hutchinson, & Whelton, 2012), and it is easier to provide such support in group homes. In small group homes, in addition to access to other ser-vices, adults with ID have better opportunities to enhance their quality of life in terms of contributing to meaningful activities and social relationships (Mansell et al., 1987; Mansell, Beadle-Brown, & Bigby, 2013; Stancliffe, Harman, Toogood, & McVilly, 2007).
The support and services provided to people with ID through healthcare and social care are part of Sweden’s municipal social work. The combination of support and services, which, in some ways, is equal to homecare, should be provided in accordance with the Act concerning Support and Service for People with Certain
Received November 22, 2018; accepted March 10, 2020
Correspondence: Sylvia Olsson, Department of School of Health Care and Social Welfare, Mälardalen University, Box 325, SE-63105 Eskilstuna, Sweden.
E-mail: sylvia.olsson@mdh.se
© 2020 Mälardalen University. Journal of Policy and Practice in Intellectual Disabilities published by International Association of the Scientific Study of Intellectual and Developmental Disabilities and Wiley Periodicals, Inc.
Functional Impairments (LSS) (National Board of Health & Welfare, 2012, 2016, 2017). In addition to fulfilling the aim of providing care to people with ID, such services should reflect the disability policy vision of “a good life for the individual” (Government Offices of Sweden, 2017), which covers aspects such as recreational activities, full community participation, equal living conditions, and an environment that facilitates autonomy and self-determination.
It was possible for us to undertake this study because of the sponsorship provided by the European Union (EU) Interregional Central Baltic Sea Project (NURED). The NURED project has the overarching aim of developing aligned curricula in the field of home care nursing in the Central Baltic region.
Intellectual disabilities
In Sweden, ID is defined according to the World Health Organization’s (WHO) classification, whereby mild, moderate, and severe ID levels are used to define the degree of intellectual impairment. ID is defined as an IQ of 70 or less and a limitation on adaptive ability in at least two of the following skills: aca-demic, practical, and social skills (Dammert, 2013). Therefore, persons with ID need support or assistance (Cederborg, Hellner, & Larsson, 2009), which can be provided by profes-sionals at a group home. Approximately 1% of the population of Sweden suffers from ID (Kindwall, 2016).
Referring to Article 19 of the United Nations Convention, Sauer, Molin, and Ineland (2013) stated that people with ID should have the same rights as people without ID to choose how and where they want to live. Persons with ID should not be forced to live in special accommodation (Patja, Iivanainen, Vesala, Oksanen, & Ruoppila, 2000; Sauer et al., 2013). A report published by the National Board of Health and Welfare (2013) revealed that compared to the rest of the population, persons with ID are more vulnerable to both diseases and mental health issues and have more demanding health service needs (Howlett, Florio, Xu, & Trollor, 2015). Examples of such diseases include allergies, diabetes, heart disease, incontinence, depression, behavioral disorders, and autism. Most people with ID are pro-vided for through the social security system and have little con-trol over their finances. Often, their social lives are limited to family and colleagues, and few have friends; moreover, persons with ID tend to spend large amounts of their time detached and isolated (Mansell et al., 2013; Mansell & Beadle-Brown, 2012; Netten et al., 2010). Of late, life expectancy has increased for younger people with mild ID, who are now expected to live as long as people without ID. This means that the population of older people with ID will increase, leading to an increase in the need for additional home care that can simultaneously support the needs of both the elderly and people with ID.
The quality of healthcare and social care education provides the basis for the skills that health students will need in their future professions, both in terms of theoretical and practical knowledge. Therefore, it is essential to have a deeper understanding about the obtainability and accessibility of education about persons with ID so that home care staff can cope with the health challenges of this population (Furst & Salvador-Carulla, 2019). Tveiten (2003) debated the significance of communication in professions in which
people collaborate and interact with other people. High-quality support has been shown to be important and decisive for enhanc-ing the quality of life of people with ID, as measured by their involvement in significant activities (Mansell, Beadle-Brown, Mac-donald, & Ashman, 2003; Mansell, Beadle-Brown, Whelton, Beck-ett, & Hutchinson, 2008; Stancliffe et al., 2007). To perform high-quality work, professionals in ID practice need adequate knowl-edge and experience of ID. The provision of high-quality support, service, and care is linked to the competence of professionals in ID practice. Formally, competence is based on education, and infor-mally, it is grounded in work experience in the specific context of ID practice and development (Eliasson-Lappalainen & Runesson, 2000). However, as mentioned before, within municipal social care, employees often work independently. They do not receive ade-quate training or guidance on how to support the people they serve. Instead, they often provide support by relying on their own attitudes or on their coworkers, who, too, lack adequate prepara-tion and experience (Mansell & Beadle-Brown, 2012).
The degree of ID plays an important role in a person’s ability to participate in society, and the right support can help them transition from social exclusion to supported inclusion and improve their quality of life (Antonsson, 2013; Felce & Emerson, 2001; Mansell & Beadle-Brown, 2012; Wilson, Jaques, Johnson, & Brotherton, 2017). Unlike people with mild ID, people with moderate-to-severe ID have a greater need for support and ser-vices from the society (Grey, Totsika, & Hastings, 2018; Sauer et al., 2013). Supporting people with moderate-to-severe ID is considered advanced care because it is difficult to understand and manage the lives and inconveniences of persons with ID (Antonsson, 2013). Persons with ID are dependent on others not only for performing practical tasks but also for making decisions in their lives. Recent research has shown that the health and well-being of persons with ID improve when they live at home with their relatives rather than in settings away from home (Grey et al., 2018). Persons with ID face many challenges in important aspects of their lives, and they must rely on the help and support of others to go about their daily routines (Pratt, 2012; Sauer et al., 2013; Verdonschot, De Witte, Reichrath, Buntinx, & Curfs, 2009). The support provided by caregivers to persons with ID is an important part of social care, and employees must be respon-sive to signals from persons with ID to help strengthen their autonomy (Antonsson, 2013).
Modern Swedish education in thefield of ID practice can be traced back to educational programs of the 1950s offered by the Red Cross (Nordström, 1998). In these programs, great impor-tance was attached to legislations characterized by solidarity and equal rights for all people, with limited attention to actual ID practice, for example, supporting the daily lives of people with ID (Gustafsson, Lindström, & Löwenborg, 2015). The healthcare and social care sector is the largest employer in Sweden with more than half a million employees. Of these, 257 000 employees are enrolled nurses working in the public and private sectors (Swedish Association of Local Authorities and Regions [SALAR], 2018). Over the next few decades, the need for social care employees is expected to rise in Sweden owing to retire-ment and an aging population (SALAR, 2018; Statistics Sweden, 2017). People who require the service of a personal assistant receive tax-funded care and service from public (municipal) or private providers according to the LSS Act (1993, p. 387).
There is a paucity of research on ID practice training. One pertinent question is as follows: What is the best practice in sup-port of people with ID? To the best of our knowledge, this sub-ject has barely been explored in the literature. If education for staff working in ID practice lacks adequate content about dis-ability and ID, quality issues may arise. Nonetheless, if we fail to advance our knowledge about the educational experiences of the staff working in ID practice and enhance the content on disabil-ity and ID, we may not be able to accurately determine what needs to be changed, if anything at all, in their training. Another question pertains to the quality of ID practice, which is closely connected to staff education. This study asks the following ques-tions: (a) Do the staff feel that their education has adequately prepared them to perform their daily activities in ID practice? (b) How do the staff in ID practice perceive the quality of the content of their educational programs? This study aimed to col-lect data on how healthcare employees perceive their education and training of ID practice and how do the educational pro-grams prepare them for their working environment.
The Swedish education system
The Swedish education system comprises a variety of school and education types that are designed for individuals of different age groups, needs, and abilities. The participants in this study had the following education levels: upper secondary school, voca-tional education, tertiary or university education, and workplace training.
Upper secondary school: Health and care program. All young people in Sweden who have completed compulsory schooling are entitled to a 3-year secondary education course. The students can choose from among 18 national programs. One such program provides students with the skills needed to work in the healthcare and social services sectors. The health and care program imparts generalist education. However, it offers the possibility of specialization in the field of program development. This means students can select courses that spe-cialize in the field of disability (National Board of Health & Welfare, 2012). Candidates who graduate from this program can be employed as enrolled nurses, assistant nurses, or ID sup-port employees in the healthcare and social carefields.
Vocational education. Vocational education leads to a vocational title in a given domain. Vocational education is com-monly offered by private education providers. Given that many vocational programs are developed in cooperation with busi-nesses, these programs continue to be offered so long as there is demand for them in the labor market. These duration of vocational education courses can be between two weeks and three years (Educations Media Group, 2018).
University education. There are about 50 universities at more than 25 locations around Sweden. To gain admission to these universities, candidates should have certain basic qualifica-tions. Often, special qualifications may be required depending on the course or program of study. In universities, independent
disability studies courses may be available. Moreover, universi-ties can offer educational programs to both the public and the private sectors (Swedish National Agency for Education, 2018). Workplace training. Many participants choose this pro-gram, which is often referred to as workplace education focused on specific needs or problems in the workplace.
Methods
In this study, we used a quantitative approach to gain insights into employees’ reflections on their knowledge about ID and other disabilities (OD) and the sources of such knowl-edge. The staff of four ID organizations, each from a different municipality in the mid-Sweden region, participated in an online survey.
Participants
This study was part of an EU project (NURED http://rdi. arcada.fi/nured/en/), which, in the Swedish work packages, focuses on thefield of ID practice. The population and sample consisted of the employees from the included municipalities who are engaged in ID practice. Four participating municipalities were selected to reach out to more than 746 potential participants. These four municipalities were selected through convenience sampling (Marshall, 1996) because they were nearby and had shown interest in“Pedagogical attitude and way of work in the care of/support to people with ID” (PFA). Among all the partici-pants, 262 (35%) completed the survey (Table 1). All municipali-ties accepted the researchers’ invitation to ask their employees to participate in the survey. The participating municipalities repre-sent both small and large populations, ranging from 34 000 to 105 000 inhabitants. In all municipalities, the participants offer support people with ID in different group homes or as personal assistants in their own homes. A group home comprises several apartments around a shared kitchen and living room. The staff of a group home support and offer care to the resident persons with ID in their daily lives. The goal is to promote the right of self-determination and gender equality so that persons with ID can lead an independent and enriched life according to their current life situation. Personal assistance is a constitutional right that allows people with disabilities to live a life on an equal footing, TABLE 1
Total population, employees invited, and respondents from the participating municipalities (percentage values within brackets)
Population Employees Response rate
Municipality A 105 000 258 71 (28)
Municipality B 55 000 113 34 (30)
Municipality C 35 000 138 63 (46)
Municipality D 34 000 237 94 (40)
just like everyone else. Personal assistance is classified as person-alized support designed to help people with disabilities whofind it difficult to cope with their basic needs, such as personal hygiene, meals, or communication with other people.
A formal letter was sent to all unit managers of the invited municipal ID practices. The letter was followed by phone calls and emails. The unit managers of the four invited organizations in a mid-Sweden county council provided their employees’ email addresses for distribution of the online survey. To obtain the participants’ informed consent, the online survey provided information about the aim of the study, voluntary nature of par-ticipation in the research, right to withdraw from the research at any time, and data privacy and confidentiality. In addition, it provided the participants with the researchers’ contact details (e.g., phone numbers and e-mail addresses). By filling in the questionnaire and mailing it to the researchers, the participants’ informed consent was implied.
The online survey was sent out three times, with the latter two instances being reminders. All participants were given approximately one month to complete the questionnaire. Even so, the response rate was low (Table 1). The employees had worked in ID practice for periods ranging from less than one year to more than 16 years. Table 2 presents a breakdown of the participants by gender and job title for each municipality. In Sweden, one can be employed as an enrolled nurse after they complete upper secondary school (the health and care program) or an equivalent 2-year adult education special course. All the job titles listed in Table 2 require 1–2 years of education, in addition to upper secondary school, except for the behavioral science course, which is a 3-year university program.
Description of efforts by participating in ID practices concerning employees’ workplace training
The ID practice of Municipality A has been collaborating with a regional university since 2011 to develop a modified mechanism to support people with ID: PFA. PFA is a craftwork practice man-ual for providing professional care, support, and service to people with ID. PFA is theoretically based on Antonovsky’s (1979, 1991)
salutogenic theory, which focuses on every person’s right to experi-ence a sense of coherexperi-ence. PFA has inspired the work done by treatment and education of autistic and related communication handicapped children (Mesibov, Shea, & Schopler, 2004). PFA aims to help caregivers with the creation of a meaningful existence based on a person’s own definition of existence. In ID practice, the-ories and models are rarely used for offering everyday care, sup-port, and services.
PFA was developed through an inductive approach and is based on experiences accumulated in ID practice. It involves starting from each person’s individual skill set and difficulties and then creating a better life from those conditions by focusing on the person’s strengths while helping them compensate for their difficulties. The goals of PFA are personalized to support people with ID. To realize this, employees and caregivers require prior knowledge about persons with ID. The cornerstones and guidelines of PFA are as follows:
• Knowledge of cognitive functions.
• Knowledge of ID and the meaning of living with ID (e.g., how it affects a person’s life).
• Knowledge about the specific person with ID.
• Knowledge and skills to apply adaptations and adjustments to compensate for the person’s difficulties (both physical and cognitive).
• Knowledge of the organizations to which PFA is applicable. PFA focuses on changing and adjusting employees’ attitudes and work style to specific abilities and needs of each individual. PFA can be described as a person-centered model of care, support, and service that can be tailored to individuals instead of a general model that is applicable to everyone. PFA expects employees to change, develop, and adapt their work to an individual’s specific resources, skills, and difficulties. In Municipality A, PFA is somewhat implemented in all ID practices. The employees in the ID practice of this municipality have been provided with additional training or have participated in lectures on The International Classification of Functioning, Disability, and Health (ICF), low arousal approach (e.g., McDonnell, McEvoy, & Dearden, 1994), and similar concepts.
Unlike Municipality A, Municipalities B, C, and D have not provided specific training in ID practice to their employees. TABLE 2
Overview of informants and their employment (percentage values within brackets)
Gender and job title Municipality A Municipality B Municipality C Municipality D
Men 12 (17) 4 (12) 7 (11) 25 (27)
Women 57 (80) 30 (88) 56 (89) 69 (73)
ID support employee 49 (43) 7 (6) 33 (29) 25 (22)
Quality assurance coordinator 10 (77) 0 (0) 3 (23) 0 (0)
Enrolled nurse 1 (3) 5 (15) 1 (3) 27 (79)
Behavioral science employee 6 (86) 0 (0) 0 (0) 1 (14)
Personal assistant 0 (0) 16 (59) 10 (37) 1 (4)
Call assistant 0 (0) 0 (0) 0 (0) 1 (100)
Work supervisor 1 (2) 0 (0) 15 (36) 26 (62)
Coordinator 4 (6) 1 (11) 1 (11) 3 (33)
However, the ID practices in these municipalities have offered employees training and lectures on ICF (WHO, 2002) and the low arousal approach (McDonnell et al., 1994). Moreover, the ID practice of Municipality B has provided many of its employees with training in autism and pedagogical support for one week.
Research procedure and instruments
An online survey was developed and sent to the participants from the four participating ID practices by using the SUNET Web tool. A total of 262 employees completed the online questionnaire survey, which contained 24 questions. The first six questions pertained to background information, such as the participants’ level of education, professional experience, gender, and age. The question about the participants’ education level was as follows: “What is your educational background level?” The participants could choose“upper secondary school,” “vocational education,” “university education,” or “workplace training” as the answer. In Sweden, one must graduate from upper secondary school to be eli-gible for higher education. Therefore, participants with a university degree would by default have an upper secondary school degree. Of all the participants, 26% had additional vocational education or workplace training and 24% had university degrees; whereas 25% of them had upper secondary school degrees, 27% held a university degree and had also had the opportunity to participate in voca-tional or workplace training from work.
The survey contained 12 questions asked about the participants’ knowledge of, and experience with, ID and disability practice (Table 3). In the questionnaire, a Likert scale ranging from 1 to 5 was used, with 1 corresponding to very bad/dissatisfied/never/ strongly disagree and 5 corresponding to very good/satisfied/always/ strongly agree. ID and OD were the dichotomous variables.
Data analysis
Data analysis was performed using Statistical Package for the Social Sciences (Version 24). Descriptive statistics were used to obtain the characteristics of the study population and its sub-groups. The categorical variables were subjected to cross-tabulation and chi-square (χ2) computation, a non-parametric test recommended when analyzing ordered categorical data (Svensson, 2001). Moreover, cross-tabulation and chi-square (χ2) computation were performed to investigate the relationship among the questions querying how the participants had gained knowledge of ID/OD (Table 3) and whether this knowledge came from education or work or both. The results corresponded to Option 4 (i.e., good) or Option 5 (i.e., very good) on the Likert scale used herein. The results are expressed in percent-ages. A two-way between-subject analysis of variance was con-ducted on sentencing differences between the municipalities and the number of years in terms of knowledge of ID for the participants’ daily work. Variables with p values less than 0.05 (based on two-sided tests) were considered statistically signi fi-cant and were reported in the text. Pairwise deletion was employed to manage missing data. All percentages presented in the study are valid, with missing values left uncounted.
Reliability and validity
To measure the reliability of the results, the researchers con-ducted a pilot test in which the survey questionnaire was admin-istered to 14 people (students and enrolled nurses). In addition, the apparent task values scale was subjected to a reliability anal-ysis. Cronbach’s alpha indicated that the questionnaire reached acceptable reliability (i.e.,α = 0.70). Most items appeared wor-thy of retention, and their deletion led to decrease in alpha. The one exception to this rule was the following statement: “My knowledge of disabilities has mainly been gained through my work,” the deletion of which increased alpha to 0.72. Although we considered removing this item, we retained it because of its immense importance for the aim of the study. All four groups received technical IT support from the researchers when they had any questions or faced problems with the survey.
Ethical considerations
The research was carried out in accordance with the Declara-tion of Helsinki (2008), and the ethical principles of the Swedish Research Council (2011) were followed with regards to partici-pants’ informed consent. According to the Swedish law for ethical boards, this research did not require any ethical approval. How-ever, the study adhered to all the required ethical principles. Infor-mation about participation, handling of personal data, informed consent, confidentiality, and right to withdraw from the research at any time was provided to all participants in a formal letter before they attempted the online survey (Swedish Research Council, 2003, p. 460; Swedish Research Council, 2018).
Results
Knowledge about ID and disability through education Education levels of the participants in terms of support, healthcare, and social care for persons with ID exhibited varia-tions. Participants’ knowledge of ID/OD and which type of TABLE 3
Overview of questions in the survey
My education involved support, service, care, and healthcare for people with disabilities/ID.
My education was sufficiently comprehensive in terms of support, service, healthcare, and social care for disability/ID. My educational course(s) gave me sufficient knowledge of
disability/ID.
I have used knowledge from my education in disability/ID. I predominantly received my knowledge of disability/ID
through work experiences.
I have adequate knowledge of disability/ID for my daily ID practice.
Abbreviation: ID, intellectual disability.
education provided the most knowledge to the participants were cross-tabulated (Table 4). Of all the participants, 35% received this knowledge through upper secondary education, 24% through vocational education, 13% through university educa-tion, and 36% through workplace training. In case of the knowl-edge related to the provision of support, healthcare, and social care for people with OD, 36% of the participants had gained it through secondary school education, 24% through vocational education, 14% through university education, and 32% through workplace training (Table 4).
One of the questions queried whether the participants con-sidered their ID and OD education to be comprehensive. In terms of the comprehensiveness of upper secondary education, 32% of the participants agreed for ID and 45% for OD. As for vocational education, the participants had similar answers (i.e., 36% = ID and 35% = OD). The participants who had attended university reported similar results (i.e., 32% = ID and 30% = OD). The results indicated that the participants with workplace training were most likely to perceive that their educa-tion was comprehensive for both ID (41%) and OD (40%).
The respondents were asked whether they drew on their ID and OD knowledge gained from education in their work. The results for ID support, health, and care differed slightly for the respondents who had attended upper secondary school (40%) and workplace training (44%); the participants with vocational education (30%) and university education (29%) reported mutu-ally similar results as well. The results for OD exhibited a similar trend. Greater numbers of respondents with secondary school education (44%) and workplace training (41%) agreed that they drew on their education to deal with OD patients than did the respondents’ university (30%) and vocational education (29%).
ID and OD expertise through occupational experiences For the statement, “I gained my knowledge of ID/OD mainly through my work,” the results of a chi-square test of the frequency of the staff members answering yes or no to this
statement indicated that 40% of the participants selected ID and 42% OD (p < 0.054). The results showed that the participants who had received workplace training agreed with this statement at a rate of 44% for ID and 42% for OD. Approximately 15% of the participants with vocational education agreed with this statement for both OD and ID.
The last question inquired whether the participants thought they had adequate knowledge of ID and OD for their daily work. The responses exhibited the same pattern as the responses to the other questions. The participants with secondary school education thought they had adequate knowledge of ID (42%) and OD (41%). The participants with workplace training offered similar responses for both ID (39%) and OD (40%). The results illustrate that many of the staff do not regard themselves as well trained to work with people with ID or OD in their daily work.
A chi-square test of the OD knowledge relevant to the par-ticipants’ their daily work and work experience yielded a signifi-cant result (p < 0.001). Those who had worked 11 years or more were more likely to hold that they had adequate knowledge. However, in terms of ID, there was no significant difference in how participants perceived their knowledge based on years of experience. For example, those who had worked for 0–10 years thought that they had adequate knowledge of ID for their daily work.
Differences among municipalities
A few differences were found depending on which munici-pality the respondents worked in (Table 5). A cross-tabulation showing the results of a chi-square test of the statement,“I have enough knowledge of ID for my daily work,” demonstrates the differences among the four municipalities. In Municipalities A, B, C, and D, 33, 6, 18, and 43% of the participants, respectively, agreed that they had adequate knowledge. These results dis-played a tendency for significance (p = 0.006).
With the statement, “I have enough knowledge of other functional disabilities for my daily work” (Table 5), 41% of the TABLE 4
Knowledge of ID and OD through education and occupational experiences (percentage values within brackets)
Upper secondary school Vocational education University education Workplace training Statements ID OD ID OD ID OD ID OD
Courses involved support, health, and care 92 (35) 96 (36) 62 (24) 64 (24) 34 (13) 37 (14) 94 (36) 85 (32) Education was sufficiently comprehensive 30 (32) 33 (45) 36 (36) 34 (35) 31 (32) 28 (30) 40 (41) 38 (40) Education provided sufficient knowledge of
support, health, and care
23 (36) 31 (45) 18 (28) 18 (26) 14 (22) 15 (22) 24 (38) 22 (32) Used knowledge gained from their education 45 (40) 52 (44) 43 (30) 44 (30) 40 (29) 42 (29) 61 (44) 60 (41)
Knowledge gained mainly through work 57 (40) 60 (42) 46 (26) 46 (26) 42 (24) 44 (24) 77 (44) 74 (42)
Sufficient knowledge for their daily work 51 (42) 55 (41) 50 (32) 55 (32) 42 (27) 43 (26) 59 (39) 67 (40)
Abbreviations: ID, intellectual disability; OD, other disability.
Note: Respondents could pick more than one educational level. The results presented correspond to Option 5 (i.e., very good/satisfied/always/strongly agree, etc.) or Option 1 (i.e., very bad/dissatisfied/never/strongly disagree, etc.).
employees in Municipality D and 35% in Municipality A agreed completely. However, considerably lower percentages of employees from Municipality B (7%) and Municipality C (17%) agreed with this statement. In terms of whether the participants believed that their knowledge of OD mainly came from their work, 44% in Municipality D agreed. About a quarter (24%) of the participants in Municipality C agreed that their knowledge of disabilities came from their work practice. The result was similar for Municipality A (20%). However, only 12% in Munic-ipality B agreed that their knowledge of OD mainly came from their work. The participants provided similar responses to the same statement regarding ID. In Municipality D, 41% fully agreed that their knowledge of ID mainly came from their work. Municipality C had the next highest rate (27%). Both Munici-palities A and B scored lower at 17% and 15%, respectively.
Finally, the results showed a difference among the partici-pants’ estimates of their ID knowledge, work experience in their current occupation, and the municipality in which they worked (Table 6). In a univariate analysis between the municipalities and the number of years of ID knowledge for daily work, knowledge of ID affected the number of years for which the par-ticipants had worked in a municipality, and knowledge of ID
had a significant effect on which municipality the participants worked in, F(1, 248) = 4.63, p = 0.004. Table 6 summarizes the differences among the municipalities, length of the participants’ work experience, and their estimate of their ID knowledge. Municipality A, which offered PFA training, exhibited the highest mean (3.91) for the participants who had worked between 0 and 10 years. Moreover, Municipality A exhibited the highest mean (4.32) for those who had worked for 11 years or more. All other participants in the other municipalities had con-siderably lower estimates of their ID knowledge (Table 6).
Discussion
This study aimed to collect data on how employees perceive their education and training of ID practice and how educational programs prepare them for their working environment. The right skills and knowledge are both important and necessary for employees who provide support, service, and care to people with disabilities. With the right skills and knowledge, employees can offer high-quality services. In terms of how employees perceive their knowledge of OD and ID, the results indicate that most of the respondents had gained their knowledge through workplace train-ing rather than upper secondary school, vocational education, or tertiary education. This may be the case because workplaces train their employees through workplace education. Studies have dem-onstrated that varied learning experiences are related to variances, for example, in competence and vocational identity development (Bound & Lin, 2013; Grytnes, Grill, Pousette, Törner, & Nielsen, 2018; Virtanen, Tynjälä, & Eteläpelto, 2014), as well as creativity and productivity at work. Most employees have some weaknesses in their workplace skills. Workplace education provides employees with the theoretical and practical support for strengthening the skills that each employee needs for professional advancement. These results reflect those of Reegård (2015) and Goller, Steffen, and Harteis (2018), who found that in some workplaces, profes-sionals do not have the opportunity to hone their workplace skills because they were given many responsibilities early in their terms. Advanced workplace education ensures that all employees have opportunities to develop their skills and knowledge to similar levels as those of their peers. Providing the necessary workplace educa-tion can help create a pool of knowledgeable employees who can work autonomously without constant assistance and supervision from others and that the professionals had learning and support TABLE 5
Differences among the municipalities in terms of knowledge of ID and OD (percentage values within brackets)
Statements
Municipality A Municipality B Municipality C Municipality D
ID OD ID OD ID OD ID OD
Enough knowledge for their daily work 21 (33) 24 (35) 4 (6) 5 (7) 11 (18) 12 (17) 27 (43) 28 (41)
Knowledge mainly through their work 16 (17) 19 (20) 14 (15) 11 (12) 25 (27) 22 (24) 38 (41) 41 (44)
Have used knowledge from their education 25 (35) 25 (32) 8 (11) 8 (10) 16 (22) 20 (25) 23 (32) 26 (33)
Abbreviations: ID, intellectual disability; OD, other disability.
Note: The results presented correspond to Option 5 (i.e., very good/satisfied/always/strongly agree, etc.) or Option 1 (i.e., very bad/dissatisfied/never/strongly disagree, etc.).
TABLE 6
Differences among municipalities and number of years of ID knowledge for the participants’ daily work
I work in Years Mean SD N
Municipality A 0–10 years 3.91 0.741 44 11 years or more 4.32 0.690 25 Total 4.06 0.745 69 Municipality B 0–10 years 3.71 0.920 17 11 years or more 3.67 0.900 15 Total 3.69 0.896 32 Municipality C 0–10 years 3.61 0.945 41 11 years or more 3.57 0.870 21 Total 3.60 0.914 62 Municipality D 0–10 years 3.85 0.892 34 11 years or more 4.07 0.828 59 Total 3.99 0.853 93
abilities at work (Grytnes et al., 2018). This could explain why the respondents thought that their knowledge of ID was more exten-sive than their knowledge of other functional impairments. Per-haps, their employers paid more attention to ID education than to education about OD. These findings mirror the conclusions of Rintala and Nokelainen (2019) that professionals’ knowledge depends on the productive work and goals of their workplaces.
Such a conclusion echoes previous researchfindings in Swe-den pertaining to many local and regional development projects aimed at raising employees’ skills or strengthening their profes-sional roles (Byström, 2013; National Board of Health & Welfare, 2013). Byström (2013) insisted that it is crucial for home care professionals to participate in both formal and informal training opportunities and develop their professional roles through exchanges with professionals from diverse backgrounds. It should be possible for workplaces to provide their employees with powerful tools to support translation of the knowledge gained from education into practice (Bigby, Knox, Beadle-Brown, & Clement, 2015). Work from the perspective of an ethic of care, which has been ignored in disability studies owing to the focus on support, might offer a valuable lens for guiding the practices of group home staff (Rummery, 2011). It is vital that employers determine the skills needed in thisfield and ensure the availability of opportunities for skill development (National Board of Health & Welfare, 2013). Internationally, the obligation for ID healthcare has shifted from specialized nurses to untrained sup-port staff and families (Furst & Salvador-Carulla, 2019). This has influenced education on the subject as well. Internationally, numerous models of ID education exist, but ID education varies across countries, and ID content in general programs is usually integrated into other modules (Salvador-Carulla et al., 2013; Sprinks, 2015). Today, nursing education courses are increasingly including the knowledge and skills required by enrolled nurses to support persons with ID (Tuffrey-Wijne et al., 2014). Although the rate of occurrence of mental illnesses is greater in people with ID than in the general population, as has been demonstrated in several studies (Whitehead, 2007), there is a lack of mental health nurses and enrolled nurses in ID in the education system (Adshead, Collier, & Kennedy, 2015; Evans et al., 2012).
Another aspect worth noting about education level is the lack of focus on healthcare and social care in disability practice in Sweden’s education system. In Sweden, only one university offers a specialized higher education program on disabilities. Other courses (i.e., polytechnic education and post-upper secondary school education) that focus on disability practice are vocational. The results of this study indicated that the participants with sec-ondary school education thought they had some basic knowledge of disabilities. Hence, it can be concluded that employees in ID practice need to acquire specific knowledge through workplace training (e.g., through hands-on practice). Employees must have a breadth of knowledge about people with ID that can only be acquired through prolonged work experience (Zijlstra, Vlaskamp, & Buntinx, 2001). However, people with ID do have individual and specific needs, and a general education will not provide employees with the specific knowledge required to han-dle special scenarios. Basic educational content can be developed, such as PFA education, which is a one-week workplace training course conducted in Municipality A (Gustafsson et al., 2015). The correct support and education could help employees to
decrease their own values at work, which were found to rely strongly on the depth of their knowledge about each resident of the group home in which they work.
This study demonstrated that the requisite knowledge is bet-ter gained through work experience than education. The essential vocational qualifications required for the social and educational aspects of nursing and social care include habilitation and reha-bilitation, support for older people and people with disabilities, prevention of disease and health promotion, good care, technical skills, cooperation, and self-awareness (National Board of Health & Welfare, 2006). Coles (2002) asserted that the knowl-edge needed by healthcare personnel can best be gained through an internship, contact with patients, and interactions with col-leagues. Specialist education and experience aimed at a particular group offer the most comprehensive knowledge. A critical issue in this study was the participants’ lack of knowledge of the skills required for both ID and OD. Many of the staff members believed that they had not been adequately trained to support people with ID or OD. Competence development in the form of workplace training is needed to upskill the staff. It may be needed to increase employee involvement in daily care and to maintain the knowledge already available at the workplace as well (Karlöf & Lövingsson, 2007). Vocational education, traineeships, and other methods of work-based learning have been promoted at the pol-icy level in recent years (European Council, 2018). This progress requires an understanding of how work-based learning experi-ences can fulfill the needs of professionals and organizations.
Coffey (2004) showed that healthcare professionals are posi-tive about upskilling provided through workplace education and feel that such programs are important to help them understand their roles. Professionals have unique practice knowledge about the context of their specific workplace and group home practice in general, but they need knowledge replenishment. To this end, internal training improves healthcare professionals’ self-esteem about the importance of their roles in their workplaces. A focus on upskilling through workplace education can play an impor-tant role in fulfilling society’s requirements for educated employees and their unique contextual knowledge accumulated through diverse daily experiences (Quilliam, Bigby, & Douglas, 2018a, 2018b). Mattson and Dunér (2005) claimed that work-place training results in mentally stronger and healthier employees. Therefore, it is important that employers allow and encourage their employees to receive training and participate in in-house professional development opportunities. In this way, employees turn into assets and resources for their workplaces. The results of this study show that the employees mainly gained knowledge on the job and through workplace training.
Work experience plays an important role in employees’ con-fidence and their estimate of the adequacy of their knowledge as well. The longer an employee’s work experience, the deeper is their knowledge and experience of both ID and OD. However, an interesting result in this study was that those who had worked forfive years and had been trained in both ID and OD exhibited the same level of confidence in their knowledge as those who had worked for 16 years or more. In some cases, edu-cation is an important complement to one’s experiential knowl-edge. A fascinating insight was that in Municipality A, where PFA education acted as a foundation for developing the requi-site skills for ID practice. The above analysis indicates that the
employees who had participated in the PFA program had the same level of confidence as those who had 16 years or more of experience in ID practice.
Working in different municipalities could lead to other dif-ferences in the employees’ estimate of their own knowledge of ID. The four municipalities considered in this study differ in terms of population size, political governance, economic condi-tions, and investment in workplace education. These factors could explain why the results differed depending on the munici-pality in which the participants worked. In the municimunici-pality with the highest population, more than a third of the employees felt they had adequate knowledge to do their daily work. In that municipality, the focus was on educating the employees in ID practice through PFA education. By contrast, only 15% of the employees in the small Municipality D felt that they had ade-quate knowledge. One explanation for this perception could be long work experience. Having a work experience of more than 16 years can provide the employees with all the knowledge they need to do their daily work.
Having said that, can education replace several years of experiential knowledge? In this study, Municipality A, which educates all its ID practice employees through PFA, yielded sim-ilar results to Municipality D, whose employees had the most work experience. Is it possible to consider the 1-week PFA workplace training to be comparable to a very long ID practice experience in some respects? The results of this study indicate that given the right education, it is possible for new employees to gain the same knowledge as those with many years of experience.
Methodological considerations
A few limitations of this study should be considered when interpreting its results. One limitation is that the study is built on self-reports, meaning that in a sense, it is based on personal judgments of the employees’ work experiences in ID practice. This probably contributed to a greater sense of self-efficacy con-cerning the participants’ estimates of their knowledge. On a similar note, another limitation is that all the self-reports were provided through an online survey. Web-based surveys are advantageous in terms of data quality, anonymity, and the speed and cost of data collection (O’Brien et al., 2014). However, low and selective participation may bias the results of such surveys. Moreover, it is hardly possible to verify whether the intended recipient of the online survey is the same person who actually completed the survey.
In educational research, online survey has become a popular data collection method. However, the response rates of online surveys may be lower than those of paper-based questionnaires (Ebert, Huibers, Christensen, & Christensen, 2018). One reason for low response rate observed in this study could be that the email addresses were invalid, inactive, or seldom used. Another reason could be that the participants did not use their working email when they were not at work and they did not have time to respond to the survey when they were at work. The low response rate could also be ascribed to a lack of interest among the participants to answer a survey. The low response rate of online surveys compared to that of postal surveys has been
demonstrated in multiple studies (Fan & Yan, 2010; Fosnacht, Sarraf, Howe, & Peck, 2017; Roberts & Allen, 2015; Shannon & Bradshaw, 2002; Sheehan, 2001). However, a few studies (Koundinya, Klink, Deming, Meyers, & Erb, 2016; Liu & Wronski, 2017; Schonlau, Fricker, & Elliot, 2002) have reported opposite results, that is, the response rates of online surveys are significantly higher than those of paper-based surveys. In these studies, the important factors that could influence the response rate were as follows: correct email address list of all survey par-ticipants, good information dissemination to all parpar-ticipants, survey design and presentation that could attract participants, and, crucially, survey duration (should not be longer than 13 minutes) (Handwerk, Carson, & Blackwell, 2000). One important aspect is the relevance of the topic to the participant. If a participant feels that a topic is not relevant to them, they would probably not want to answer the survey. The use of two or three email reminders (but not too many) was found to be a significant factor as well. All of these findings are vital for designing future online surveys.
Nevertheless, the characteristics of a sample are not auto-matically determined by a high response rate (Templeton, Deehan, Taylor, Drummond, & Strang, 1997). If the response rates are higher, the data yield more significant relationships. Notwithstanding these shortcomings, online surveys are useful when asking respondents about sensitive issues that may be dif-ficult to discuss in person or at work, thus creating an environ-ment conducive to eliciting honest responses and reducing social desirability bias (Whitehead, 2007).
Another limitation of this study is the differences among the municipalities. The four municipalities differed in population size, political governance, economic conditions, and provision of workplace training. These differences could have affected the results in several ways. For example, favorable economic condi-tions could increase the opportunities for staff training, which may increase knowledge levels, satisfaction, and tenure length. Moreover, clear political goals are important not only for mak-ing decisions and changes but also for the development of a cul-ture in thefield.
The differences in response rates among the municipalities are important (Table 1). One reason for the differences could be the unit managers’ interest in participation in the data collection process, that is, the manner in which the managers emphasized the importance of participation in the survey and how they spread the information to their employees. Another difference among the municipalities can be in terms of the frequency of using the Internet and the opportunities available for workplace training. Dillman’s (2007) social exchange theory states that individuals’ behaviors are motivated by the responses they expect to elicit. Thus, the survey response rates were perhaps contingent on various aspects, such as reward, trust, and costs. These aspects may have affected the probability of individual employees responding to the survey.
The conclusions of this study should be treated with caution because of the problem of external dropout. The response rate in the current study was 35%. This is consistent with studies in the literature that have reported that online surveys have lower response rates compared to postal surveys (Fosnacht et al., 2017; Roberts & Allen, 2015). The response rate for web surveys is esti-mated to be 11% lower than that for other survey methods
(Fan & Yan, 2010). This type of external dropout could affect the external validity of the survey. The higher the response rate of a survey, the lower is the risk of nonresponse bias, although lower response rates affect survey estimates only if the nonresponses are related to substantive responses in a survey. Significant vari-ances were observed, illustrating nonresponse bias. A low response rate does not necessarily affect the validity of the data. However, it is essential to consider the effects of nonresponse and modify the original data to ensure data validity. In data analysis, it is important to take note of these considerations. Numerous studies (e.g., Buchanan & Smith, 1999a; Buchanan & Smith, 1999b; Krantz, Ballard, & Scher, 1997; Nathanson & Reinert, 1999) have examined the validity of online surveys compared to the validity of conventional methods. These studies have suggested that the validity and reliability of the data obtained through online surveys are comparable to those of the data obtained through conventional methods, despite the possibility of a lower response rate.
Conclusions
Education is of paramount importance and is a long-term investment that helps employees to fulfill the needs of individ-uals with disabilities. Education can, in some respects, replace years of work experience. A sound education could impart in a shorter period the important skills gained through several years of work experience. Some weeks of PFA workplace training were found to be comparable to years of ID practice experience, which would render it a beneficial investment for employers, as demonstrated by the results of this study. However, further research is needed to verify this. The low response rate in this study could have influenced the results. Therefore, it would be useful to conduct future studies on a large scale with greater numbers of participants. All workplaces are advised to examine their employees’ skills regularly to ensure that they can fulfill the needs of people with ID. Employees should be provided ample opportunities to develop their skills and work closely with their superiors to take responsibility for such development.
Acknowledgments
We would like to thank all the study participants and the municipal ID practice staff members who participated in this study. We wish to extend our heartfelt thanks to our collabora-tion partners Karin Liljegren, Anders Lindström, Carl-Mikael Feldt, and Marie Skoghill from The Department of Care and Sup-port to People with ID, Eskilstuna Municipality. We would like to acknowledge the EU project (NURED), Interregional Central Baltic Sea Region (http://rdi.arcada.fi/nured/en/). Finally, we would like to thank Scribendi for their professional editing and proofreading of this article.
Conflict of interest
The authors declare no potential conflict of interest.
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