Plain English Summary
Background and study aims
Research findings suggest that around one in six people with a learning disability (LD) are thought to have “challenging behaviours” (CB). CB may include aggression towards others, destruction of property and even self-harm. These behaviours are rated, based on how much they affect the sufferer (i.e. injury or exclusion from a community) and those around them (i.e. physical harm and stress). Some studies have shown that the way that support staff and carers in residential homes behave towards people with LD could actually trigger CB and even make it worse, through negative attitudes, prejudice, and lack of understanding and empathy. “Who’s Challenging Who?” (WCW) is a training programme which has been developed to help staff become more empathetic to those with learning disabilities so that they can better deal with challenging behaviours. The aim of this study is to see how effective the WCW programme is at improving staff attitudes and empathy towards residents with LD who show CB.
Who can participate?
Staff of community-based residential homes that cater to people with learning disabilities.
What does the study involve?
The residential homes are randomly allocated to one of two groups. For those in the first group, the social care staff of the residential home receives the WCW training. This training involves a half-day session given jointly by a trainer with a learning disability and a trainer without a learning disability. At the end of the training session, attendees develop an action plan with the trainers about improvements they can make when they return to work. Those in the second group (control group) are put on a waiting list for the length study period. After the study period, the residential homes in the second group are offered the WCW training, although no additional data is collected. Participants in both groups complete a number of questionnaires to test their empathy and confidence dealing with challenging behaviours at the start of the study, after 6 weeks and after 20 weeks.
What are the possible benefits and risks of participating?
Participants may benefit as they may be able to better empathise with those with learning disabilities as a result of this training. There are no risks of taking part in this study.
Where is the study run from?
118 residential services for people with learning disabilities in the UK
When is the study starting and how long is it expected to run for?
July 2015 to November 2017
Who is funding the study?
National Institute for Health Research (UK)
Who is the main contact?
Professor Richard Hastings
Prof Richard Hastings
Centre for Educational Development
and Research (CEDAR)
+44 24 7652 2912
Who’s Challenging Who: A cluster randomised controlled trial to test the effectiveness of a staff training intervention to improve support staff attitudes and empathy towards adults with learning disability and challenging behaviours
The Who's Challenging Who training programme will increase staff attitudes (empathy) towards residents with challenging behaviour.
Social Care Regional Ethics Committee, 12/05/2015, ref: 15/IEC08/0030.
Multi-centre cluster randomised controlled trial
Primary study design
Secondary study design
Cluster randomised trial
Patient information sheet
1. Learning disability (LD)
2. Challenging behaviours (CB)
The study will be a cluster randomised controlled trial. Residential group homes will be randomised to either:
Group 1: Homes immediately receive the "Who’s Challenging Who" (WCW) training
Group 2: Homes have delayed access to WCW training (i.e. as a waiting list control group)
In both arms of the trial, staff will continue to receive training as usual (on LD social care and specifically on CB if provided) following their organisations’ ongoing staff development policies. Outcome measures will be collected prior to randomisation (at baseline), at 6 weeks post-randomisation (following WCW training), and then again at 20 weeks post-randomisation. Following the 20 week follow-up data collection, staff in the residential homes from the waiting list control arm of the study will be offered the WCW training.
WCW was developed jointly with people with LD and CB and the training course is fully manualised. Trainers with LD and CB are trained to deliver WCW using a process that is also manualised (Co-Trainer Training). WCW training covers the following topics (from the perspective of people with LD and CB):
1. Communication and how staff listening can prevent escalation of CB
2. How the living environment contributes to frustration and CB
3. The experience of being physically restrained
4. What it is like to be on medication “for” CB
5. Experiences of feeling excluded because of CB
6. Unhelpful attitudes and behaviour of care staff, and a discussion of positive qualities that contribute to good support/care
Primary outcome measures
Staff empathy for people with challenging behaviour is measured using the "Staff Empathy towards those whose Behaviour Challenges" questionnaire at baseline, 6 and 20 weeks post randomisation.
Secondary outcome measures
1. Staff confidence in dealing with challenging behaviours is measured using Challenging Behaviour Self-Efficacy Scale at baseline, 6 and 20 weeks post randomisation
2. Staff attitudes towards people with challenging behaviours is measured using Similarity and Empowerment attitude scales from the Community Living Attitude Scales at baseline, 6 and 20 weeks post randomisation
3. Staff work-related burnout is measured using Maslach Burnout Inventory – Human Services version at baseline and 20 weeks post randomisation
4. Staff work related positive experiences is measured using Short version of the Staff Positive Perceptions Questionnaire at baseline, 6 and 20 weeks post randomisation
5. Recorded incidents of challenging behaviour and use of restrictive practices in each residential home is measured by A count of the total number of incidents of challenging behaviour noted in the records of a residential home at baseline and 20 weeks post randomisation
Overall trial start date
Overall trial end date
Participant inclusion criteria
Inclusion criteria for residential homes:
1. Provides services via English publically funded contracts (Local Authorities, CCGs)
2. Provides support to between one and 10 people with LD
3. The home staff provide at least some support 24 hours for the people with LD
4. The residential home is in a community setting
5. Provides care for at least one person with LD who engages in aggressive challenging behaviour
6. The residential home manager (or equivalent lead staff member) and one other support staff member can be released attend a WCW training session together
Inclusion criteria for the staff:
1. One staff member will be the group home manager or other lead staff member (as defined by the service provider organisation)
2. The second staff member will be a direct support worker whose role is no more than 50% in administrative/staff management tasks
3. Both staff work the equivalent of .70 FTE or more
Target number of participants
236 social care staff participants from 118 residential homes (clusters)
Participant exclusion criteria
Exclusion criteria for the residential homes:
1. “Inpatient” hospital facility (typically NHS or independent providers)
2. The manager does not receive approval from the service provider organisation for the residential home to be a part of the study
3. Home is more than 150 miles round trip by car from the University of Warwick
Exclusion criteria for staff:
1. Staff do not provide their consent to take part in the research
2. English reading skills that prevent completion of the questionnaire measures
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
Centre for Educational Development, Appraisal, and Research (CEDAR)
University of Warwick
Trial participating centre
Centre for Trials Research, Cardiff Unviersity
7th Floor Neuadd Meirionnydd Heath Park
University of Warwick
The University of Warwick
National Institute for Health Research
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
All publications and presentations relating to the study will be authorised by the Research Management Group. The study report will be used for publication and presentation at scientific meetings. Investigators have the right to publish orally or in writing results of the study, subject to contract conditions with the NIHR School for Social Care Research. Published results will not contain any personal data that could allow identification of individual participants. Summaries of results will be sent to participants and participating services, after the findings have been accepted through the peer review process.
Intention to publish date
Participant level data
Not provided at time of registration
Results - basic reporting