Online Course - by Emma Beckett

Emma Beckett and Samantha Owens are final year Speech and Language Therapy students from the University of Manchester. They were on placement with Total Communication Services CIC throughout lockdown and we have continued working together ever since.

The placement offered a unique challenge, as we had to think about how to work together throughout lockdown and how we could engage staff online in training. They set about working with our good friends from Bury People First to develop resources and then wrote and delivered training sessions to two local services. Emma describes her placement experience in the blog below beginning with the self- advocates followed by a review of the literature and an analysis of their project.


Total Communication Services CIC and Bury People First met on zoom each week through 2020 to discuss good communication, strategies and adjustments, which can be used to support communication with people with learning disabilities, and messages which were important to the group around communication that they wanted to share with health and social care staff. We used the notes from the meetings to develop an online short course.

Once we had secured live sessions, lots of thought had to go into making the materials interactive to maintain engagement amongst the staff, due to the online format. It was a challenge to condense the course materials into a two-hour timeframe while allowing time for group discussion. Also, working over Zoom comes with its own set of challenges, so we had to factor in time for microphones malfunctioning and breakout rooms failing.


The aim of the course was to increase staff members’ knowledge around understanding language in people with learning disabilities. We discussed why it is important to know about the level of understanding that the people we work with have, and the complexities of receptive communication and how it can be perceived. We discussed the theory behind understanding, including information around the speech chain and where this can be impaired, complexity of morphosyntax at sentence level, non-literal language, and facial expressions. Finally, we discussed using a total communication approach and what this involves, strategies to support understanding, accessible information, and the five good communication standards (RCSLT, 2013). Some scenarios of utterances which may be difficult for a person with communication difficulties to understand were included, one giving an example of using negation, where a member of staff informs a service user of an activity being cancelled by saying “we aren’t going out now”. The group responded well to this and were able to identify that negation can be difficult to understand. In the morning group, one attendee then asked us how negation can be avoided, and we had a discussion using the given scenario around offering alternatives, using gestures, removing objects of reference related to the cancelled activity, and using visual timetables to remove or cross out the activity. Later on in the session, we discussed the easy-read version of the Five Good Communication Standards, and how this document could be used as an auditing tool for services, as it is written from the perspective of the service user and includes checklists under each standard.


Communication difficulties are prevalent amongst people with learning disabilities of varied severities (Tuffrey-Wijne & McEnhill 2008), with 57.9%-81% of people with learning disabilities needing support with their communication (Smith, Manduchi, Burke, Carroll, McCallion & McCarron, 2019; Blackwell et al 1989; Law & Lester 1991). Communication facilitates and develops social relationships, choice-making, expression of oneself, self-identity and having control over one’s life (Dobson, Upadhyaya & Stanley, 2002; Thurman, 1997). The communication skills of people with learning disabilities are heavily influenced by the support they receive from communication partners (Bartlett & Bunning, 1997).


Healthcare staff frequently misestimate the communication abilities of people with learning disabilities. Generally, the person’s receptive communication level is overestimated, and hearing deficits underestimated (Purcell, Morris & McConkey, 1999; McConkey, Morris & Purcell, 1999; Kevan, 2003; Bartlett & Bunning, 1997; Bradshaw, 2001; Banat, Summers & Pring, 2002). Misestimation of communication ability in people with learning disabilities results in the person's needs not being met, an atmosphere that feels overwhelming and confusing, failure of communication partners adjusting their communication, and potentially, behaviour which can be seen as 'challenging' to staff, poor self-esteem, and isolation (Martin, O’Connor-Fenelon & Lyons, 2010; Kevan, 2003; McConkey et al, 1999; Bartlett & Bunning, 1997; Dobson et al, 2002). Healthcare staff should endeavour to make reasonable adjustments to enhance communication, as the person with learning disabilities may be incapable of altering their own communication methods (McConkey et al, 1999; Murphy, 2006; Kevan, 2003; Bartlett & Bunning, 1997). The training course that we delivered to staff was centred around staff adapting their communication style, and stepping into the world of the person with a learning disability, to support them to understand in their own way.


Evidence suggests that occurrences of service user-staff contact can be low in learning disability services, and it is reported that staff are likely to communicate verbally, regardless of the communication abilities of their communication partner (Bradshaw, 2001; McConkey et al, 1999; Martin et al, 2010). Research suggests that staff cannot always interpret non-verbal communication acts appropriately (Purcell et al, 1999; Iacono & Johnson, 2004). Martin et al’s (2010) study detailed aspects of staff communication, such as overuse of complicated and long sentences, overuse of questions, and providing inadequate response time for the person with learning disabilities. Staff often perceive their communication styles differently than their practice of them, and frequently cannot identify when the context of the situation is communicating to people with learning disabilities, rather than the staff members' speech (Bradshaw, 2001). The training course we developed outlines practical strategies for staff to utilise when supporting the understanding of those with learning disabilities, with a focus on techniques to adapt communication styles. We discussed simplifying language, supplementing speech with gestures, pictures, and objects, ensuring that the person has adequate processing time by using the six second rule (count to six before moving on to the next point, although it was stressed that this is an average and may be different for others), and ensuring to always check back understanding by asking the person to summarise the information in their own words, repeating the information and asking if they understand, and/or watching the person's response to see if it is appropriate to the information that has been given.


Positive experiences of staff communication were reported when staff took the time to listen and show empathy and kindness (Bell, 2012), when they took the time to make a double appointment and paid attention to non-verbal communication (Murphy, 2006), used a facilitative approach over a directive approach, spoke more slowly and clearly, used visual support (McConkey et al, 1999; Bartlett & Bunning, 1997), and used consistent methods of communication (Thurman, 1997). Positive experiences were reported in particular when staff took the time to get to know the individual (Martin, O'Connor-Fenelon & Lyons, 2010; Murphy, 2006; Whittington & Burns, 2005; McKenzie, Sharp, Paxton & Murray, 2002). The staff that attended our online course appeared to work closely with service users, and appeared to know them well. The group were able to give examples of service users they have had experiences with, and to ask specific questions relating to these service users.


There are a variety of things that influence staff practice. An important focus of this is the value that staff place on service users - do they see them as peers or patients? (McConkey et al, 1999). Many staff members experience frustration when working with people with learning disabilities. This can be due to a mutual lack of understanding (Murphy, 2006; Martin et al, 2010), lack of knowledge/training with the client group, lack of emotional support for staff (Bartlett & Bunning, 1997; Cumella & Martin, 2004), and coping with behaviour seen as 'challenging' (Whittington & Burns, 2005). If staff are given little training to understand why people with learning disabilities may present with behaviour that is seen as 'challenging', this can impact their view of the behaviour, which in turn, shapes their intervention approach towards it (McKenzie et al, 2002). Kevan (2003), Bartlett and Bunning (1997) discuss the concept of normalisation, and how staff may believe that they should practice with this client group by treating them 'the same as everyone else', not acknowledging the complex level of support required by people with learning disabilities. In order to obtain information from the attendees of the online course around influences is on their practice, a question was included in the evaluation and feedback form sent out following the session asking, "what support do you need to be able to implement the strategies learned on the course?". This was included in follow-up feedback as it was believed that the attendees would be more honest on an anonymised form than on camera in front of their colleagues.


Kevan (2003) notes that staff and services generally focus on discernible aspects of communication, with little acknowledgement of the person with learning disabilities' understanding, and McConkey et al (1999) identified recommendations of simplifying language and increasing non-verbal communication, with a particular area to be addressed in training 'matching language to client's understanding'. A priority for training outlined in a great deal of the research is for staff to be aware of their own communication style, and learn different modes of communication to increase their skills in using a total communication approach, to support the person's understanding and expression (Bell, 2012; Cumella & Martin, 2004; Whittington & Burns, 2005; Kevan, 2003; Thurman, 1997; McConkey et al, 1999; Martin et al, 2010; Murphy, 2006; Bartlett & Bunning, 1997; McKenzie et al, 2002). This includes adaptations to the environment to maximise the person's support for communication (Kevan, 2003), and using the environment to provide concrete context to information given (Bartlett & Bunning, 1997). The online course is centred around the mechanisms of understanding speech, language, and communication in people with learning disabilities, and how to support their understanding. There is little discussion around the expressive language of service users. This is due to the tendency of staff to focus on expressive over receptive communication. There is, however, a focus on the expressive language of staff members, and how this can be adapted to use a total communication approach. The course also discusses things to avoid in speech, such as negatives and abstract concepts.


Training can be more effective when developed with a focus on existing staff attitudes (Dobson et al, 2002), and when training is made more meaningful to them, by discussing and reflecting on their practice with real people that they work with rather than hypothetical clients (McKenzie, Sharp, Paxton & Murray, 2002; Shakespeare & Kleine, 2013). A heavy focus was placed on applying the online course content to specific service users that the staff work with. Staff shared their experiences in their practice, particularly in the activity at the end where course attendees were asked to apply the easy-read Five Good Communication Standards to their current practice, and think of ways that they could implement it further in their future practice. As training can be more effective when developed with knowledge of existing staff attitudes, it may have been appropriate to send out a pre-training questionnaire, in order to tailor the training more specifically to the learning objectives of the members of staff.


Training at this level should work towards a higher quality of communication environment, staff having the appropriate communication skills, demonstrable understanding of service users' communication abilities and needs, and evidence of the utilisation of a total communication approach across the staff team (Baker et al, 2010).


Appropriate training is likely to positively impact staff practice, however, it is important to note that there are deeper issues in services which training is insufficient to affect, the values of services and the examples they set for their staff teams are significant in shaping service delivery (Bell 2012; Cumella & Martin, 2004; Ravoux, Baker & Brown, 2012; Windley & Chapman, 2010; Thurman, 1997). The context staff are working in in terms of service design must be considered when providing training (McKenzie et al, 2002). Supervisor-facilitated sessions should be available consistently to staff as a safe space to discuss their concerns around working with people with LD as a means of ongoing learning (McKenzie, Sharp, Paxton & Murray, 2002; Whittington & Burns, 2005; Dobson et al, 2002; Ravoux et al, 2012). A particular area highlighted by health and social care staff is the need for access to support to cope with the stress of working with people with learning disabilities (Whittington & Burns, 2005; Ravoux et al, 2012). It is important to liaise with the multidisciplinary team as part of the training package, to ensure that practice is put in place to help staff to talk about their concerns and manage their wellbeing. As part of the online course, we have offered follow-up advice to the companies who took part, to support them in implementing new strategies learned. It is outside the scope of the trainers to make changes to the designs of the services we provide training to; however, it is important to provide as much support as possible to facilitate these changes.

The most important part of training for me is the changes that occur as a result of it. Due to this, I wanted to ask the attendees to complete two evaluation and feedback forms, one immediately after the course, and one in four-six weeks, so that we are able to measure the changes to staff knowledge pre- and post-training, and then to gather information on how the training has impacted the staff members’ practice and the consequential impact this has for the people that they work with. The evaluation and feedback forms also identify which parts of the course materials were engaging and which bits need to be adapted for future deliveries of the course.


We received three feedback forms. The roles of those who replied were director of care, assistant manager, and care coordinator. The feedback was as follows:


Ease of engagement with course materials

P1: Documents presented in easily understood format, difficult online as it is harder to read from a screen, a couple of the slides had too much written information (8/10)

P2: Felt comfortable and relaxed on the course, was easy to participate, answers were listened to and discussed, good use of zoom (9/10)

P3: Fantastic discussions (10/10)

Ease of engagement with course facilitators

P1: Not the same as face to face, felt people were conscious of interrupting and speaking over people, difficult without the physical interaction with the therapist teaching the course, was unable to contribute to the latter half of the session because I was muted as I forgot to switch my phone off (8/10)

P2: Things were explained clearly, questions were answered in depth and with great understanding (10/10)

P3: All course providers gave good, clear answers and questions. Gave me the opportunity to think outside of my usual way of communicating (10/10)

Rate your knowledge

  • How speech and language is understood

  • Before the course

  • P1: 6/10

  • P2: 5/10

  • P3: 8/10

  • After the course

  • P1: 8/10

  • P2: 9/10

  • P3: 10/10

  • How speech and language may be interpreted differently by people with communication difficulties

  • Before the course

  • P1: 6/10

  • P2: 4/10

  • P3: 7/10

  • After the course

  • P1: 8/10

  • P2: 8/10

  • P3: 10/10

  • Strategies to help people with learning disabilities and/or autism understand

  • Before the course

  • P1: 6/10

  • P2: 7/10

  • P3: 8/10

  • After the course

  • P1: 8/10

  • P2: 9/10

  • P3: 10/10

  • Strategies to help people with learning disabilities and/or autism in meetings

  • Before the course

  • P1: 6/10

  • P2: 7/10

  • P3: 7/10

  • After the course

  • P1: 8/10

  • P2: 9/10

  • P3: 10/10

  • Using a total communication approach

  • Before the course

  • P1: 6/10

  • P2: 5/10

  • P3: 8/10

  • After the course

  • P1: 8/10

  • P2: 8/10

  • P3: 10/10

  • Accessible information

  • Before the course

  • P1: 6/10

  • P2: 8/10

  • P3: 7/10

  • After the course

  • P1: 8/10

  • P2: 10/10

  • P3: 10/10

  • Facilitating choices

  • Before the course

  • P1: 6/10

  • P2: 6/10

  • P3: 8/10

  • After the course

  • P1: 8/10

  • P2: 9/10

  • P3: 10/10

Which strategies included in the course will be useful in your practice? How will you implement these into your practice?

P1: It is always good to relearn material and be reminded of the basics, I think for staff who are experiencing total communication strategies for the first time the course needs to be less wordy at the beginning and some practical examples at the beginning would help people relax into the session.

P2: Tailoring strategies to meet the individual’s needs. Using visual aids, photographs, implementing the 6 second processing time rule in conversation, physical cues, using more positive and less complicated language, chunking information.

P3: Using visual support, checking back understanding, using accessible information.

What support do you need to be able to implement these strategies?

P1: Staff need to understand the importance of communication and how we are barriers to communication, staff will need support to record daily activities which include thinking about communication first.

P2: Time to work with clients and staff to implement the strategies and establish a consistent approach that works. Funding for further staff development, resources, and equipment if necessary.

P3: I feel that our company give both employees and clients the opportunity to increase their learning and knowledge base with communication. However, I do think that having more access to bespoke learning skills may increase our understanding.

How do you think the implementation of these strategies will change the lives of the service users that you work with?

P1: We support people who receive individualised budgets so it is imperative that we offer every opportunity and support to express their choices and wishes and to understand the services we offer, we support individuals to live their daily lives the way they want to so total communication is key to giving people processing time and express their needs.

P2: Empowers our service users that they have a voice, choice, and control over their own support and lives. Build stronger and more trusting relationships between clients and staff. Service users will receive more person-centred care and support.

P3: It will give clients a better choice base. Offer a more independent way of living and communication.

Additional feedback

P1: Had to change form to word to make us able to respond (this may impact on feedback if people are having to print the form and scan or email back. I enjoyed the session but I imagine some staff may feel a bit intimidated by the formal slides with lots of written information at the beginning of the session, an icebreaker or visual example of some of the challenges people face may be helpful to get staff thinking first – maybe an example of when they have been in a situation where they feel they couldn’t explain themselves or were misunderstood and how this made them feel. I found it difficult to do the course on Zoom as I am a visual learner and like to be in the room with people. Hopefully as Covid restrictions life we can share training the old fashioned way and share ideas and examples in person.

P2: Thank you for taking the time to offer us this training, it was really useful for our team and will be cascaded throughout the company. It had good content and was a good refresher and I think we will all be more mindful about how we communicate as a result.

P3: Thank you all for taking the time to offer us this training, it has been insightful and useful.

As mentioned in the additional feedback, the format of the form had to be changed in order for the attendees to write comments. A further two forms were received showing that the participants had made gains in all areas however they were unable to detail these in the comment section.

The second feedback form to see what differences have been made to the attendees’ practice was sent, but we did not receive any responses.


This has been an invaluable learning experience. Training needs to be adaptable to suit the situation, particularly in the current climate with many training courses being delivered in an online format. New and creative ways must be explored to ensure that sessions are interactive. Using visual examples and asking the group to discuss where communication has broken down was an effective way of prompting discussion amongst the group, and led on to some interesting examples and sharing of ideas. If we were to do the session again, the inclusion of a word cloud or a padlet or a Zoom poll to obtain immediate feedback from the group may be beneficial. An anonymised pre-training questionnaire may also be useful, to obtain a view of the context staff are working in, and their attitudes and perspectives towards their practice, to inform the training package and the way it should be adapted to be delivered to them as an individual team. ​​​​​​​


References:

Baker, V., et al. (2010). Adults with Learning Disabilities. RCSLT Position Paper. London: RCSLT.

Banat, D., Summers, S. & Pring, T. (2002). An Investigation into Carers’ Perceptions of the Verbal Comprehension Ability of Adults with Severe Learning Disabilities. British Journal of Learning Disabilities, 30. 78-81.

Bartlett, C. & Bunning, K. (1997). The Importance of Communicative Partners: A Study to Investigate the Communicative Exchanges Between Staff and Adults with Learning Disabilities. British Journal of Learning Disabilities, 25. 148-152.

Bell, R. (2012). Does He Have Sugar in His Tea? Communication Between People with Learning Disabilities, Their Carers, and Hospital Staff. Tizard Learning Disability Review, 17(2). 57-63.

Bradshaw, J. (2001). Complexity of Staff Communication and Reported Level of Understanding Skills in Adults with Intellectual Disabilities. Journal of Intellectual Disability Research, 45(3). 233-243.

Cumella, S. & Martin, D. (2004). Secondary Healthcare and Learning Disability: Results of Consensus Development Conferences. Journal of Intellectual Disabilities, 8(1). 30-40.

Dobson, S., Upadhyaya, S. & Stanley, B. (2002). Using an Interdisciplinary Approach to Training to Develop the Quality of Communication with Adults with Profound Learning Disabilities by Care Staff. International Journal of Language and Communication Disorders, 37(1). 41-57.

Iacono, T. & Johnson, H. (2004). Patients with Disabilities and Complex Communication Needs: The GP Consultation. Australian Family Physician, 33(8). 585-589.

Kevan, F. (2003). Challenging Behaviour and Communication Difficulties. British Journal of Learning Disabilities, 31. 75-80.

Law, J. & Lester, R. (1991). Speech Therapy Provision in a Social Education Centre: Is It Possible to Target Intervention? Mental Handicap, 19. 22-28.

Martin, A., O’Connor-Fenelon, M. & Lyons, R. (2010). Non-Verbal Communication Between Nurses and People with an Intellectual Disability: A Review of the Literature. Journal of Intellectual Disabilities, 14(4). 303-314.

McConkey, R., Morris, I. & Purcell, M. (1999). Communications Between Staff and Adults with Intellectual Disabilities in Naturally Occurring Settings. Journal of Intellectual Disability Research, 43(3). 194-205.

McKenzie, K., Sharp, K., Paxton, D. & Murray, G.C. (2002). The Impact of Training and Staff Attributions on Staff Practice in Learning Disability Services: A Pilot Study. Journal of Intellectual Disabilities, 6(3). 239-251.

Murphy, J. (2006). Perceptions of Communication Between People with Communication Disability and General Practice Staff. Health Expectations, 9. 49-59.

Purcell, M., Morris, I. & McConkey. (1999). Staff Perceptions of the Communicative Competence of Adult Persons with Intellectual Disabilities. British Journal of Developmental Disabilities, 45(1/88). 16-25.

Ravoux, P., Baker, P. & Brown, H. (2012). Thinking on Your Feet: Understanding the Immediate Responses of Staff to Adults Who Challenge Intellectual Disability Services. Journal of Applied Research in Intellectual Disabilities, 25(3). 189-202.

RCSLT. (2013). The Five Good Communication Standards. London: RCSLT.

Shakespeare, T. & Kleine, I. (2013). Educating Health Professionals about Disability: A Review of Interventions. Health and Social Care Education, 2(2). 20-37.

Smith, M., Manduchi, B., Burke, É, Carroll, R., McCallion P., & McCarron, M. (2019). Communication Difficulties in Adults with Intellectual Disability: Results from a National Cross-Sectional Study. Research in Developmental Disabilities, 97(2020). 103557.

Thurman, S. (1997). Challenging Behaviour Through Communication. British Journal of Learning Disabilities, 25. 111-116.

Tuffrey-Wijne, I. & McEnhill, L. (2008). Communication Difficulties and Intellectual Disability in End-of-Life Care. International Journal of Palliative Nursing, 14(4). 189-194.

Whittington, A. & Burns, J. (2005). The Dilemmas of Residential Care Staff Working with the Challenging Behaviour of People with Learning Disabilities. British Journal of Clinical Psychology, 44(1). 59-76.

​​​Windley, D. & Chapman, M. (2010). Support Workers within Learning/Intellectual Disability Services Perception of Their Role, Training, and Support Needs. British Journal of Learning Disabilities, 38. 310-318.

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