Insane Logic and MCCH Pilot Project

MyChoicePad and Inclusive Communication

October 2015            

 

      

Overview MCCH and Insane Logic were interested in finding out whether MyChoicePad could be used flexibly by staff teams to support inclusive communication in a person centred way. To this end they committed to a 12 week pilot study involving 6 participants and 12 staff members who supported them.

Results Theme: Promoting a total communication environment and person centred care.

100% of staff agreed that MyChoicePad made communication more person centred.

● 100% of staff agreed that they were more confident in using pictures, symbols and signs to support communication.

● 100% of staff agree that they enjoyed using MyChoicePad with the person they support.

● For pilot participants there was a 45% increase in sign knowledge and a 59% increase in symbol knowledge.

Theme: Staff skills and motivation

● 80% of staff agreed that MyChoicePad reduced instances of communication breakdown.

● 80% of staff agreed that using MyChoicePad allowed them to use their own initiative.

● 100% of staff agreed that using MyChoicePad made their job more enjoyable.

Conclusions

● All staff improved their skills as communication partners, increasing their awareness of all modalities of communication.

● It was reported that in a supportive environment the pilot participants will take control and drive the creation of their own resources.

● MyChoicePad supported and consolidated the learning from training. ● The increase in satisfaction in communication exchanges reported by nearly all

staff shows how using MyChoicePad to support the introduction of an inclusive communication environment has led to an improvement in relationships between staff and the people they work with.

● MyChoicePad promotes both a reduction in communication breakdown and an increase in 1-1 time spent communicating with staff. For some individuals this was reported to contribute to a reduction in the behaviour that challenges services.

Pilot Context MyChoicePad is a highly flexible Inclusive communication app for both iOS and Windows which uses photos and Makaton symbols in a unique grid system and a bank of 4000 Makaton signs to support both the expressive and receptive communication skills of both pilot participants and staff. The MyChoicePad app can be tailored to the user – as a voice output communication aid, a staff training tool, a storytelling support, a social communication starter, a choice facilitator, a conversation scaffold, or all of these, depending on the individual’s need. MCCH is an organisation that supports around 2,000 people across London and the south east of England. It defines itself as an organisation by a set of values –

­ Helping people to be the best they can be ­ Respecting people as individuals ­ Listening and learning by working together ­ Thinking of new ways to make good ideas happen ­ Working to the highest standards and making sure they are the best they can

be. And a set of standards, in terms of how they aim to give people the best support –

­ Having choice and control ­ Respect and dignity ­ Being independent, healthy safe and well ­ Involvement and taking part ­ Rights and responsibilities

Its stated vision is ‘a world where everyone is valued for who they are and can live the life they choose’. MCCH and the creators of MyChoicePad, Insane Logic, committed to a 12-week pilot study. MCCH and Insane Logic were interested in finding out whether the app could be used flexibly by staff teams to support inclusive communication in a person-centred way and to pursue their shared organisational aims. Staff selected six people, supported by MCCH, and guided by the criteria provided by Insane Logic, and finally screened by the Speech and Language Therapist. They and their support teams were each given ipads with a full copy of MyChoicePad. Previous to this introduction, baseline measures were taken, looking at Makaton sign and symbol knowledge in both the staff teams and the people they supported. The staff teams were given two days training in Makaton and in the use of MyChoicePad, run by the Speech and Language Therapist, including: stages 1-4 Makaton signs and symbols; creating grids;

accessing the signing vocabulary in the app; thinking about communication; and tailoring the app to individuals’ needs. The pilot project lasted 12 weeks and a midway review was offered to staff on week six, run by a speech and language therapist and the project manager, offering technical support, communication advice and goal setting. Finally, assessments were repeated at 12 weeks, along with questionnaires with staff members. Previous studies have found that use of the app by staff with the people they support can increase frequency and length of interactions, boost speech and signing skills, increase staff satisfaction, knowledge and confidence, and save time. The variety of modalities offered by the app encourages the introduction of an inclusive communication environment, and staff were encouraged to follow the leads and needs of the people they support and to use their own initiative as those who know them best. Challenges in this pilot included: being able to assess the same staff and people they support pre- and post-pilot; lack of direct interview with some staff; the lack of familiarity of the assessor and the pilot subjects; the lack of direct assessment of functionality of skills due to time constraints; the lack of standardised assessments for this purpose available for this group; staff availability to attend the midway review and the final assessment; the perception of staff of the time they had to introduce something ‘new’ and to spend time on a new way of communicating; staff recognition of their own skills and innovative practice; the staff team’s perception of and confidence in the work they were doing; and familiarity and interest in iPad technology. Inclusive communication is a philosophy whereby all modalities of communication are equally valued and used as relevant by and with the individual. This is particularly valuable for people with learning disabilities, as the augmentation of the spoken word that photos, symbols and sign offer can make a fundamental and functional difference to both expressive and receptive skills. Speech, photos, symbols, sign, writing, drawing and objects are all methods of Total/Inclusive Communication. Such communication is vital if people with learning disabilities are to be truly in control of their lives. The social model of disability states that disability belongs to the environment as a whole, not just the individual, and this is nowhere more true than in the area of communication disabilities. Communication is a two-way process requiring a sender and a receiver – it is all of our responsibilities to modify our communication accordingly.

The use of photos, symbols and signing all serve to make communication more concrete and less abstract – photos and symbols particularly often look like what they represent and thus their presence in a grid serves to ‘scaffold’ communication both expressively and receptively. This is particularly useful for people with learning disabilities who can struggle with the abstract and temporal nature of verbal communication for a variety of reasons (e.g. poor short term memory, language processing difficulties, attention problems) Additionally, the grids themselves ‘scaffold’ communication cognitively – giving prompts with regards to topics to talk about as well as a way to talk about them. The years since the publication of Valuing People (2001), specifically after the Winterbourne View abuses were exposed, have seen a raft of papers published with regards to services for people with learning disabilities and ‘what good looks like’, most recently “Transforming Care for People with Learning Disabilities” in 2015, the Bubb report in 2014 and the Mansell Report (1993/2007). The common threads of ‘what good looks like’ in the commissioning and provision of services can be drawn together in four common themes:

­ Individualisation and personalisation of care and support; ­ Choice and control for service users and families; ­ Treating people with dignity and respect; and ­ Investment in and commitment to staff and relationships.

It can be seen that good communication is vital to making these aims a reality. Research suggests that as many as 94% of people with a learning disability have some kind of difficulty with communication, which is often hidden or overlooked, leading to a lack of choice and control, isolation and behaviour that challenges services. In turn this implies that the majority of services for people with learning disabilities need to be making reasonable adjustments and using a variety of individualised communication supports for both expressive and receptive skills to make the above recommendations a reality. Building relationships and fostering intimacy is core to a good quality of life, and both rely on good communication – choice and control are vital, but so are positive relationships, chat and gossip. The Royal College of Speech and Language Therapist’s response to Winterbourne View has been to devise ‘Five Good Communication Standards’. These are recommendations for ‘what good looks like with regards to communication. They are: Standard 1: There is a detailed description of how best to communicate with individuals. Standard 2: Services demonstrate how they support individuals with communication

needs to be involved with decisions about their care and their services. Standard 3: Staff value and use competently the best approaches to communication with each individual they support. Standard 4: Services create opportunities, relationships and environments that make individuals want to communicate. Standard 5: Individuals are supported to understand and express their needs in relation to their health and wellbeing. The MCCH Project was a microcosm of the huge successes and challenges introducing a new approach can bring. Most individuals whose experience was captured pre- and post-pilot benefitted from the project in a variety of ways. Some made small but significant gains, others great strides. For one it is possible that staff not being able to attend the midway review was significant. For another person, technology and support did not bring about the outcomes hoped for. In this particular case, the final questionnaire was not completed as MyChoicePad had not been used and the results are not reflected below. The following is a presentation and discussion of that data gathered. The most notable theme of this particular pilot is that focused and enthusiastic staff can be transformative in individual’s experiences and the outcomes achieved. Direct quotes

from MCCH staff are ‘in bold larger font’.

Results

  Both staff and pilot participants increased their knowledge of sign and symbols over the period of the pilot. For pilot participants the increase in Makaton knowledge was significant, with a 45% increase in sign knowledge and a 59% increase in symbol knowledge. In the case of the MCCH staff team, most staff had just received Makaton training in the weeks before the pilot began, so their skills were already at a high level. It is notable however that staff skills were still improved after 12 weeks using the app with a 19% increase in sign knowledge a 11% increase in symbol knowledge from a relatively high base. This implies that the app supported and embedded what had been learnt in the training in a way that training alone had not managed.

 ‘Communication is just easier’ 

   

  

All of the staff surveyed felt that they knew more signs by the end of the project. These signs far extended the range used for the direct assessment. Staff were able to use the MyChoicePad sign and symbol content on their own initiative to look up and learn a huge variety of signs, a goal set by them, for them. This enthusiasm was particularly notable in the day service staff that used the project and the app as a professional development tool, among other things, widely extending their signing vocabulary. Most staff felt that the people they support also extended their signing skills. This was confirmed by the direct assessment measure. This might be because of direct learning from the app, from learning due to increased usage by the people who support them, or from reintroduction of previously learnt skills because of a receptive environment. An increase in the variety of modalities used by staff and the people they support can only by a positive – implying improved communication and a more open attitude to all modalities. In one case, the participant’s skills were reported not to have improved. Interestingly, this was an individual who had used the app for the pathways games with their support staff. It was reported that a lot of fun was had and communication had increased, but not that knowledge and skills had improved. The staff member in this case reported that they knew ‘significantly more’ than pre-pilot. It appears that in this case MyChoicePad and learning pathways allowed the staff member to increase her sign and symbol knowledge in line with the person they support, thus improving their skills as a communication partner. 

    

 

All staff surveyed agreed that the pilot study and the ongoing use of the app had made their communication with the individuals concerned more person-centred. This is in line with wider drivers and the goals of MCCH as an organisation. More person-centred communication means improved control over your life, relationships and more involvement in your life in general. Additionally, all staff felt that they were more confident and competent in using inclusive communication tools to support communication more widely – spreading the benefit from the individuals directly involved in the pilot to the other individuals they support now and in the future. Most individuals with learning disability will benefit greatly form an inclusive communication approach so there are wider benefits to this type of staff development. Additionally, it was reported that people also extended the reasons they communicated for, as well as the range of ways in which they communicated. MyChoicePad was used to: communicate about choices; to give information; to talk about feelings, to talk about the future and the past; to discuss the football; and to crack jokes.

‘He’s more confident. He can get his needs across’ ‘We can understand his speech better because he can show us the context’ ‘He takes it everywhere and brings things in to take pictures of – he uses it to make choices and talk about the future’ ‘We’ll keep on adding to it – it’s driven by J with suggestions from staff’ 

  ‘We spend more time communicating 1-1’

  Most staff agreed that using MyChoicePad increased the length of time they spent communicating with the people they support. We have found that responses to this question differ according to how MyChoicePad is being used in that context e.g if MyChoicePad is used as a conversation scaffold or a storytelling aid, then more time will be spent communicating as the extra supports aid the conversation both expressively and receptively for people and their communication partners. If MyChoicePad is used as a voice output aid, then time communicating specific choices may actually be reduced due to the use of signs symbols or photos expediting the process. If MyChoicePad is used for learning pathways alone, it may not be recognised that playing games together is time ’communicating’, although, of course, it is. The responses in this case reflect the different person-centred uses of the app – the majority of users used it as a conversation scaffold, but some used just the learning pathways and one for making choices (as a voice output). 80% felt that communication breakdown was reduced. Again, this result reflect the way the app had been used. In the case where this was ‘completely not’ felt to be the case, the staff and person they support had confined their usage to learning pathways. The staff member had not been able to attend the midway review where some support with wider usage would have been extended.

 “Previously (when he wasn’t understood) he would cry, or leave… now he has the iPad he asks for it as the first thing’ ‘We’ve seen a reduction in his ‘crying behaviour’ ‘We’ve seen a reduction in his challenging behaviour, he’s calmed down- you can understand him’ ‘There’s a faster resolution’ ‘It gives us 1-1 time’ 

   

  

It is a great result that all staff reported that they really enjoyed using MyChoicePad with the person they support. This is testament to the improved relationships and intimacy that making reasonable adjustments for individuals’ communication needs can bring. 80% reported they were satisfied with the interactions they had using MyChoicePad. The individual who reported neither satisfied or unsatisfied is again the individual who used pathways only. A higher level of satisfaction and enjoyment for staff in having interactions with the people they support can only breed an increase in these interactions leading to improved relationships, choice making and control.

‘He’s happier and more independent’ ‘He uses more words” ‘We discussed it and we really like the games and she enjoyed playing them’ 

   

  

It is clear from the result above that the staff team were unanimously enthusiastic with regards to this pilot, and the results for them and the people they support. This marries well with commitment to staff team development and relationships. It was interesting that, when given a flexible tool that could support communication in a variety of ways, staff were able to work with the person they supported in each case to find the best ways modalities for them together and to use their own initiative to make this work. The results of this positivity and initiative were most clearly visible in the day service setting where the two individuals and the staff team were observed to benefit in different ways from the project. The results for these two individuals and the people who support them are analysed further below.

     

Case Study Jim and Joire - pre and post pilot using Effectiveness Framework for Functional Communication (Murphy and Cameron)  Completed with the same staff members pre and post pilot. This asks the staff member to rate various criteria out of 5 – how well they understand the person they support; how well they engage with each other; how well the individual understands them; how well their interactions stay on track; whether the individual has their needs met and how mutual the control of the interaction is (i.e. is it lead by the staff member asking questions or the person they support fixating on one thing?). This looks at more communication in more functional terms, as reported by the support worker.

Jim 

Joire – as above

  In both cases it is striking that staff report a significant increase in their understanding of the individuals and thus an increase in the individual's needs being met. They also reported that when using MyChoicePad they were more mutually engaged by having a grid to provide common structure, and to this end it was easier to stay ‘on track’ conversationally and not lose context. In the case of Jim it was reported that staff found his speech easier to understand because of this shared context – showing how the use of different modalities support each other to convey meaning. In both cases, staff reported an increase in 1-1 time, as MyChoicePad gave them a mutual project to work on on one hand and a means of supporting and facilitating conversation on the other. It was notable that in both cases a reduction in behaviour staff identified as challenging was observed. At the final assessment both Jim and Joire had long chats with the Service Manager using a combination of grids, sign, speech and text. He reported that this would not have happened before the introduction on MyChoicePad.

 

  This is a striking result – in both cases staff reported a large increase in satisfaction with their interactions with each individual. Higher satisfaction indicates a reduction in communication breakdown and an increase in enjoyment and intimacy which in turn leads to improved relationships, increased participation and control. These two individuals and their staff teams had a very positive experience of the project. It is striking that, in this case, the responsibility for implementation lay with day services rather than residential services. Day service staff tend to feel it is their role to concentrate on wider skills development while residential staff also have to consider personal care and the skills associated with self care, perhaps this is a factor. Additionally, both Jim and Joire were clearly well matched with the technology and found it motivating and enjoyable. They clearly enjoyed the increase in 1-1 time and the shared experience that both building and using grids afforded them. Joire was observed having an interaction where he used sign, symbols, photos, text and speech to engage for some time. At the pre-pilot assessment it was reported that engagement ‘depends on his mood – its up to him’, and that he could be ‘isolated’. On observation post pilot he was clearly keen to engage and communicate – he had found a way that worked for him with open and competent communication partners.

  

Themes Staff improvement in competence and confidence 100% of staff felt that both their competence in Makaton signing and symbol use and their confidence in using all modalities in an inclusive communication approach had improved. To this end all staff improved their skills as communication partners, increasing their awareness of all modalities both to support being understood and their own understanding.

 

Person-centred communication Staff were able to use their own initiative to co-produce grids with the people they work within the using the modalities that best support their communication. Additionally and importantly it was reported that in a supportive environment the people they support will take control and drive the creation of their own resources.

 

The introduction of an inclusive communication environment is supported and encouraged by the use of MyChoicePad. Of particular interest here is the result showing that MyChoicePad supported and consolidated the learning from training. Staff had all recently been on Makaton training – hence the reasonably high result on the initial assessment, but all had higher scores for sign and symbol knowledge at the final assessment (despite the fact more time had elapsed between training and assessment than in the first instance). How to maintain skills from learnt in a training environment is an on-going concern for many organisations, and this is an interesting addition to the discussion.

 

An inclusive communication environment is of benefit to the development of relationships, choices, inclusion and control.  The increase in satisfaction in communication exchanges reported by nearly all staff shows how using MyChoicePad to support the introduction of an inclusive communication environment led to an improvement in relationships between staff and the people they work with. These relationships are at the basis of all excellent support work.

 

MyChoicePad is a focal point for an increase in 1-1 time  MyChoicePad promotes both a reduction in communication breakdown and an increase in 1-1 time spent communicating with staff. For some individuals this was reported to contribute to a reduction in the behaviour that challenges services.

 MyChoicePad has offered a simple and enjoyable way to support the introduction of an inclusive communication environment. The pilot shows MyChoicePad has been used in a totally personalised way – to support signing in the staff team, to support communication through grids using photos, pictures and symbols, teach signing skills, or to support daily living activities. Staff have taken the initiative to co-produce grids with pilot participants and in each case the way MyChoicePad has been used has come from the staff and person they support rather than an outside professional. Staff teams have enjoyed this use of initiative and a new and different way of working with the people they support. In addition, the results would seem to be in line with wider policy drivers:

­ Individualisation and personalisation of care and support; ­ Choice and control for service users and families; ­ Treating people with dignity and respect; ­ Investment in and commitment to staff and relationships

However, the important thing is the results can be seen in staff reports with regards to effects for people that they support:

 ‘He has more choice and more involvement – he’s happier and more independent”   

Lisa Morsley

Speech and Language Therapist, Insane Logic

10/2015