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The impact of a whole-organisation approach to positive behavioural support on the use of physical interventions
Abstract
Background: Allen (2011) reviewed the key independent variables associated with reducing the use of restrictive practices (such as restraint, seclusion and as required medication) and proposed that the adoption of PBS at an organisational level might be expected to produce similar reductions. The present paper seeks to test this proposition.Method and materials: A series of initiatives were undertaken to establish PBS as the primary clinical model in a specialist service for adults with intellectual disability. Routine monthly data on physical intervention use were collected across eleven different specialist services settings using PBS as their clinical model over a period of seven years.Results: Clear reductions in physical intervention use were evident over the study period. Reduction profiles were slightly different in acute and long-stay settings, though clear reductions were evident in both.Conclusions: Though there are a number of important qualifications to this organisational case study, the systematic adoption of PBS within a service system would appear to be associated with substantial reductions in the use of physical interventions.
... Ensuring senior management support: System-wide implementation of PBS is likely to be reinforced by strategic support at a senior level within organisations, and achieving senior management buy-in is likely to contribute to achieving a systems change approach to PBS. For example, this could include developing a PBS policy which provides detailed organisational procedures for the use of PBS; or the developing of key performance indicators in relation to PBS implementation may be helpful to ensure ongoing commitment to its use (Allen et al, 2012;). ...
... Mansell et al (1994) describe whole environment training, which identifies key elements within an effective change process, including mechanisms for communicating and monitoring standards, such as that used in the PSR. The issue of whole-system implementation is so central to PBS that Carr (2007) suggested 'the central independent variable in PBS is systems change' (p4) and a range of other studies have shown associations between implementing a whole-system approach to PBS and improved outcomes for service users both in terms of challenging behaviour and quality of life (Allen et al, 2012;Perry et al, 2011;. Implementing PBS in a service or organisation must reach further than just individual behavioural changes towards systemwide implementation; and PBS training must address this issue, if trainees are to leave the training and implement what they have learnt. ...
... If we are to see long-term positive changes being created in the lives of people with intellectual disabilities and behaviour support needs, then it seems likely that a focus on practice leaders and creating long-term sustainable practice leadership within organisations will be vital to achieving this. strong internal message of support to PBS as the preferred method for supporting those whose behaviours challenge Allen et al, 2012;DOH, 2007). ...
Abstract
Allen et al (2018) have commented elsewhere in this edition on the clinical trial conducted by Hassiotis et al
(2018), offering further thoughts on intervention, implementation and interpretation. This paper considers the
issues raised by Allen et al (2018) and places these in the context of research around implementation of positive
behavioural support (PBS) training and the factors that must be in place for successful implementation: the
practical aspects of training, such as ensuring the right people are trained and that the training is of sufficient
duration; the importance of supported implementation as part of the training process; the need for practice
leaders to lead on PBS implementation within the workplace; and the fact that PBS training must focus on
systems change, rather than just change for individuals. Consideration is given to the evidence for each of these
factors within the PBS study reported by Hassiotis et al (2018) with reference to the additional information in the
paper from Allen et al (2018). Finally some recommendations are made for the successful implementation of PBS
training within organisations.
... Post incident review has been reported to decrease use of restraint in some cases, however in other cases it has been reported to increase use of restraint (21). Multi-component models that include a focus on senior leadership, feedback from frontline staff, target setting, outcomes monitoring, and staff training have been shown to reduce the use of restraint (22,23). ...
... At the organisational level, various models have been shown to reduce the use of physical restraints, for example multicomponent models such as 'Six Core Strategies' (61). Multicomponent group interventions include a range of activities such as senior leadership focus, target setting, monitoring, and reviewing outcomes data at all levels, feedback to frontline teams, in addition to staff training (22,61). Two studies included in this review evaluate training as part of a multicomponent model (44,45). ...
Background
Restrictive practices are used frequently by frontline staff in a variety of care contexts, including psychiatric hospitals, children’s services, and support services for older adults and individuals with intellectual and developmental disabilities. Physical restraint has been associated with emotional harm, physical injury to staff and consumers, and has even resulted in death of individuals in care environments. Various interventions have been implemented within care settings with the intention of reducing instances of restraint. One of the most common interventions is staff training that includes some physical intervention skills to support staff to manage crisis situations. Despite physical intervention training being used widely in care services, there is little evidence to support the effectiveness and application of physical interventions. This review will examine the literature regarding outcomes of staff training in physical interventions across care sectors.
Method
A systematic search was conducted following PRISMA guidelines using Cochrane Database, Medline EBSCO, Medline OVID, PsychINFO, and the Web of Science. Main search keywords were staff training, physical intervention, physical restraint. The MMAT was utilised to provide an analytical framework for the included studies.
Results and discussion
Seventeen articles have been included in this literature review. The included studies take place in a range of care settings and comprise a wide range of outcomes and designs. The training programmes examined vary widely in their duration, course content, teaching methods, and extent to which physical skills are taught. Studies were of relatively poor quality. Many descriptions of training programmes did not clearly operationalise the knowledge and skills taught to staff. As such, it is difficult to compare course content across the studies. Few papers described physical interventions in sufficient detail. This review demonstrates that, although staff training is a ‘first response’ to managing health and safety in care settings, there is very little evidence to suggest that staff training in physical intervention skills leads to meaningful outcomes.
... Most studies (N = 14) were non-experiments. Almost all nonexperiments used pre-post designs (Allen et al. 1997(Allen et al. , 2012Baker and Bissmire 2000;Brooker et al. 2014;Craig and Sanders 2018;Deveau and Leitch 2015;Foxx et al. 1986;Foxx 1998;George et al. 2013;Leoni et al. 2018;Miller et al. 2005;Ryan et al. 2007a, b;Sanders 2009;Simonsen et al. 2010;Singh et al. 2016a;Williams and Grossett 2011). There were six experiments, one early institutional study using a multiple baseline design across three different types of restrictive procedures During a 5-month preprogram phase a data system was developed and the supervisor was responsible to a mid-level administrator. ...
... Further, in comparisons of per year for a total of $161.4 M, primarily from reduction in costs associated with staff injuries (f) No social validity data were reported 9. Allen et al. (2012) (a) Data on three forms of restrictive procedures were collected over 7 years. All physical interventions fell from 110 to 28 per year (− 74%, breakaways fell from 54 to 15 per year (− 73%); removals from 33 to 10 (− 70%) and restraints from 11 to 3 (− 73%) ...
Safe restraint reduction is important to remove unnecessary stigmatizing and harmful behavior management practices in individuals with developmental disabilities. Despite calls to reduce such practices, they remain common. The literature was searched to identify empirical papers using interventions of any kind to reduce restraint and related restrictive behavior management practices in group settings, such as institutions, community group homes, and schools. This systematic review identified 21 empirical papers of which 7 were experiments. The three most commonly used interventions were (1) packages of organizational reform, target setting, staff training and feedback in institutional; (2) interventions in community settings; (3) mindfulness sometimes combined with positive behavior support; and (4) interventions in schools including organizational reform, goal setting, and feedback. Almost all studies reported large reductions in use of restraint and other restrictive behavior management practices without substitution of one form of restrictive behavior management practice by another. Papers that reported data on client and staff safety and economic analyses reported positive outcomes. Those studies that reported follow-up data reported positive outcomes with maintenance of up to 13 years. These findings have three main implications, namely, (1) large-scale, safe restraint reduction is possible in a variety of settings using varied methods; (2) large-scale restraint reduction results in improved safety for clients and staff and reduced costs, primarily due to reduced coasts of staff injuries and lost time; and (3) future research should focus on measures of treatment integrity, independent replication of promising interventions, complete reporting of all settings recruited to studies, manualization of all treatment strategies, and comparison of alternate approaches.
... Positive Behaviour Support can be implemented in a number of ways, including by a single practitioner co-ordinating all elements of the framework and leading each stage of the process, 30-32 by professional teams in which different members contribute to different elements of the PBS framework or process, 13,33 and systemwide, whereby the PBS framework is implemented at varying levels of intensity via a tiered model of prevention that covers an entire organisation or geographical area. [33][34][35] Specific staff competencies have an impact on the effectiveness of PBS in improving challenging behaviour. However, as a result of the resources required to deliver PBS, this type of support is not always available. ...
Background
Preliminary studies have indicated that training staff in Positive Behaviour Support (PBS) may help to reduce challenging behaviour among people with intellectual disability (ID).
Objective
To evaluate whether or not such training is clinically effective in reducing challenging behaviour in routine care. The study also included longer-term follow-up (approximately 36 months).
Design
A multicentre, single-blind, two-arm, parallel-cluster randomised controlled trial. The unit of randomisation was the community ID service using an independent web-based randomisation system and random permuted blocks on a 1 : 1 allocation stratified by a staff-to-patient ratio for each cluster.
Setting
Community ID services in England.
Participants
Adults (aged > 18 years) across the range of ID with challenging behaviour [≥ 15 Aberrant Behaviour Checklist – Community total score (ABC-C T )].
Interventions
Manual-assisted face-to-face PBS training to therapists and treatment as usual (TAU) compared with TAU only in the control arm.
Main outcome measures
Carer-reported changes in challenging behaviour as measured by the ABC-C T over 12 months. Secondary outcomes included psychopathology, community participation, family and paid carer burden, family carer psychopathology, costs of care and quality-adjusted life-years (QALYs). Data on main outcome, service use and health-related quality of life were collected for the 36-month follow-up.
Results
A total of 246 participants were recruited from 23 teams, of whom 109 were in the intervention arm (11 teams) and 137 were in the control arm (12 teams). The difference in ABC-C T between the intervention and control arms [mean difference –2.14, 95% confidence interval (CI) –8.79 to 4.51; p = 0.528] was not statistically significant. No treatment effects were found for any of the secondary outcomes. The mean cost per participant in the intervention arm was £1201. Over 12 months, there was a difference in QALYs of 0.076 in favour of the intervention (95% CI 0.011 to 0.140 QALYs) and a 60% chance that the intervention is cost-effective compared with TAU from a health and social care cost perspective at the threshold of £20,000 per QALY gained. Twenty-nine participants experienced 45 serious adverse events (intervention arm, n = 19; control arm, n = 26). PBS plans were available for 33 participants. An independent assessment of the quality of these plans found that all were less than optimal. Forty-six qualitative interviews were conducted with service users, family carers, paid carers and service managers as part of the process evaluation. Service users reported that they had learned to manage difficult situations and had gained new skills, and carers reported a positive relationship with therapists. At 36 months’ follow-up ( n = 184), the mean ABC-C T difference between arms was not significant (–3.70, 95% CI –9.25 to 1.85; p = 0.191). The initial cost-effectiveness of the intervention dissipated over time.
Limitations
The main limitations were low treatment fidelity and reach of the intervention.
Conclusions
Findings from the main study and the naturalistic follow-up suggest that staff training in PBS as delivered in this study is insufficient to achieve significant clinical gains beyond TAU in community ID services. Although there is an indication that training in PBS is potentially cost-effective, this is not maintained in the longer term. There is increased scope to develop new approaches to challenging behaviour as well as optimising the delivery of PBS in routine clinical practice.
Trial registration
This study is registered as NCT01680276.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 15. See the NIHR Journals Library website for further project information.
... It can be implemented in a number of ways, including via a single practitioner, [11][12][13] via professional teams offering interdisciplinary contributions to the PBS framework, 14,15 and via a system-wide implementation comprising a tiered model of prevention that covers an entire organisation or geographical area. 16 The only pilot randomised controlled trial (RCT) of PBS incorporating applied behaviour analysis was delivered by a specialist behaviour team in one area in England and it showed promising results by reducing the lethargy and hyperactivity domain scores of the Aberrant Behaviour Checklist-Community (ABC-C). 17,18 A naturalistic 2-year follow-up of the same trial participants showed a continued positive effect of the intervention compared with treatment as usual (TAU). ...
Background
Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability.
Aims
To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276).
Method
We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS ( n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants.
Results
No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = −2.14, 95% CI: −8.79, 4.51) or secondary outcomes.
Conclusions
Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour.
Declaration of interest
None.
... Although research evidence to support this proposition is currently sparse, a series of papers has described how the adoption of a whole-organisation approach to PBS across services (specialist behavioural community teams, acute admission units and long-stay specialist residences) for adults with intellectual disability and severe challenging behaviour in South Wales was associated with improve- ments in quality of life, reductions in challenging behaviour and reductions in the use of restrictive procedures (Perry et al, 2011;Allen et al, 2011Allen et al, , 2012Gray et al, 2013). ...
Background
The Positive Behaviour Support (PBS) is a multidimensional framework which aims to increase understanding of the function of a person’s behaviour. PBS consequently helps to develop effective support strategies (Allen et al., 2012; Carr et al., 1999). The PBS model was introduced in a low secure mental health hospital for females in order to maximise the support offered, increase feelings of safety, and reduce secondary gains from enhanced observations.
Method
Staff views on the implementation and effectiveness of the PBS model were evaluated using qualitative and quantitative analysis. The evaluation was based upon responses from 20 participants, who were regular Care Assistants and Nurses working on admission wards within the aforementioned clinical setting. Semi-structured interviews and short questionnaires were completed anonymously by participants.
Results
Overall, staff reported that the PBS model had a positive impact on the day-to-day running of the wards. The PBS model was identified as an effective tool to address challenging behaviour. Staff reported that PBS is a useful approach when working with patients with learning disabilities and personality disorders.
Conclusion
It has been suggested that further training and development of PBS strategies (e.g. functional analysis) would be beneficial.
The use of physical restraint, seclusion, excessive psychotropic medications and other restrictive practices applied with people who have developmental disabilities and present with behavioral challenges is commonplace. Policy and practice guidance aimed at reducing the excessive and inappropriate use of such methods is timely and appropriate given new and effective non-aversive treatments for people who are aggressive. What is needed are tools for safely managing aggressive and other behavior problems that put people at risk while reducing the need for the restrictive practices. The techniques that comprise Positive Behavior Support (PBS) offer humanistic treatment methods that can now significantly reduce pharmacotherapy for behavior control, seclusion and restraint as the standards of practice for managing aggressive behavior. In this chapter, we shall illustrate the implementation of Positive Behavior Support by training clinicians to effectively employ PBS with clients having challenging behaviors as well as initiatives at the regional and national levels. Case examples will further illustrate PBS and its effect on the reduction of restrictive practices. Developing an individualized PBS plan for effective treatment of people who exhibit aggression and other challenging behavior is based on comprehensive functional assessment as described in Chapter 3. In this chapter we shall report the dissemination and adoption of PBS within treatment programs at the regional and national levels in the United Kingdom.
This chapter reviews staff training in Positive Behavior Support (PBS) and considers the outcomes from published reviews of PBS training. Firstly, the development of PBS is briefly outlined and the need for staff training in PBS is identified; the chapter then goes on to describe what PBS training is, based on a range of studies which have attempted to define this. Four key features are presented as being essential in the definition of PBS training; based on these key features, 15 studies presenting outcomes from PBS training have been identified and the findings from these studies are summarized. A discussion of the findings follows, concluding with some recommendations for future training in PBS.
Purpose
– The purpose of this paper is to investigate the impact of a six-and-a-half day, Positive Behaviour Support (PBS) informed training course on staff’s self-efficacy and outcome expectations of managing challenging behaviour (CB). Training programmes for other non-psychology staff were deemed necessary due to the high demand for services and the specialist knowledge held by other professionals or carers.
Design/methodology/approach
– A repeated measures design was used to capture changes in specific self-efficacy and outcome expectations before and after the training programme. A questionnaire methodology was employed.
Findings
– Staff self-efficacy and positive outcome expectations increased on all four measured variables following training: understanding of CB, working out the functions of CB, developing and implementing a PBS plan, and managing CB for the benefit of the service user.
Research limitations/implications
– These findings are considered in light of previous research suggesting an impact on staff practice and burnout.
Practical implications
– The findings suggest that the training model delivers changes in staff cognition and may be useful in other locations where demand for services is likely to increase in the future.
Originality/value
– This research considers the impact of a medium length PBS training on staff cognition, evidencing the model’s utility in the current service context.
Background: Social and organisational contexts have a major influence on both challenging behaviour and interventions designed to ameliorate such behaviour and improve quality of life.Method and materials: A non-systematic review was conducted in order to identify social and organisational factors that impact upon positive behavioural support (PBS) intervention.Results: A series of micro and macro influences on intervention effectiveness were identified. Possibilities for improving intervention effectiveness that extend the scope of traditional behavioural interventions were discussed.Conclusions: Implications and opportunities for building capacity at an individual service user, organisational and cultural level are highlighted.
Background:
There is a dearth of research on the perspectives of adolescent siblings growing up with a brother or sister with an autism spectrum disorder (ASD).
Method:
Semistructured interviews were used to elicit the perceptions and experiences of 12 typically developing adolescents with a brother with an ASD. Interpretative phenomenological analysis was used.
Results:
The data analysis of the siblings' perceptions yielded 6 themes: (a) difficulties and negative impact of their brother's condition on themselves and their family, (b) how others' reactions to their brother negatively affected them as siblings, (c) how their histories with their brothers contextualised their present circumstances, (d) the varying degrees of acceptance and tolerance towards their brothers, (e) positive perceptions and experiences with their brothers, and (f) their thoughts and worries about the future.
Conclusions:
The main implications are for supports to adolescent siblings by helping them to develop skills in managing others' reactions and openly discussing concerns about their brother's future.
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