Improving the quality of behaviour support plans to decrease restrictive interventions and increase quality of lifeDr Lynne WebberOffice of Professional Practice, Department of Human Services, Victoria

What we know from research:

Over 20 years of research into Positive Behaviour Support shows use of PBS can:

• Increase:

• A person’s skills (Cook et al., 2012)• Quality of life (Claes, Hove, Vandevelde, van

Loon & Schalock, 2012)• Client outcomes (LaVigna & Willis, 2012)

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PBS can reduce• Behaviours of concern (Carr et al., 1999; McClean &

Grey, 2012)• Risk of work place injuries (LeBel, Chan & Webber,

2012)• Referrals from clients with complex needs (Crates &

Spicer, 2012)• Use of restrictive interventions (Webber, Richardson,

Lambrick & Fester, 2012)

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Restrictive intervention: any intervention that is used to restrict the rights or freedom of movement of another person.

• Chemical restraint• Mechanical restraint• Physical restraint• Seclusion• Other restrictive interventions

Restrictive interventions

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What our research in Victoria tells us

1. Current wave of PBS through Victoria is making a difference (McVilly, Webber, Paris & Sharp, 2012)

2. Support workers act on plans (Webber, McVilly, Fester & Chan, 2011)

3. Quality plans can lead to improvement in outcomes for people with a disability (Webber, Richardson, Lambrick & Fester, 2012)

Quality of behaviour support plans

Behaviour Support Plan-Quality Evaluation II (Browning Wright, Saren & Mayer, 2003) 12 components:

1. Behaviour/s of concern

2. Function/s of all behaviour/s of concern

3. Triggers the behaviour

4. Setting factors that support the behaviour/s

5. Environmental changes

6. Reactive strategies

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Quality components of BSP-QE II cont.

7.Replacement behaviour that meets the same function as behaviour

8. Strategies, tools or materials used to teach the replacement behaviour/s

9. Goals and Objectives

10. Reinforcement to use replacement behaviours

11. Team co-ordination

12. Communication & review

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Scores in 2010-11

0%10%20%30%40%50%60%70%80%90%

100%

0

1

2

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Research questions

1. Is quality of behaviour support plans associated with the number of restrictive interventions used?

▪ Preliminary evidence : Yes! (Webber, McVilly, Fester & Chan, 2011)

2. Do some components of quality have more impact on restrictive interventions than others?

▪ FBA could almost halve challenging behaviours (Carr et al., 2004)

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What is cut-off for reasonable quality?BSP-QE II:

• Total scores range 0-24

• Component scores range 0-2 (2 x 12=24)

• Reasonable quality appears to be at least total =13 points (>50%) for reducing the use of PRN restrictive interventions!

• Good quality plans (13+) associated with less restraint and seclusion use

• Poor quality plans (<13) associated with no change or more restraint and seclusion use

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Quality plans reduces the use of restrictive interventions

-30

-25

-20

-15

-10

-5

0

5

10

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Behaviour/s Predictors Analysis Team coord Environment Reactive Function/s Skills Goals

Quality Components

Dif

fere

nce i

n r

estr

icti

ve i

nte

rven

tio

ns

Poor Quality

High Quality

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Bottom line

PBS is:

• not only good evidence-based practice

• but also ethical practice in supporting people who show behaviours of concern

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Positive Intervention Framework

Proactive strategies

What to do to prevent the behaviour occurring

De-escalation strategies

What might help when the behaviours occur

Short-term change strategies for rapid change to behaviour

Change the environment

Teaching skills Evaluate safety of all

Try least restrictive interventions first: e.g., ask what the person wants

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Short term strategies: providing immediate support

Areas to think about for people who have complex high needs:

impact of trauma and attachment

importance of syndrome specific characteristics

medical conditions

mental illness

medications

knowing the person’s preferences and abilities.

human relations and sexuality

sensory impairments

communication

Functional Behavioural Assessment (FBA)

• Understanding the message underlying the person’s behaviour (McClean & Grey, 2007)

• Not based on opinion or intuition

• Requires careful observation

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Changing the environment

• What changes to the psycho-social and physical environment that would decrease the likelihood of the behaviour’s occurring?

• Anna and bus travel• Suzi and the doona cover• TJ and his name

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Replacement skills• Replace the need to use the behaviour of

concern

• To determine replacement skills need to know:▪ Function of behaviour because it must meet the function of the

behaviour▪ Example TJ—kicks staff to let them know he is unhappy about

something▪ Ask instead of kicking staff, TJ will be taught to…..

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Replacement skills

• Must be able to be learnt by the person

• Must be able to be taught by staff and used by all support staff and carers

• Must be reinforced/encouraged

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Teaching replacement skills

In considering replacement skills need to plan:• How will you teach it to the person?• How will you make sure everyone uses it?• How will you reinforce/encourage the use of it?• Time for a result (months rather than days)• What will be accepted as mastery of the skill?• Did you get it right?

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Monitoring and review

1. How will you know which positive behaviour supports are working?

2. Goals and objectives of the BSP for teaching skills:

1. Goal increase: What do you want to increase by when?▪ Replacement behaviour

2. Goal to decrease: What do you want to decrease by when? ▪ Behaviours of concern

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De-escalation strategies: Immediate response strategies

What to do when behaviour of concern occurs.

1. Assess safety of person and others, if safe:• Suggest the person use their replacement behaviour and support

them to use it.• Try to help the person resolve the issue.

• If not safe:• Reactive strategies (need to know what works for this person)• Least restrictive first• Leaving• Calling emergency services

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Debriefing

• When adverse incidents occur, everyone involved is debriefed as soon as possible

• Problem solving (learning opportunity) not punitive (Grafton services in USA view it as “treatment failure”)

• Need a good description of what happened

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Debriefing

• Immediate Debriefing: everyone is safe• Learning opportunity (individual)• Learning opportunity (employees)*

* Sanders, K. Marshall, L. & Sadeghzedah, S. (2012). Fostering quality of life and goal mastery for individuals with significant disabilities. Participant manual.

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Learning opportunity: Employees

• Purpose: Determine strategies to prevent similar incident

• When: within 48 hours• Participants: Employees and support team• Outcomes:

▪ Understand everyone’s perspectives▪ Develop a plan to avoid similar incident ▪ Offer “Employee Assistance Programs” if available▪ Updates any missing team members with revised strategies▪ Changes are made to BSP etc

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Learning opportunity: IndividualPurpose: understand individuals perspective

• Participants: Individual and employees that the individual wants to include

• Outcomes:

▪ Individual feels heard▪ Understands why the staff did what they did▪ Individual identifies triggers and alternative responses for future▪ Documented and followed up with support team

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Implementation of BSP

• The support team believes it will work (McClean & Grey, 2012) • The interventions are implemented by the team:

• Involve as many of support team that is possible• For casual or temp workers BSP must be easy to understand

WHY?

• Good quality behaviour support will result in:

▪ Decreases in use of restrictive interventions and behaviours of concern

▪ Increases in skills, competence, self-determination

Leading to:◦ Less restraint and seclusion◦ Achieving positive lifestyle change ◦ Increases in quality of life