Staff Training in Positive Behaviour Support: Impact on Attitudes and Knowledge

Building high-quality interpersonal staff-client relationships with people with severe to profound intellectual disabilities and challenging behavior: Insights of professionals and relatives

Background: Staff-client relationships impact the quality of support and life of people with severe to profound intellectual disabilities and challenging behavior, but are challenging to build due to clients' intense, complex and varying support needs. The present study explores the perspectives of professionals and relatives on what affects these interpersonal relationships. Method: 17 professionals and 11 relatives participated in focus groups and interviews. Data collection and analysis was performed in collaboration with a co-researcher. Data were synthesized thematically. Results: Interpersonal relationships constituted equivalence, striving for mutual understanding, trust and exploring clients' potential. The combination of staff characteristics (enthusiasm/passion, patience, resilience, creativity/humor, flexibility) and expertise (knowledge, vulnerability/sincerity, self-reflection) enabled staff to build these relationships. The importance of involving relatives was addressed. Contextual influences included the team (cooperation, flexibility, culture), organization (cooperation, boundary conditions) and setting (predictability, interior/atmosphere). Conclusions: The findings make practical knowledge explicit and scientifically underpinned for this specific population.

"It's Opened My Eyes to a Whole New World": Positive Behaviour Support Training for Staff and Family Members Supporting Residents With Dementia in Aged Care Settings

OBJECTIVES

This study examined the acceptability and usefulness of Positive Behaviour Support (PBS) training in enhancing the capabilities of support staff and family members providing behaviour support to residents with dementia in residential aged care (RAC).

METHODS

A mixed-methods pilot study was conducted across 3 RAC organisations, involving pre- and post-training questionnaire assessments for clinical leaders (n = 8), support staff (n = 37) and family members (n = 18).

RESULTS

Findings indicated increased confidence among support staff and family members in providing behaviour support, with 96% indicating it would support their practices across settings. Key training benefits included identifying and addressing underlying causes of challenging behaviours. A majority (89%) expressed the need for further behaviour support training.

CONCLUSION

Recommendations focus on developing systems to enable effective and collaborative behaviour support practices. Further research is needed to examine application of PBS principles and planning for residents living with dementia.

'Stakeholders are almost always resistant': Australian behaviour support practitioners' perceptions of the barriers and enablers to reducing restrictive practices

A restrictive practice (RP) is defined as a practice or intervention that has the effect of restricting the rights or freedom of movement of a person, and includes physical, mechanical, and chemical restraint, and seclusion. If misused or overused, RPs may present serious human rights infringements. In Australia, behaviour support practitioners who deliver behaviour support funded by the National Disability Insurance Scheme are responsible for developing positive behaviour support plans that aim to reduce and eliminate the use of RPs. At present, little is known about the barriers that behaviour support practitioners experience when attempting to reduce and eliminate the use of RPs and, conversely, what helps (or enables) them to reduce and eliminate RPs. To learn more, we conducted an online survey consisting of two open-ended questions with 109 Australian behaviour support practitioners to identify barriers and enablers. We found that fear and reluctance on the part of stakeholders were often barriers to reducing the use of RPs. However, we found that having time, funding, and resources for training, supervision, other implementation activities, care team collaboration, and data-based decision-making helped overcome barriers. We provide specific recommendations for addressing identified barriers for individual behaviour support practitioners, service provider organisations, and government and regulatory agencies.

Changes in Attitudes and Knowledge after Trainings in a Clinical Care Pathway for Autism Spectrum Disorder

Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.

A systematic review of training methods to increase staff's knowledge and implementation of positive behaviour support in residential and day settings for individuals with intellectual and developmental disabilities

Behaviour support plans (BSPs), if accurately implemented, have been found to increase skills and decrease challenging behaviour of individuals with intellectual and developmental disabilities. Training is essential for staff to acquire the skills necessary for accurate implementation. The aim of this systematic literature review was to evaluate procedures used to train staff in Positive Behaviour Support (PBS), on both knowledge of PBS and implementation of BSPs. Systematic searches of 4 databases identified 18 studies as meeting criteria. Findings indicate that description alone was not consistently effective in increasing knowledge and should be used in combination with other training strategies. Staff's implementation of BSPs were increased by different combinations of the following training components: description, feedback, modelling, role-play, monitory incentive, and escape contingency. To identify evidenced based practice when training staff on BSPs, it is necessary to evaluate active and feasible training components from current training models.

Health-promotion intervention in a group home: Perspectives of residents, staff and rehabilitation professionals

Promoting healthier lifestyles in people with intellectual disabilities is important in order to improve health and reduce health inequalities. Few studies have explored how health-promotion interventions for people with intellectual disabilities in community-based settings are experienced. The aim of this study was to explore residents', staff members' and rehabilitation professionals' experiences of how a health-promotion intervention affected the habits of people living in a group home regarding eating habits and physical activities and staffs' ways of working. Semi-structured group interviews were conducted with five residents, six staff members and five rehabilitation professionals. The group discussions were analysed with content analysis separately for each group. Four different categories described residents', staff members' and rehabilitation professionals' views respectively. It is suggested that including people with intellectual disabilities as active parties throughout the process would facilitate implementation of a health-promotion profile in community residences.

Exposure to challenging behaviours and burnout symptoms among care staff: the role of psychological resources

BACKGROUND

Staff supporting individuals with intellectual disabilities are at risk of burnout symptoms. Evidence suggests an association between exposure to challenging behaviours of individuals with intellectual disabilities and burnout symptoms of staff, but the protective role of staff psychological resources in this relation has been understudied.

METHOD

We investigated the association between exposure to challenging behaviours and burnout symptoms of staff and the direct and moderating effects of several psychological resources. Staff (N = 1271) completed an online survey concerning burnout symptoms (subscale Emotional Exhaustion of the Maslach Burnout Inventory), exposure to challenging behaviours and a range of potential psychological resources. We examined main and moderating effects with multilevel analyses. In order to control for the multiple comparisons, P values corrected for false discovery rate (PFDR ) were reported.

RESULTS

We found a direct relation between exposure to challenging behaviours and increased levels of burnout symptoms in staff (b = .15, t(670) = 4.466, PFDR  < .0001). Perceived supervisor social support (b = -.97, t(627) = -7.562, PFDR  < .0001), staff self-efficacy (b = -.23, t(673) = -3.583, PFDR  < .0001), resilience (b = -.19, t(668) = -2.086, PFDR  < .05) and extraversion (b = -.20, t(674) = -3.514, PFDR  < .05) were associated with reduced burnout symptoms. None of the proposed psychological resources moderated the association between exposure to challenging behaviours and burnout symptoms of staff.

CONCLUSIONS

Of the psychological resources found to be associated with reduced risk of burnout symptoms, staff self-efficacy and access of staff to supervisor social support seem to be the factors that can be influenced best. These factors thus may be of importance in reducing the risk of developing burnout symptoms and improving staff well-being, even though the current study was not designed to demonstrate causal relations between psychological resources and burnout symptoms.

Survey of Japanese Welfare Facility Staff and Special School Teachers Facing Difficulties at Work with Persons with Challenging Behaviors

BACKGROUND

Effective training programs for managing people with challenging behaviors should be established in both welfare and education settings, as it is important that the support system for challenging behaviors covers the entire life span. For consistent support, it is necessary to understand the difficulties and needs of support staff in caring for people with challenging behaviors from infancy through adulthood. The purpose of this study was to gather data from welfare facility staff and special school teachers regarding their difficulties and needs for managing challenging behaviors, and to determine the differences between teachers and staff members.

METHODS

We investigated Japanese special school teachers (n = 317) and the staff of welfare facilities for intellectual disabilities (n = 202) regarding their difficulties and needs. The questionnaire comprised 23 items related to the needs and difficulties in responding to challenging behaviors.

RESULTS

Three factors were extracted from the analysis of the survey items: "Difficulty in coordination and information sharing with other organizations," "Difficulty in the workplace," and "Difficulty in support and response." The overall trend was that welfare staff have more difficulties and needs than special school teachers.

CONCLUSION

It is necessary to emphasize not only how to respond to challenging behavior but also the importance of establishing a collaborative system within the workplace and with other organizations for staff training in light of their perceptions of working conditions.

Exploring how support workers understand their role in supporting adults with intellectual disabilities to access the Internet for intimate relationships

BACKGROUND

Some adults with intellectual disabilities need support to access the Internet. This study explores how support workers understand their role in facilitating Internet access for intimate relationships.

METHOD

Eight support workers in the West Midlands of the UK were interviewed face-to-face, using semi-structured interviews and a thematic analysis was used to interpret the data.

RESULTS

Three main themes emerged; social and organizational dilemmas (including sub-themes of; role and moral positioning, expectations of support, and protected and reflective space), power and position and policy dilemmas.

CONCLUSION

Support workers said that adults with intellectual disabilities should have access to the Internet for intimate relationships. There was a range of views on whether it was their job to support this. A lack of training in Internet use was highlighted.

Clinical outcomes of staff training in positive behaviour support to reduce challenging behaviour in adults with intellectual disability: cluster randomised controlled trial

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.

Relabelling behaviour. The effects of psycho-education on the perceived severity and causes of challenging behaviour in people with profound intellectual and multiple disabilities

BACKGROUND

Prevalence rates of challenging behaviour are high in children and adults with profound intellectual and multiple disabilities (PIMD). Moreover, many of these behaviours are observed daily. Direct support staff report that most challenging behaviour identified has little impact on the person with PIMD and attribute challenging behaviour in children and adults with PIMD mainly to a biomedical model. The purpose of this study was to evaluate whether an intervention (psycho-education) had any effect on direct support staff's assessment of challenging behaviour in terms of its severity and their biomedical causal explanations (attributions) for this behaviour.

METHOD

A stepped wedge study design was used to evaluate the effects of a psycho-education intervention on the perceived severity and the attributions offered for challenging behaviour of people with PIMD by 198 direct support staff. We used questionnaires assessing the perceived severity of challenging behaviour and staff views of its causes. Data on the dependent variables were collected at four 1-month intervals.

RESULTS

The intervention was found to have an effect on the perceived severity of challenging behaviour identified in people with PIMD in the sense that staff generally scored challenging behaviour as more severe in its consequences after the intervention. However, this effect was very small. No significant effects were found in terms of reduction in the biomedical scale scores.

CONCLUSION

No evidence for the effectiveness of a psycho-educational approach on the assessment of challenging behaviour in terms of severity and the biomedical attributions for behaviour was found. More research is required to explore further the effects of more elaborate training using methods to enable direct support staff to reflect on the behaviour of people with PIMD and on their own behaviour.

Staff attributions of the causes of challenging behaviour in children and adults with profound intellectual and multiple disabilities

A study has shown that staff do not generally perceive challenging behaviour in people with profound intellectual and multiple disabilities (PIMD) as being of serious consequence. In this study we aimed to gain a better understanding of the causal explanations that direct care and support staff give for challenging behaviour in this group. The purpose of this study was twofold: (1) to determine the way staff attribute challenging behaviour in children and adults with PIMD; and (2) to analyse whether more experienced staff attribute challenging behaviour in children and adults with PIMD differently than less experienced staff. In total, 195 direct support staff and an equal number of children and adults with PIMD participated in the study. Direct support staff filled out the Challenging behaviour Attribution Scale (five causal explanatory models of challenging behaviour) to explain challenging behaviour in one individual that they supported. The results show that direct support staff as a whole report the biomedical model as the most plausible explanation for challenging behaviour in children and adults with PIMD. However, in the present study the mean scores on all models are low. This might indicate that a large number of staff found none of the models particularly useful as possible explanations of challenging behaviour in people with PIMD. This could mean that staff have difficulties stating the cause of challenging behaviour in this group. Another possible explanation could be that there is little scientific knowledge about causing and maintaining factors of challenging behaviour in people with PIMD. It could also mean that staff have additional explanations for challenging behaviour in this target group that are not mentioned in the instrument used. Future research should address these issues. No differences were found between more experienced and less experienced direct support staff.

Interventions aimed at increasing knowledge and improving attitudes towards people with intellectual disabilities among lay people

Despite policies aimed at ensuring equal rights and maximising respect and social inclusion for people with intellectual disabilities, in their daily lives many continue to face negative attitudes and discrimination within society. Misconceptions about what it means to have an intellectual disability and about the capabilities of people with intellectual disabilities appear widespread, and may contribute to prejudice and discrimination. This review provides a summary and evaluation of empirical interventions aimed at increasing knowledge and targeting negative attitudes towards this population among lay people of working age. An electronic search using PsycINFO, Web of Science and PubMed identified 22 English language studies published between 1990 and early 2014 that reported a specific intervention with a lay population sample. The majority of studies reported promising outcomes, particularly those aimed at increasing knowledge of intellectual disability through education. Support for the positive influence of contact with people with intellectual disabilities was demonstrated across several interventions. Interventions delivered at least partly by individuals with intellectual disabilities, and educational interventions appear to hold the most promise. The evidence is limited though by the weaknesses of measurement tools employed.

Clinical and cost effectiveness of staff training in Positive Behaviour Support (PBS) for treating challenging behaviour in adults with intellectual disability: a cluster randomised controlled trial

BACKGROUND

Many people with intellectual disability present with challenging behaviour which often has serious consequences such as the prescription of long term medication, in-patient admissions and disruption of normal daily activities. Small scale studies of Positive Behaviour Support (PBS) delivered by paid carers suggest that it reduces challenging behaviour and costs of care and improves quality of life. This study aims to investigate whether professionals training in the delivery of PBS as part of routine practice is clinically and cost effective compared to treatment as usual in community intellectual disability services.

METHOD

The study is a multi-centre cluster randomised controlled trial involving community intellectual disability services in England and service users with mild to severe intellectual disability and challenging behaviour. The teams will be randomly allocated into one of two conditions, either training and support to deliver PBS or treatment as usual. We will carry out assessments of challenging behaviour, use of services, quality of life, mental health, and family and paid carer burden at six and 12 months. We will monitor treatment fidelity and we will interview a sample of paid and family carers, service users, staff and managers about what they think of the treatment and how best we can deliver it in routine care. The main outcome is reduction in challenging behaviour at one year after randomisation. We will also carry out a health economic evaluation to examine the costs and consequences of staff training in PBS.

DISCUSSION

The study findings will have significant implications for the delivery of PBS in community based services with the potential for reducing inpatient admissions and out-of-area placements for adults with intellectual disability and challenging behaviour.

TRIAL REGISTRATION

This trial is registered with Clinical Trials.gov (Ref NCT01680276 ). Clinical Trials Unit: PRIMENT https://www.ucl.ac.uk/priment/ .

Who's challenging who? Changing attitudes towards those whose behaviour challenges

BACKGROUND

Although staff attitudes towards individuals with intellectual disability (ID) whose behaviour challenges may be an important part of a positive support culture, very little research has focused on the development of training specifically designed to change staff attitudes. Positive contact is hypothesised to be an effective way to change attitudes towards stigmatised groups.

METHODS

We designed and developed a half day training package about the experiences of individuals whose behaviour challenges - Who's Challenging Who (WCW). The WCW package was delivered according to a manual by a trainer with ID and a professional without disability. Seventy-six staff from a variety of organisations participated in one of 10 WCW training sessions and provided data on their attitudes and empathy towards individuals whose behaviour challenges prior to the WCW training and immediately at the end of training. Staff also completed a post-training evaluation questionnaire.

RESULTS

A training package was successfully developed collaboratively with individuals whose behaviour challenges, and received very positive evaluations from staff participants. Short-term positive change was shown for empowerment and similarity attitudes, and staff empathy and self-efficacy. These outcomes were associated with small to moderate effect sizes.

CONCLUSIONS

Meaningful short-term positive staff attitude changes were found and the WCW training model was shown to be feasible. More robust research designs are needed for future evaluation. In addition, the function of an attitude change intervention such as WCW within organisations' training strategies requires further development.

The impact of staff and service user gender on staff responses towards adults with intellectual disabilities who display aggressive behaviour

BACKGROUND

The impact of staff and service user gender on responses of staff in intellectual disability (ID) services is poorly understood. The present study set out to assess the role of gender in influencing staff emotions, attributions and behavioural intentions in response to aggression displayed by adults with ID.

METHOD

A new scale measuring staff behavioural intentions was developed. A two × two (staff gender × service user gender) between subjects design was used to compare the responses of day and residential support staff to physical aggression by a hypothetical service user. In response to a vignette depicting a service user with ID assaulting a member of staff, 160 respondents completed measures of affective responses, causal attributions and behavioural intentions while imagining themselves as the target of the service user's assault.

RESULTS

Female participants reported feeling more fear/anxiety, more depression/anger and less confident/relaxed than male participants. The longer staff had worked with people with ID, the more likely they were to favour safety-focused behaviours. More confident female participants were less likely to favour safety-focused behaviours, but confidence had no effect on male participants' endorsement of these behaviours. Increased confidence in both was associated with lower agreement of safety-focused behaviours in relation to the female vignette, regardless of participant gender. The more control women believed the service user had over their behaviour, the more likely they were to choose safety-focused behaviours. Punitive behaviours were favoured more in response to the male rather than the female service user. Punitive behaviours were also favoured more by more junior staff and by participants who expected feeling more depressed/angry in response to the vignettes.

CONCLUSIONS

Both staff and service user gender influenced staff responses to aggression, yet the latter played a smaller role than expected. The role of gender in staff-service user interactions should be the focus of further research and should be considered in service delivery.

Towards the prevention of behavioural and psychiatric disorders in people with intellectual disabilities

Intervention for behavioural and psychiatric disorders in people with intellectual disabilities often only takes place once these conditions are well established and more resistant to change. As an alternative, this paper promotes a public health prevention model and maps out opportunities for intervention at primary, secondary and tertiary levels. The resulting model is partly derived from generic research into these issues and partly on specific evidence on interventions for people with intellectual disabilities; it also contains more theoretical considerations. The additional research that is necessary to demonstrate the efficacy of the interventions identified is also considered. Central to this proposal is a greater integration of issues for people with intellectual disabilities within much broader policy and research agendas.

Coping with challenging behaviours of children with autism: effectiveness of brief training workshop for frontline staff in special education settings

BACKGROUND

The present study examined the effectiveness of three staff training elements: psychoeducation (PE) on autism, introduction of functional behavioural analysis (FBA) and emotional management (EM), on the reaction of challenging behaviours for frontline staff towards children with autism in Hong Kong special education settings.

METHODS

A sample of 311 frontline staff in educational settings was recruited to one of the three conditions: control, PE-FBA and PE-FBA-EM groups. A total of 175 participants completed all three sets of questionnaires during pre-training, immediate post-training and 1-month follow-up.

RESULTS

Findings showed that the one-session staff training workshop increased staff knowledge of autism and perceived efficacy but decrease helping behavioural intention.

CONCLUSIONS

In spite of the limited effectiveness of a one-session staff training workshop, continued staff training is still necessary for the improvement of service quality. Further exploration on how to change emotion response of staff is important.

Workforce development and challenging behaviour: training staff to treat, to manage or to cope?

Staff working directly with adults' challenging behaviours in learning disability services need to be very good at what they do. They also need to want to do the job. A theory-practice gap exists, however, between what is known about effective, evidence-based approaches and whether and how these are used in person-centred community services. Many frontline staff working with people with the most serious challenging behaviours do not have the skills to implement programmes to change behaviour. This discussion article reviews workforce development in the context of clinical and service guidelines and asks whether the legitimate purview of frontline staff is treating challenging behaviour, managing it or simply coping with it on a daily basis, whilst maintaining the best quality of life possible for service users.

Interactive training for active support: perspectives from staff

BACKGROUND

In this study, we describe the experience of participating in interactive training (IT) for active support (AS). Staff (N = 58) working with adults with an intellectual disability (ID) received IT on providing effective assistance for participation in daily activities.

METHOD

Semi-structured interviews were conducted with staff (N = 37) on their experience of IT, the way it affected their work, and their views on the implementation of AS.

RESULTS

High levels of satisfaction with IT were reported. Most staff identified at least one skill learnt during IT that they were still using 8 months later. No clear and consistent picture of AS implementation emerged across the service; staff identified a number of barriers, with lack of managerial support as the most significant.

CONCLUSIONS

Interactive training can directly affect staff behaviour and has the advantage of being positively perceived by staff. However IT alone cannot ensure successful AS implementation, which is affected by a number of other factors, such as managerial support and input, residents' challenging behaviours, and staffing levels.