improving the quality of behaviour support plans to decrease restrictive interventions and increase...
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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
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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)
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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
15
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
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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
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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
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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