Leading change

A Nurse Consultant at PBS4, (a non-profit social enterprise) developed a support model which aims to reduce behaviours that challenge, by supporting improvements in quality of life. The programme has raised awareness of positive behavioural support locally which is enhancing outcomes and experiences.

Where to look

The Winterbourne View Hospital Review (Department of Health, 2015) specifically focused on two things:

• Individual failings, that occurred at multiple levels, which resulted in the culture of abuse at Winterbourne View going undetected for so long by the authorities;
• The wider issue of whether the care system, in all parts of the country, is providing effective and appropriate treatment for people with learning disabilities and autism.

Skills for Care explain that behaviours which challenge always happen for a reason and might be the only way a person can communicate – it can arise for different reasons which are personal to the individual. People who display or are at risk of displaying behaviours which challenge might need care and support which involves both positive support, such as Positive Behavioural Support (PBS) and some form of restrictive practice or intervention, such as physical restraint or use of devices, medication or seclusion. Any restrictive intervention must be legally and ethically justified, to prevent serious harm and be the least restrictive option. They highlight the importance that staff working with patients who may exhibit behaviours that challenge have the right skills and knowledge to support these individuals effectively and safely to reduce the need for restrictions to maximise their independence.

PBS4 provide skilled social care for people with learning disabilities and challenging behaviour. Positive Behaviour Support is a clinical intervention that is underpinned by Applied Behaviour Analysis. The Nurse Consultant at PBS4 examined the national picture in training and competencies in Positive Behaviour Support, identifying unwarranted variation in practice. They saw this as an opportunity to address this internally as well as across the local area with other providers.

What to change

Relevant literature was reviewed, as well as a survey of PBS conducted with 329 practitioners. Survey results demonstrated that 100% felt their role met the provided definition of behaviour practitioners. However, there was unwarranted variation in this being regulated. Only 41% were regulated by a professional body, with 61% receiving regular supervision. Further, training levels appeared to vary.

In practice, the nursing leads observed that staff were not routinely demonstrating the key, evidence based principles of Positive Behavioural Support. At times, this had been misinterpreted and was simply based on a ‘positive manner’ and being nice to people.

How to change

The Nurse Consultant and the team developed a Positive Behaviour Support model, underpinned by an evidence based intervention for reducing challenging behaviours by making improvements to quality of life. The model focuses on positive behavioural support as a functional assessment, supporting staff to consider the reasons for the behaviour as a starting point. Practitioners are supported to understand what a behaviour is about and listen. This can develop positive behaviours with the individual, rather than just stopping behaviours that aren’t deemed helpful. Together this can positively impact quality of life.

The Nurse Consultant visited areas where PBS networks had been developed to share learning and drive forward good practice. With this knowledge and understanding, with the support of the Transforming Care Partnerships, the leads established a regional PBS network. This network supports individuals, their families, and providers to talk about PBS and take steps to improve service provision and learning. Guest speakers are invited to attend the meetings to talk about PBS related content as well as to promote awareness of contemporary issues in Positive Behaviour Support Practice. Led by the local providers and with the support of local commissioners, partnerships have been forged and collaborative working is becoming the norm.

The partnership and co-production in this project means that people with learning disabilities and their families have been active members in the network and instrumental in setting the direction for the network as it has evolved. The network is an environment where skills and knowledge are shared openly, and everyone is supporting each other.

Due to the success of the network, the team are involved in supporting the PBS Academy to develop PBS Core Competencies and are working with other PBS networks to support larger scale change and shared learning.

Adding value

Better outcomes – In the first 18 months, there have been 6 network meetings, with attendance between 10 – 30 at each session. At each session, there has been a PBS relevant educational session, as well as an opportunity to cascade national updates on work and research in this field. Each organisation in the network is now developing local action plans to address skill gaps, education and training needs and support for PBS as part of local quality improvement initiatives. The project has supported those attending (and their organisations) to develop a better understanding of why people might be displaying behaviours that they find challenging. By looking at behaviour differently, staff are approaching it differently which is leading to better outcomes for the people they support. It is also positively influencing job satisfaction.

Better experience – The model is raising awareness of PBS locally. The development of supportive networks has encouraged and supported collaboration across providers, people the services support, their families, NHS services, CCGs and Local Authorities. Families have welcomed the opportunity for engagement and feel empowered to enhance the quality of support locally. Staff have embraced the PBS model and the network. The team continue to support members across the network to attend further training to obtain formal PBS qualifications. Internally, a ‘PBS Champion’ training programme has been established which has led to support workers developing advanced skills. A survey of network attendees will be conducted to seek feedback on experiences and to establish ongoing priorities and areas for development.

Better use of resources – It is anticipated that embedding this PBS model in practice will have a positive impact on care for individuals, including improving their therapeutic relationship with staff. Anecdotally, those behaviours that could be challenging have reduced. Behaviours are now better understood and supported. This is resulting in a shift towards more time for staff to spend with individuals who are happier in their environment. The network is also anticipated to reduce duplication following the more collaborative approach to care provision.

Challenges and lessons learnt for implementation

It has been challenging to maintain good attendance at the network meetings and seeking commitment from attendees to undertake pieces of work to drive forward this project, as people are busy in their day-to-day role.

Identifying synergies with the Local Authorities’ and Clinical Commissioning Groups’ programmes of work and working together is important.

The nursing leads have also established a regional position statement on PBS as well as mapping out what training is available nationally and locally.

Find out more

For more information contact:

• Jonathan Beebee, Nurse Consultant, PBS4, Jonathan.beebee@pbs4.org.uk