Who is Providing Positive Behaviour Support?

Gillian Martin of Callan Institute details a recent audit of Irish Behaviour Practitioners.

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  • Positive Behaviour Support (PBS) is recognised as best practice for people who experience behaviours of concern in Intellectual Disability Services.
  • However, there is no formally recognised career pathway for behaviour practitioners in Ireland.
  • This study reviewed Behaviour Practitioners in Ireland to see
    • who is currently delivering PBS,
    • how they are doing so,
    • how they are fitting into service structure and
    • what supports they need to deliver PBS effectively.

Introduction

With the implementation of the HIQA standards and the Health Act (2007), the provision of Positive Behaviour Support (PBS) in Ireland is an area of intense focus for ID services. It is becoming recognised as its own unique area of speciality using PBS as its approach (Kincaid et al, 2015; Gore et al, 2013). Traditionally, the science of behaviour change has been embedded within a number of professions and covered as a speciality in a variety of graduate programmes including psychology, nursing, education and social care. As a result, behaviour practitioners working today come from a wide range of backgrounds. There are currently no minimum standards set for the provision of behavioural services, or for the employment of behaviour practitioners, so job descriptions for the same post can vary widely from organisation to organisation.

 

This range brings a great richness and diversity to the table, but can result in a very disparate group of professionals that can sometimes lack clarity in their role. Behaviour practitioners may have very different skill sets and very different expectations of what they are required to do. Similarly, the organisations employing them may be unsure of how best to support them. This can make behaviour practitioners vulnerable to cuts, redeployment, or an inefficient use of their skills.

 

Callan Institute have had the opportunity to link in with a number of Behaviour Practitioners across the country. It has also been involved in training staff in Positive Behaviour Support using the model of Multi-Element Behaviour Support (Donnellan et al, 1988) for in excess of 20 years at a variety of levels, from introductory courses to Masters Modules.

 

There is a huge variance in the training people have received in Ireland regarding Positive Behaviour Support, and there is no guidance in terms of what constitutes a sufficient level of training to practice. In order to try to assess the situation in Ireland, Callan Institute conducted an audit that focused on three areas:

  1. Skills: Who are the behaviour practitioners? What skill sets do they have and how are these skills being utilised?
  2. Service Delivery: Where do practitioners fit into organisational structures? Are they adequately supported to work effectively?
  3. Professional Supports: Where do practitioners feel they need more support to deliver an effective and professional service?

 

Callan Institute conducted an internet survey using a snowball sampling technique to ask these questions. Ninety-eight people responded who fulfilled the inclusion criteria.

 

Who is the ‘average’ Behaviour Practitioner?

Basic demographic information was requested from participants to find out who they were and where they were working. What emerged was that the average behaviour practitioner is likely to be female (74%) and may be a psychologist (47%) or have been trained specifically in applied behaviour analysis (23%). She may be more likely to support children (71%), with just under half of practitioners supporting adults (40%). She may be employed in a school (55%), in the client’s home (38%), in community based residential services (37%) or in a community-based day programme (32%).

 

In terms of the professional affiliation of behaviour practitioners, we asked if they were registered with any professional bodies. Thirty-eight percent reported that they were members of the Psychological Society of Ireland, with many aligning themselves with the Behaviour Analyst Certification Board (20%), An Bord Altranais (now NMBI) (18%), or Teachers’ Unions (6%). A concerning 27% were not registered with a professional body at all.  This raises concerns, as we need to ask who these practitioners feel supported by and accountable to in a professional capacity. It also opens up the question of what ethical standards they operate within, both to protect themselves and their clients.

 

Figure 1: % of respondents registered with professional bodies


What does the Behaviour Practitioner do?

We asked respondents to look at their workload over the last 12 months and estimate the duties and tasks they had completed in that timeframe. The average behaviour practitioner conducts an average of 12 full assessments in any one year, alongside 38 additional consultations, usually with staff teams. Although practitioners prioritised conducting behaviour assessments as the most important aspect of their job, in reality they allocated more time to consulting with staff teams and working directly with clients implementing plans. This raises the question of whether their skills are being used effectively in a planned way, or if instead, behaviour support services are provided in a more ad-hoc manner? It seems that practitioners tend to provide short bursts of consultation at the expense of conducting comprehensive assessments, or sometimes find themselves implementing programmes rather than building up the local team’s capacity to do so.

 

Where does the Behaviour Practitioner Fit In to the Organisation?

This study looked at where behaviour practitioners fit into the overall organisational structure. This can indicate how effectively positive behaviour support is integrated into the overall organisational system of service delivery. Only 50% of the respondents answered this question. Of those who did respond, 25% came under a psychology department. Others had dedicated applied behaviour analysis (20%) or behaviour support (15%) departments in place. Fourteen percent were accountable to a multi-disciplinary team, whilst the same number fell under an education department. Four percent identified themselves as working alone (See Figure 2).

 

Figure 2: Where do Behaviour Practitioners fit into the overall model of Service Delivery?

 

Possibly of more interest is the other 50%, who felt unable to clearly and confidently state to which department they belonged. This may possibly indicate that some practitioners are ‘falling between the cracks’, professionally speaking. This idea is supported when we look at who is providing supervision to these practitioners. Most practitioners (88%) said that they responded directly to a line supervisor. However, only 58% responded to a clinical supervisor and so may not be operating within an appropriate system of clinical governance. Of these clinical supervisors, 72% had behaviour-specific training. Putting these results together, it seems that less than half of practitioners are receiving behaviour-specific supervision, which could leave them vulnerable in terms of clinical governance. More crucially, it may leave the clients they are supporting vulnerable, as practitioners may be operating without the benefit of the most up-to-date information, and without adequate evaluation and feedback on their work.

 

Where do Behaviour Practitioners get support?

So if a lot of practitioners are not receiving behaviour-specific supervision and support in their workplace, where do they turn? Sixty-two percent of the respondents reported managing to obtain support elsewhere. Nearly 60% of these relied heavily on a colleague in the same position, whilst 36% were able to access some other form of peer supervision. Nearly a quarter of those obtaining support elsewhere sought supervision from an external senior clinician, and nearly 20% found support by way of web-based forums.

 

Where do Behaviour Practitioners Feel they want more training?

Many of the respondents reported that they wanted to undertake further training in behaviour. The majority were seeking to undertake courses such as a doctorate in clinical psychology, or university-accredited applied behaviour analysis and cognitive behaviour therapy programmes. A lot of respondents were interested in training that was focused, that emphasised content and skills acquisition over academic recognition. Examples of these included

  • Sexuality
  • Education
  • Autism
  • Picture exchange
  • Communication systems
  • Feeding programmes
  • Play therapy.

 

Beyond training, practitioners highlighted that they had other needs in order to fulfil their roles professionally. Top of the list was wanting to have more colleagues with behaviour training, and accessing supervision, mentor and peer support. Along with this, they highlighted the need for better and clearer integration with the multi-disciplinary teams. They also sought improved links with other professionals, and a greater recognition of their specific expertise and skills.

 

What can be done to support Behaviour Practitioners?

Positive Behaviour Support services have a long way to go. Teams are well developed in some areas, but for many, positive behaviour support as a stand-alone discipline is still in its infancy. Although this is desirable in terms of Positive Behaviour Support being recognised as a speciality in itself, it does mean that it can be difficult for it to gain traction in services. In time, more structures and standards are likely to be developed nationally and also locally within organisations as they develop more effective teams and structures. There needs to be an awareness that a lot of practitioners are currently working hard to conduct themselves professionally whilst working outside of a recognised professional path, without adequate supervision or professional support. They need to be supported by their employers in seeking, establishing and maintaining this professional development in order to provide the best support to the clients referred to them.

 

In the absence of established structures, there are two avenues to best protect the professional wellbeing of practitioners in the short term.

 

1) The first is to seek appropriate external supervision if it is not already available in-house, or to make it more available to practitioners if it is. This means that practitioners are much more likely to be working effectively to best practice standards and within an established ethical framework.

 

2) Secondly, the most easily accessible form of support is peer support. From a small survey of members of a peer support forum that Callan Institute run, a number of benefits to peer support have been identified, including

  • The opportunity to network, keeping up to date with developments,
  • Problem solving,
  • Sharing effective ways of working,
  • Information sharing,
  • Obtaining emotional support, as often they may be working as the only behaviour practitioners within their organisation dealing with highly emotive issues, such as instances of abuse or self-injury.

 

However, the current pressures on organisations means that getting the time and opportunities to go off-site and meet face-to-face at these sort of forums can be difficult, so practitioners are increasingly turning to the internet for support. As a result, a number of online communities are springing up, with up-to-date information, debate and chat forums, allowing practitioners to share their expertise and materials, and ask questions. This can provide an informal but very valuable network for practitioners to feel part of a larger professional community.

 

An example of how the information from this audit can feed into practice, is to take a tiered approach to the provision of Positive Behaviour Supports. In this instance, everybody is responsible for the provision of support, but at the level appropriate to their skills, experience and professional training. For example, staff, families and communities at large can all play a part in developing a culture of Positive Behaviour Support in which it can flourish. More experienced practitioners with some level of training, but perhaps without a professional qualification, may be well placed to provide support to teams by way of advice and troubleshooting; whilst professionally accredited, highly experienced practitioners may be in a position to focus on the more complex cases and provide oversight and clinical governance for others.

 

Those working in Behaviour Support are part of a relatively new field in a state of rapid development. The HIQA reports currently being published are consistently highlighting that Positive Behaviour Support is a high priority in organisations, and an area in which much investment is required. By exploring the rich diversity we already have in the field, we can see where we are starting from, the richness of the existing resources, and identify what may be needed to develop more unified, effective, professional services for the people that we support.

 

References:

Donnellan, A; LaVigna, GW; Negri-Shoultz, N. & Fassbender, LL. (1988) Progress Without Punishment. Teachers College, Columbia University, New York.

Gore, N; & McGill, P; Toogood, S; Allen, D; Hughes, JC; Baker, P; Hastings, R; Noone, S. & Denne, L. (2013). Definition and scope for positive behaviour support. International Journal of Positive Behavioural Support. 3.

Kincaid, D; Dunlap, G; Kern, L; Lane, KL; Bambara, LM; Brown, F; Fox, L. & Knoster, TP (2015) Positive Behavior Support: A Proposal for Updating and Refining the Definition. Journal of Positive Behavior Interventions 18(2) pp. 1-5.

The Health Act 2007 (Care and Support of Residents in Designated Centres for Persons (Children and Adults). Department of Health, Ireland. Available from www.irishstatutebook.ie/eli/2007/act/23/enacted/en/pdf Accessed on 15th Feb 2018.

Health Information and Quality Authority (2013) National Standards for Residential Services for Children and Adults with Disabilities. Available from https://www.hiqa.ie/sites/default/files/2017-02/Standards-Disabilities-Children-Adults.pdf. Accessed on 15th Feb 2018.

Gillian MartinGillian Martin is a Chartered Psychologist and Board Certified Behaviour Analyst working with the Callan Institute, Saint John of God Community Services, Clg.

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