by Ms Judy Ryan, Nursing Development Officer, Tullamore, Co. Offaly,


The ongoing development and support of people with an intellectual disability who present with behaviours that challenge within the intellectual disability nursing services in Ireland is improving. Nursing is a practice discipline and, hence, the attainment of higher level competencies is integral to the achievement and delivery of good standards of care. These competencies may be achieved through participation in further education at Higher Diploma level. An Bord Altranais (2000, p.10) suggests that competence is ‘developmental’ and ‘not static’, thereby alluding to the notion of competency as a continuum, which allows the practitioner to develop specialist knowledge and skills throughout their career. The Higher Diploma in Behaviours that Challenge, delivered by the Department of Nursing and Health Sciences, Athlone Institute of Technology, is in its third year.

Nurses who have completed the programme are now putting into practice the skills and competencies that they have acquired. The continuation and development of the programme will provide the evidence to underpin a model in behaviours that challenge for specific individuals. This will assist nurses in their role when supporting people with an intellectual disability who present with behaviours that challenge.


Behaviours that challenge are described as ‘behaviour of such intensity, frequency and duration that it threatens the quality of life and/or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion’ (Royal College of Psychiatrists 2007, p14). The influence of staff behaviour in the maintenance of behaviours that challenge and the need for staff training in behaviour support skills is widely recognised in the literature (Bamford Review 2006; Hastings and Remington 1994; Cullen 1992).

The HIQA (2009) National Quality Standards for Residential Services for People with Disabilities recommends that all staff supporting people with disabilities should have awareness and a qualification in behaviours that challenge. Nurses working in the intellectual disability services in the HSE Midlands and HSE West led the drive for the development of a higher education programme that focused on supporting people with an intellectual disability who present with behaviours that challenge.

Collaboration between Nurse and Midwifery Planning and Development in the HSE Midlands, HSE West and AIT led to the development of a level 8 An Bord Altranais Category II Higher Diploma in Behaviours that Challenge. The aim of the programme is to provide frontline staff with the practical and applied skills to support individuals within their organisations who present with behaviours that challenge. This is achieved through the use of a comprehensive holistic approach to positive behaviour support, in line with contemporary research and best practice, reflective of the evidence. The assessment and evaluation process ensures that students’ work is of the highest ethical and procedural quality.

This programme, now in its third year, took in its first cohort of 19 students in September 2009. Students on the current programme are working in services throughout Ireland and this offers the participants an opportunity to develop links with colleagues nationally.


In the UK Shaping the future: A vision for learning disability nursing (2006) recognised that there is a growing evidence of a very high incidence of unmet health needs in the population of people with learning disabilities and this has a negative effect upon many people’s quality of life. Gates (2006) commented that it is vital that intellectual disability nurses are leaders in avoiding social exclusion and that they work to ensure that service users’ overall needs are addressed sufficiently. The influence of staff behaviour on the maintenance and frequency of behaviours that challenges has become an important emergent issue in the last decade (Hastings and Remington 1994). The most recent document, Linking service and safety has highlighted within their educational remit that ‘education and training in the management of work-related aggression and violence be provided to all healthcare personnel’ (2008 p13).

The authors of this report have placed emphasis on the need for service specific education that is fit for purpose. The Higher Diploma in Behaviours that Challenge provides students with a clear pathway to achieve the posts of Clinical Nurse Specialist and Advanced Nurse Practitioners in behaviours that challenge, in line with national standards. The area of management of behaviour that challenges has been under-researched and often inadequately addressed (Braine 2005). This current programme, run over the academic year, offers students the opportunity to share experience, pool knowledge and examine professional and organisational boundaries. This facilitates the development of specialist knowledge and skills to meet the requirements for holistic support for people with intellectual disabilities.

Preliminary evaluations of the programme

Continuing education is a lifelong learning process. This programme consists of planned learning experiences which are designed to augment the knowledge, skills and attitudes of registered nurses, thereby enhancing nursing practice, education, administration and research (ABA 1989). It is essential that we continue to develop initiatives that enhance the support and understanding that people with an intellectual disability receive in the clinical environment within the domain of behaviours that challenge.

Successful completion of the programme provides nurses with the requisite knowledge and competence to function more effectively within a holistic interdisciplinary environment.

An important consideration is that on completion of the programme the student has the necessary skills to effect real change within the workplace. In order to capture information on the views, opinions and considered appraisal of the programme from all of the relevant stakeholders, a questionnaire was sent to each of the clinical site managers and students. Students have commented that the mix of expertise in teaching makes the programme worthy, interesting, legitimate and contributes to the wider exploration of the value of a multidisciplinary approach in supporting people with an intellectual disability who present with behaviours that challenge.

Some of the students and their managers’ responses are outlined as follows:

Question: How has the student added value from a professional perspective to the work of staff in your area of responsibility?
Manager’s response: ‘After attending the course the student was able to adopt positive strategies when behaviours that challenge presented and was able to direct other staff members on how to manage a crisis situation.’

Question: Did the course meet with your expectations?
Students’ response: ‘This course has helped me view and deal with challenging behaviour from a different perspective and I am using more positive evidenced-based approaches to overcome these challenges.’ ‘The course lived up to my expectations and beyond.’ ‘I gained a wealth of knowledge and insight.’


The considerable growth in specialisation within nursing is reflected nationally in the range of programmes that are available to nurses. Successful completion of this programme in AIT provides nurses with the requisite knowledge and competence to function more effectively when supporting individuals with an intellectual disability who present with behaviours that challenge. The programme reflects the national agenda ensuring that all staff should have awareness and a qualification in behaviours that challenge (HIQA 2009; Linking Services to Safety 2008). The programme content engages constantly with professional and organisational boundaries. By doing so, it facilitates the development of the specialised requisite knowledge and skills that are required to ensure that the current and future needs of this vulnerable group of people are adequately met.

Further information is available from:
Dr Mary McDonnell/Naughton, Department of Nursing and Health Science, Athlone Institute of Technology, HSE. Email: mmcdonnell@ait.iee


  1. How do I enrol on a course that addresses behaviours of concern in children and adults with intellectual disabilities. I am a staff nurse working in this area with the HSE.

    Thank you



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