Leading Practice Guidelines

Positive Behaviour Support

Type: Wellbeing

Guideline: The organization provides behavioural support to people served by the organization that promotes a positive approach. While a Behaviour Support Plan (BSP) may be required, medical, psychiatric, or environmental causes for the behaviour must be ruled out first.

The organization has clear, transparent and respectful practices of supporting people whose behaviour creates difficulties for them and others.

The organization uses an approach that integrates the following elements:

• Principles of normalization
• Social validity (or acceptable to the person the approach is used with)
• Protection of rights
• Principle of least intrusive first
• Commitment to positive behaviour support

What does this look like?

The organization has a policy on the provision of behavioural support to people served that promotes positive behaviour supports and details how interventions are implemented. This policy would include:

• A description of positive behaviour support that is provided by the organization
• The values, strategies and activities that are undertaken to support those whose behaviour creates difficulties for them.
• Positive behaviour support emphasizes the acquisition and maintenance of positive skills (e.g. building healthy relationships) to increase the person’s quality of life–understanding that a natural reduction in other less positive behaviours will follow.
• Specifically, behaviour support identifies skills and capacities that contribute to a person’s ability to experience success and satisfaction in a range of settings.
• Support includes all efforts to teach, strengthen, and expand positive behaviours. The focus of support is primarily on assisting and guiding the person toward opportunities to pursue the goals that genuinely represent what is most important to him/her.
• An important, but secondary consideration is to understand, anticipate, and prevent problem behaviours that have general and specific outcomes or functions for the person. The usual function of problem behaviour becomes less useful when people are supported effectively and when those responsible for support are given sufficient information and guidance.
• Problem behaviour may be reduced or eliminated when a person is assisted to achieve desired goals in socially desirable ways. Effective support considers changes to the environments, relationships, and activities available to a person rather than exclusively targeting problem behaviour.
• The plan will focus on changing the person’s environment, or it will seek to teach him/her new communication or coping skills, or it will try to give him/her more control over some aspect of his/her life, in the expectation that this kind of quality of life improvement will reduce his/her level of anxiety or frustration and thus reduce the frequency or intensity of the behaviour.

Where a person experiences repeated difficulty in managing their behaviour, a functional behavioural assessment is carried out by a suitably qualified professional in order to draw up a BSP to provide additional support in consultation with the person and support network.

• A BSP is a proactive plan that assists individuals to develop new skills and behaviours to replace challenging behaviours and assist individuals in accomplishing what they want to do.
• The plan must describe and define the target behaviour that the person wants to reduce or eliminate, and the strategies or activities that will be used to bring that about. This in turn will involve an outline of the desirable behaviours that will hopefully replace the undesirable ones, and the strategies for establishing or increasing these desirable behaviours.
• Behaviours that cause, or have the potential to cause injury to self or others are the priorities for the development of alternative behaviours. The plan must be sufficiently detailed that staff and the persons support network will, by reading it, understand the interventions and be able to implement them.
• While a professional behavioural consultant may be involved in developing the plan, it needs be a collaborative plan that also includes the person, their family, staff and support network.

Discussions about behaviour support are conducted in a manner that honour and respect people’s privacy and dignity and thus share details only with those whom need to know.

During implementation of the plan, high risk or unsafe behaviours may occur, thus a Safety Plan may be required. This Safety plan addresses how to de-escalate the dangerous behaviours while reducing risk of harm to the person and those around him. The plan may need to include an intrusive practice, so safeguards around its approval and review must be built in, and it can never stand alone as a means of controlling the person; it must be an adjunct to a positive BSP. If necessary, a temporary Safety Plan may be implemented while a BSP and functional behavioural assessment is being completed.

A Safety Plan details how staff would be supported during a crisis situation, when and how they would call for assistance, as well as debriefing that would occur with the person and staff involved following an incident.

As positive behavioural supports take time, if the person them self, or others are at risk, it may be necessary to adopt a restricted practice that limits the person’s behaviour or their freedom of movement. However, even in this situation, positive behavioural supports will provide the framework for all interventions. The restrictive measure selected must always be the least intrusive of the strategies likely to succeed, temporary in nature, must be formally reviewed prior to implementation and regularly thereafter by organizational leadership, and its effectiveness must be monitored closely.

Restrictive measures include:

• Restitution;
• Routine use of law enforcement as part of a BSP;
• Routine use of emergency hospitalization procedures as part of a BSP;
• Use of PRN psychotropic medications for behaviour control;
• Use of protective devices for behavioural purposes (e.g., helmets for head banging, mitts or gloves for hand biting);
• Use of bed rails;
• Use of a device and/or monitoring system that may impact the person’s privacy or other rights;
• Use of any alarms to alert staff to a person’s whereabouts;
• Use of restraints – physical or chemical

The following is a list of punitive measures that should never be part of a positive BSP. The organizations policy should clearly identify these as prohibited.

• Corporal punishment: The application of any painful stimuli to the body as a penalty for certain behaviours. This may include shocking, over-correction (enforced repetitive behaviour), pepper sauce, water in the face, or aversive sounds.
• Psychological or Verbal Abuse
• Restriction of Contact with Family or with Significant Others
• Denial of Basic Needs: Denial of food or drink, sleep, shelter, bedding or access to bathroom facilities. Fasting before a medical procedure is an obvious exception.
• Limiting of a Person’s Mobility: Removal of crutches, glasses, hearing aids or wheelchair to limit mobility for the purposes of altering one’s behaviour.
• Withholding Personal Funds for behaviour control
• Unauthorized Use of a Restrictive Measure (i.e. of a physical or chemical restraint)
• Secure Isolation / Confinement Time-Out

The policy should articulate any limits or thresholds the organization has related to supporting people with unsafe behaviour so that people and their support networks can make an informed decision about whether the service is suitable for their unique needs.

People are encouraged to appropriately express their feelings and are helped by the organization to deal with issues that impact on their emotional wellbeing.

Communications are clear, appropriate and positive and help people to understand their own behaviour and how to behave in a manner that is respectful of the rights of others and supports their development. Each person is consulted with and given an explanation regarding the effects of inappropriate behaviour and what is expected of them, in a manner consistent with their ability and capacity.

Specialist and/or therapeutic interventions are evidence based and implemented in accordance with professional codes of practice and with the informed consent of each person or persons acting on their behalf and reviewed as part of the person centred planning process.

The organization consults with former support staff and family and friends with the informed consent of each person, in order to learn how to best to assist the person to manage their behaviour.

Staff are:

• Trained in provision of positive behaviour support to people with disabilities.
• Trained to understand and to respond to behaviour and verbal and non-verbal communication that may indicate an issue or concern.
• Given all the relevant information required to assist them in supporting people with their behaviour. This includes access to and explanation of people’s Support Plan, BSP or Safety Plan, as applicable.
• Trained in prevention and de-escalation to reduce the likelihood of unsafe situations and the need for restrictive procedures.
• Trained in respectful interactions and how to avoid confrontation.
• Trained in ways to manage reactive or aggressive behaviour in a non-violent, safe manner.

Where a person is served by more than one organization, the two service providers will collaborate and share information (as guided by the person) to ensure that a consistent, respectful approach is utilized by all services.

The organization regularly monitors and collects data and information on the service’s approach to behaviour support. This information is reviewed and analyzed as part of the organizations quality improvement strategy.

How would you know this is happening? (Evidence)

What you see in systems:

• Comprehensive, clear policy is in place, shared and practiced
• Training records confirm staff are trained in a timely manner
• Written BSPs are in place when needed and are positive, respectful and supportive
• Written safety plans are in place when required.
• Documented approvals are available for restrictive interventions.

What you see in actions:

• Staff are confident and competent in delivering services in a positive and respectful manner even when someone’s behaviour creates difficulties for them or others.
• People and their families/support network provide feedback that they are satisfied with the support they gain surrounding their behaviour needs.