In this assignment I am going to explain my understanding about, legislation, frameworks, codes of practice and policies relate to positive behaviour support. Understand the context and use of proactive and reactive strategies. Be able to promote positive Behaviour
Be able to Respond Appropriately to Incidents of Challenging Behaviour. People with learning disabilities show behaviours which present a significant challenge for those caring for them. Such behaviours may include aggression, destructive behaviours or self-harm. Individuals with more severe disabilities and those with additional disabilities such as sensory impairment’s and communication disorders are more likely to demonstrate challenging behaviour. Many forms of challenging behaviour are thought of as being functional and adaptive responses to challenging situations, in that they serve as a way of communication with the people with whom they interact (e.g. stopping unwanted attention, attracting attention or attempting to explain they are experiencing pain).
Some forms of challenging behaviour may be linked to mental health problems, such as depression. The most important way in the reduction of challenging behaviour is for the individual to have a thorough assessment to find out the function of the behaviour. This is known as a functional behavioural assessment and is used to create an individual’s support plan. Positive behaviour support aims to teach the individual new behaviours and enable them to achieve what they want to achieve. Understand how legislation, frameworks, codes of practice and policies relate to positive behaviour support. In all aspects of my role I am regulated by my company’s policies and government legislation. The human rights act 1998, the disabled person act 1986, disability and discrimination act 1996, Health and safety at work act 1974, the equality act 2010. I have been trained in Mandatory courses, for example protecting vulnerable adults(safeguarding) Strategies for Crisis intervention and prevention (S.C.I.P) Autism Awareness, and working safely, making sure I understand the legal policies put in place to provide the best care for the people who I support. S.C.I.P focuses on positive techniques and how to deescalate behaviour.
This allows staff to be consistent in their approach when dealing with challenging behaviour. By following the S.C.I.P policy I am able to reinforce positive behaviour and good skills in listening and learning as well as helping the individuals that I support feel safe and secure knowing that I am able to deal with their behaviours if they occur. Restrictive interventions are defined as any method which restricts the movement of an individual by physical means, including mechanical means (using straps) physical (holding) chemical restraint (using drugs). For example I support an individual who is prescribed medication (Lorazepam) by his physiatrist, to be used when he starts to become agitated. This is given to the customer as a last resort, when we have explored all other options for example is he in pain? Restrictive interventions should only be used as a matter of urgency to prevent imminent and serious harm to the individual or other people, be used in the best interests of the person with learning disabilities, and only used alongside other strategies to help people learn to behave in non-challenging ways.
Interventions need to be used in a context of a risk assessment. Incidents should be investigated and followed up, ensuring staff and customers get sufficient post-intervention support, risk assessments should be reviewed regularly to identify factors contributing to incidents, and associated action must be taken, to reduce those risks. Planned interventions should be agreed in advance at a multi-disciplinary meeting by relevant professionals working in consultation with the customer, his or her carers, and an independent advocate if appropriate. They should be implemented under the supervision of an identified member of staff who has relevant qualifications, training and experience and recorded in writing, so that the method of intervention and the circumstances when its use has been agreed are clearly understood.
Behaviour support plans should be routinely reviewed by having team meetings, support plan reviews and risk assessment reviews. If it is agreed that a customer will require some form of intervention, there must be an up-to-date copy of a written protocol included in the person’s individual support plan and staff should be regularly trained and receive updates regarding an individual’s behaviour support plan because there may be a change in how to support a customer. The use of a restrictive intervention, whether planned or unplanned (emergency) must always be recorded. In the day centre where I work the policy and procedures are to inform the manager on duty who will usually provide support for the customer involved as well as other customers in the centre, ensuring they are all safe. Offer staff support making sure an independent person checks for injuries and records them. The member of staff involved in using a restrictive intervention should: Record the incident, completing an incident report form, star chart and RIDDOR (Report of suspicious Diseases or Dangerous Occurrences) form. Record the incident in the individual’s logs.
Inform carers/ family members.
Have a post incident meeting with Manager and the staff involved. Make referrals to specialist services for example Derby City, Proactive S.C.I.P Instructors. Inform the customer’s Social worker/ care manager.
Before intervening, the member of staff should ask themselves, is there another way to manage the situation and ensure everyone’s safety? If a person has to use intervention they should do it in the least restrictive way possible to prevent the individual from being hurt and all other options have been explored. A restrictive intervention can feel very intimidating to a vulnerable person who is unable to control themselves. By not exploring other options first, there is a risk that the situation can escalate, causing more damage. For example I support a customer who will be happily smiling, singing and interacting with people, her facial expressions and body language will suddenly change. She will begin to spit, hit out, stand up and try to kick other individuals or damage objects.
The individual displayed these behaviours to a member of staff who was supporting her. The member of staff did not explore other options first or follow her behaviour support plan and used a restrictive intervention to deal with her negative behaviour. The situation escalated and the customer became more anxious, damaged property and the staff member became injured. In my opinion if the member of staff had followed the customer’s guidelines and offered calmness, communication and distraction, the incident may not have escalated. We must also use minimum intervention to encourage the customers to trust individuals who are supporting them this helps to form positive relationships with each other and also staff will not be feared. Understand the context and use of proactive and reactive strategies.
The difference between proactive and reactive strategies is that proactive strategies are put into place to avoid any problematic or foreseeable situations and a reactive strategy is a response to a situation that has already happened. In my own work role the reactive strategies that are used are based on the results of an individual’s functional behaviour assessment and the support put into place. Everyone involved in an individual’s care should be involved in creating the behaviour support plan this should include writing a description of the behaviours and working out a reason for the behaviours. Proactive Strategies are used to make sure that the person has got what they need. They also describe ways to teach the person communication and other skills. Examples of proactive strategies that I use include: Teaching the individual skills for example Makaton signs for “finished” “Thank you” “Good” Using communication charts with signs, symbols or pictures which also outlines the routine for that day. The environment for example dims the lights, tying hair back to stop the individual from pulling hair.
Routine and Structure
Giving the individual access to preferred activities
Making sure that a person’s cultural and religious needs are being met Reactive strategies are designed to keep the individual and those around them safe. Examples that I use include: I don’t respond to the behaviour, if you ignore the behaviour sometimes it stops as the individual wants a reaction I give the individual reminders
I distract the individual, by offering a different activity I give the individual what they want for example a drink or a biscuit Ask the Individual if they are in feeling ill or they are in pain. Remove myself from the situation for example leave the room, making sure I am still supporting the customer from a safe distance. Ask another member of staff if they will assist the customer as sometimes another person can be more productive. The importance of identifying patterns of behaviour or triggers that will result in challenging behaviour is that early warning signs can be spotted and acted upon before the behaviour happens or escalates. Factors that can lead to mood changes include: Body Temperature, is the customer too hot, too cold.
Over sensory stimulation
Lack of choice, boredom,
Limited communication or understanding
Over stimulation through noise
A general disruption to a customer’s routine
Overcrowding? For example are there too many people in one activity for the customer to be able to cope with. Provocation by other people, for example if a customer is showing signs of disruption they need to be removed from the situation before it escalates. The importance of maintaining a person centred approach when establishing proactive strategies is that challenging behaviours are an individual thing, the causes and triggers differ according to each individual, as do their reactions and degree of severity. I therefore feel it is important when planning strategies for dealing with challenging behaviour that we ensure they are just as individual as the triggers. No two people will respond in the same way to established strategies. In my own experience, a one size fits all approach does not work and does not show the ability to adapt and respond. By responding to customers behaviours in different ways to each other not only shows that we can identify and recognise each individuals strengths and incorporate them into the strategies planned for that individual, it also tells the individual that you are supporting that they have value and worth and no matter how challenging their behaviour may be, there is always something positive to build on.
Reinforcing positive behaviour with individuals can improve their behaviour. Positive reinforcement is a powerful and effective way to help shape and change behaviour. Positive reinforcement works by presenting a motivating item to the individual after the desired behaviour is shown, making the behaviour more likely to happen in the future. When I am supporting customers i praise them using speech and Makaton, for example when an individual has washed their hands, put their dirty dinner plates on the trolley, thrown something in the bin, put an item away they have been using in an activity. I use praise “Thank you”, “please”, “well done” which is effective when reinforcing positive behaviour. Using an incentive also works in reinforcing positive behaviour, for example a customer who i support likes football and cricket. When the customer shows positive behaviour he will get a trip out to the cricket ground to watch a match and have his packed lunch there, or to the football ground to have a cup of tea and a cake. Using reactive strategies can have an impact on an individual’s wellbeing.
For example i support customers who display challenging behaviour’s. A previous manager asked one of my colleagues and me to assist a customer to go out for a walk. The customer is extremely afraid of dogs he will scream and run when he sees one. This is because he was bitten by a dog when he went on holiday to India. Whilst we were out walking, the customer saw a dog in the distance and began to scream and run towards a busy main road. Both my colleague and I ran after the customer shouting “stop”. When we managed to catch up with the customer we had to restrain the customer using S.C.I.P (strategies for crisis intervention and prevention) because the customer was in danger of running into the road and getting hurt or even killed. The customer was very upset; he was shaking, sweating, crying, and screaming.
When we got back into the centre the customer was upset and angry for the rest of the day. He displayed the need for more sensory stimulation by rocking back and forth and flapping his hands. The customer became very vocal and began making loud noises, (which had an effect on other customers) he also began to barge into other people. This in itself is not being proactive as we did not explore other options first or even prepare the customer for going out for a walk.
What I feel should have happened is photographs of dogs should have been used and pat dog should have been brought into the centre(as it is a safe environment) on numerous occasions to begin the process of helping the customer to overcome his phobia of dogs. This had an effect on the customer’s wellbeing because he would not get out of bed in the morning and would refuse to come into the centre. He would not eat his food and if he saw a dog through the window he would scream. In my opinion, we put the customer through unnecessary anxiety and stress. Be able to promote positive behaviour. There are a range of factors that may be associated with challenging behaviours these
The need for sensory stimulation or sensory overload
Staff not working consistently,
Staff not following customer guidelines,
Past experiences that have happened to the individual,
The environment being too hot or too cold,
Lack of boundaries or goals,
Mental and physical health,
The goal of using proactive strategies on mitigating challenging behaviours is to reduce the future probability of the behaviour. It helps if proactive strategies are identified when supporting customers who display challenging behaviours. Risk Assessments means evaluating the consequences and likelihood of challenging behaviour, it identifies measures to help avoid, mitigate or control the risks. The risk assessment should take into account of personal, environmental or situational factors which increase the likelihood of challenging behaviours.
To reduce risks associated with challenging behaviour we need to identify the emotional, physical and psychological needs of the customer. Dignity and respect is important and where possible a customer should have choices concerning their care. A strategy for reducing risks also requires communication between staff to form an understanding of an individual’s behaviour and what they need to do to prevent the behaviours. Other services, family/carers should also be involved in discussions and decision making. A crucial part of managing risk is to understand the reasons for the behaviour so that strategies can be put into place for example: What is causing the distress?
What are we doing that is leading to the distress?
What can we do differently?
It is important to highlight praise when supporting customers so that we can reinforce positive behaviour. I feel it is important to offer praise to a customer I am supporting, immediately after they have demonstrated a skill, this will hopefully learn to make an association between the skill and the reward which means the customer will start to use the skill more often. For example a customer who I support is very impatient and does not like to wait. The individual has to share a toilet with other customers. In the past when another customer is using the toilet, the individual has kicked the toilet door and started pulling on the handle; she would scream and try to attack the other customer when they have come out. In the individuals behaviour support plan it is highlighted how to support the customer if the situation arises. The protocol is, if another customer is using the toilet ask K to wait using speech, Makaton and picture signs explain what is happening and why.
Keep reminding K and also use praise.” Well done K for waiting”. K will smile and wait patiently. This has and is working well and has created positive reinforcement as K will now stand away from the door and say “wait” without being reminded or prompted. It is still important to praise K and not become too complacent because of the risk that K can become challenging again in this situation and regress. It is essential that everyone working with challenging behaviour develop a general understanding of promoting positive behaviour. In my opinion a consistent and proactive approach should be followed rather than reacting negatively to situations. Strategies should be in place that allows us to work positively with individuals and focus on their achievements rather than highlighting their inappropriate behaviour.
Staff communicating with each other and sharing ideas and information is vital. In our centre we have daily half hour team briefings where we can discuss the events of the day. The meetings are also used to discuss all customers we have been supporting whether they have had a good day or bad day. Have there been any incidents that have happened, any new information about a customer? Have Colleagues had a good day? We share information and ideas about working with individual customers and share what worked and what didn’t work when dealing with challenging behaviour. I key work a customer who displays challenging behaviour, he will shout, swear, bang his fists on the table, threaten to smash a window and threaten to hit a person. This is usually when he has dropped an item on the floor and been asked to pick it up, or he is not feeling very well, there is too much noise, something has happened at home or on the bus that morning.
The individual has got a behaviour support plan which I ask staff to read and sign which enables everyone to understand his guidelines on how to support him. I have monthly meetings so that we can share ideas, information, what’s working/ not working. Is there any new behaviour or any behaviour that have resurfaced? What can we do better? We discuss activities that the customer appears to like and dislike. It is important for colleagues to support each other when a customer is displaying challenging behaviour. Where possible I ask my colleague if they need any assistance or time out for me to take over, especially if they have been injured by the customer. Blaming the member of staff is not helpful or constructive for example I have witnessed colleagues in the past say “he doesn’t behave like that when he is supported by me, what they have done to make him like that?” We must all share our experiences, skills, knowledge, thoughts and ideas with each other.
How can we promote positive behaviour with our customers if we do not promote it within our staff team? Be able to respond appropriately to incidents of challenging behaviour Challenging behaviour shows there is some need being unfulfilled or a problem with communication. Behaviour is challenging if it causes harm to the individual or others. There are different types of challenging behaviour these include: Spitting, self-harm, aggression (physical, verbal, mental, emotional) destruction (breaking furniture, tearing things up) Shouting, swearing, biting self and others, eating inedible objects, smearing faeces, soiling and urinating in odd places, stripping clothes off, eye poking, hand biting, pulling own hair and others, hitting others and self, Threatening or hitting others with objects, inappropriate sexualised behaviour, destruction of clothing.
An appropriate response to challenging behaviour depends on the type of behaviour that is being exhibited by the individual. My opinion on the response to this behaviour should be consistent, fair, so not to cause any further disruption to a group session or the individual, thus calming the situation and the customer using this behaviour. A proactive response is likely to be more effective than one that is merely reactive. When responding to incidents of challenging behaviour it is important to ensure that an individual’s behaviour support plan is followed as no two people are the same. A behaviour support plan describes situations that an individual finds difficult and what others can do to help them cope with distress. They are a very useful way of encouraging staff supporting the person to respond consistently. The plan should include Strategies to encourage staff to respond to the first signs of distress and resolve issues before they escalate. This helps to ensure that the least restrictive interventions are being used and the strategies being used are in proportion to the level of risk.
The behaviour plan should include:
Triggers –What can cause the individual distress? In Specific situations, places, activities, changes, sensory issues (noise, touch, smell?) Proactive strategies – How can staff support the person to cope with these triggers? Early warning signs- How do we know the person is becoming distressed? Are the First signs- body language, facial expression, language, behaviours, and tone of voice? What can help the individual calmer at this time?
Medium intensity behaviours – What might the individual do at this stage? Are there Specific behaviours and who might be at risk? What should staff do at this time? Things we can do to prevent the situation from getting worse. What can staff do to ensure everyone is safe? High intensity behaviours – What might the individual do at this stage? Are there specific behaviours? How long they may last and who is at risk What should staff do at this time? What can staff do to ensure everyone is safe? Often the best course of action is to withdraw and leave the customer in a safe area to calm down on their own (But this may not be the case for some individuals) When responding to an incident of challenging behaviour it is important to ensure a customer’s dignity and respect are maintained. Try to speak in a calm and clear voice using language that the individual understands this could be in the form of signs and symbols, makaton, photographs. Speak calmly, quietly and assertively
Avoid threatening body postures such as standing in front or above the individual Avoid what may be classed as threatening gestures such as pointing or waving, arms folded across the body. Avoid threatening facial expressions.
Avoid shouting or raising your voice.
Avoid giving orders or continually repeating requests.
Try to disperse any audience. Ask the individual if they would like to go into a quieter area if possible. Consider adopting a posture which reduces your size (sitting, crouching and moving away) Be aware of gender, cultural difference.
Avoid belittling and talking to others negatively about the customer. Avoid forcing compliance.
Actively listen to the customer and respect their wishes and feelings. Avoid unnecessary physical contact. Following an incident of challenging behaviour by an individual it should be recorded in their personal file. A detailed written log must be written which should be dated, timed and signed by the member of staff. An incident report form and star chart must be completed. On the star chart we use the A.B.C approach (Antecedent, Behaviour, and Consequence.) Antecedent – What occurs before the behaviour and what may have triggered it. The antecedents are all the relevant things that happened before the behaviour occurred. They can also be considered as triggers for the behaviour such as, things that other people said, emotional state (depressed, tired, anxious.)
The environment (is it too hot or noisy cramped, smell, bright lights?) Behaviour –What happens during the behaviour, what does it look like? Consequences – What are the immediate and delayed reactions from everyone involved? Consequences can be pleasant or unpleasant. A pleasant consequence will reinforce the behaviour. (When I yell, everyone gives me what I want)While a negative consequence will discourage behaviour (When I yell everyone ignores me completely) a consistent response from everyone to challenging behaviour can have a very strong effect. Parents/carers are also informed via a customer’s communication book at the end of each day or telephoned. Staff are involved in a team briefing, daily, to be kept informed of any concerns or incidents. In our centre we also have a traffic light system, using laminated cards, they inform people to be cautious or take action. Green- No concerns
Red- There has been a Serious Incident.
A manager is informed whenever the cards are on amber or red. Be able to support individuals and others following an incident of challenging behaviour. I had an incident of challenging behaviour from a male customer who I support on a one to one basis. B is prescribed P.R.N medication by his GP for when necessary, these being Paracetamol for pain and discomfort and Lorazepam for anxiety. B is known to become very agitated and anxious and will slap others very hard without warning. B has his breakfast at the centre each morning when he arrives, as I was preparing his breakfast B became very agitated and anxious slapping me very hard on my arm.
After following B’s behaviour support plan and exploring all of the options listed, I asked B if he was in pain offering him Paracetamol if he needed it but he shook his head as a negative. Cooling him down by removing his sweater I offered sensory consisting of a weighted blanket and calm relaxing music. None of the above options worked so B was given Lorazepam as a last resort resulting in B’s behaviour improving over time. I also used the traffic light system, as stated earlier in this assignment. To Support an individual to return to a calm state:
Use Reassurance and Praise.
Provide whatever support that is needed; give individual some space if that is what they want. Behave in a non-judgemental way, even if you might not feel like that. Don’t discuss the behaviour with the individual at this point, unless they want to. Support the customer to continue to recover and calm down.
I key work a male customer and support him to access his choice of activities. S enjoys going outside in the garden to feed the birds. As part of the activity S and myself make a flask of tea, sit in a poly tunnel looking at bird magazines before we venture out to feed them. I was asked to support another customer (M) at the same time, as we were short staffed and to involve him in the activity. I explained to S that M would be joining us. S was not happy with this and became very distressed, he started to swear, bang on the table using his fist and bite on his own arm. The staff that should have been supporting M had changed the routine for that day and decided to support two other customers in taking them out in a car. I tried to calm the situation down by speaking calmly and quietly to S reassuring him that it was just for that day. S continued to display the same behaviours and would not join in the activity, beginning to cry and shout” I don’t want to do it with M I want you to do it” I continued to reassure S who by this time was threatening to hit me.
Another member of staff came to my assistance, supported M whilst I continued to support S. S stopped the behaviour and became very quiet with his head down. When I felt S was calm enough for us to be able to talk about the situation together he began to cry saying he wanted the activity to be just Himself and I. I reassured S, in future, the activity would be himself and either I or another member of staff. I asked S if he still wanted to do the activity, he replied “NO” When S becomes agitated and upset he will refuse to take part in one of his activities and will realise later on in the day that he has missed out. After the incident S became very withdrawn, appeared sad, would not engage in conversation, sat with his head down and would cry throughout the day. After the incident not only did S show complex feelings both M and I also felt different emotions. M became withdrawn, would not engage in conversation or activities, eat his lunch or enter a room S was in, and also wanted to be on his own, appearing anxious and frightened. I asked M if he wanted to talk to me or another member of staff about his feelings but he declined.
I had a release of adrenaline my heart was racing; body was shaking, I felt angry frustrated, fearful, tired upset and wanted to cry. I sought help and advice from my immediate manager and explained how the incident had made the two customers and me feel. My manager actively listened and took action by informing staff that a clear plan needs to be put into place when changing activities and when we are short staffed the activity sheet needs to be followed. I feel the situation could and should have been avoided, other customers’ activities were disrupted, their needs were not met they had unnecessary upset which resulted in an individual displaying challenging behaviour. After an incident of challenging the steps that should be taken to check for injuries are: Everyone involved in the incident should be checked thoroughly for injuries by a member of staff (preferably a first aider) who was not involved in the incident. In case of any injuries being noticed, immediate action should be taken to seek the appropriate medical help. Injuries should be recorded and reported using the centres procedures.
An incident report form, body map and dangerous occurrence form should be completed. Parents/ carers should be informed. Be able to review and revise approaches to promoting positive behaviour. Working with others is important if individuals that we support are to receive good, consistent support. Family carers and close friends are important when we are thinking about partnership working. It shows respect and also values other people’s contributions, different people possess different skills which help good support, it can help with problem solving and creative thinking, and partners have different information about a person they can share with others. Working with others to review and examine information which relates to positive behaviour support should include gathering information about incidents from a variety of sources. Information can be gathered from, A.B.C charts (As mentioned earlier in this assignment, promote positive behaviour) in notes from meetings, and debriefs incident report forms and logs. It is important to promote proactive positive behaviour support and analyse the risk assessment process; whenever there is a review the risk assessment should be revisited and adjusted where necessary.
There must be continuous monitoring and review of the individual’s behaviour as sometimes physical interventions or restrictive practices are used in an emergency. To be able to work with others to review the approaches to promoting positive behaviour it is important for managers to check and update policies and organisation practice against current good practice guidelines. Reflection begins when I pause to think back after something unexpected or out of the ordinary has happened. I replay the happenings, incident or event in my head and think about it more. My thoughts begin to change from a sequence of events into a series of questioning thoughts such as; why did it happen that way? And how could I have behaved or done things differently? If I do something that way, what is likely to happen? Reflection helps me to share my ideas with others who are experiencing similar incidents of challenging behaviour which can help improve the promotion of positive behaviour.
It also helps you avoid making the same mistake again, for example, as mentioned earlier in this assignment whilst I was supporting B and preparing his breakfast, he hit me. On reflection I questioned why I had taken him in the kitchen with me and should have asked for assistance from another member of staff to prepare his breakfast. My manager has updated B’s support plan and informed staff that when B has his breakfast prepared the member of staff supporting him must ask colleagues for assistance keeping B out of the kitchen. In my opinion Individuals with the label of challenging behaviour are one of the most vulnerable groups in society.
They are often labelled as complex and are at high risk of abuse, neglect and exclusion. Despite some progress in policies and practice that advocate personalisation, the evidence for successful approaches in challenging behaviour is weak. Challenging behaviour is still too often viewed as located within the individual rather than the wider social and physical environment. The appalling events that led to the closure of Winterbourne View hospital in Bristol in 2011 were the latest in a very long line of similar cases that have occurred over many decades. The aim of the winterbourne review was to look into what happened so that lessons can be learned and look into how people with challenging behaviour are supported all over the united kingdom.