A better life: The implementation and effect of Person
Centred Positive Behaviour Support in a Community
Residential Service within the Daughters of Charity Dublin
Service
Abstract
This paper describes the process of implementing person centred positive behaviour support in the
Daughters of Charity Dublin Service and the findings from the evaluation of the implementation in
the Community Residential Service. Attention was paid to both the training of the support staff and
to the motivational structures within the Daughters of Charity Community Residential Service. Both
the quality of the support provided by staff and the level of engagement increased significantly after
the introduction of person focused positive behaviour support. In addition, the focus person
experienced decreased self-stimulatory and self-injurious behaviour, increased opportunities for
choice and control and higher levels of participation in activities of daily living within the house and
in the local community.
The Implementation Process
Training
Training of the frontline staff in how to support the focus person using person centred positive
behaviour support involved a one day classroom based workshop based on the specific individual
needs of the focus person. This workshop was facilitated by the multi disciplinary team (Clinical
Director, Principal Clinical Psychologist, Behaviour Support Specialist and Occupational Therapist).
This training was followed by between 1.5 to 2 days hands-on training with each staff member in
house with on the spot feedback, modelling and feedback to the team in the form of documented
graphical information of their progress to date. The training consisted of the Senior managers
(CNM3) and Service managers (CNM2 & CNM1), gaining knowledge and expertise on providing the
right supports to the frontline staff by providing regular practice leadership such as observing, giving
feedback, supervision and leading team meetings. The Managers were trained as observers so that
they could maintain the correct incentives for staff and provide support in the implementation
process.
Motivation
There were a number of elements for ensuring the correct motivational structure within the
organisational. Prior to implementation, a facilitated meeting was arranged with the clinical director,
director of quality and education, service managers and all staff. This meeting was to introduce the
concept of person centred positive behaviour support, discuss the issues that would affect
implementation and start the development of the implementation plan for the roll-out of this model
of service delivery. This action plan was finalised soon after this meeting ensuring clear roles and
responsibilities for all those involved.
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The organisation’s Assistant CEO and Administrator were also involved by introducing them to the
concept from the beginning so that there were a shared understanding of its importance at all levels
of the organisation.
Systems were also put in place to deliver the full training to new staff before their start date in the
service.
Evaluation
In order to evaluate the success of the implementation of person centred positive behaviour support
within the service data was collected before the implementation of person centred positive
behaviour support and then three months after the implementation and then every quarter
thereafter.
Methods
Focus Person:
At the time of referral the focus person was presenting with the most severe of challenging
behaviours within the community residential service. The focus person presented with long standing
severe aggressive behaviour and self-injurious behaviour. Major wounds had formed on the focus
person’s body due to self inflicted injuries that needed daily medical treatment by staff.
Review of historical records indicated that behaviours had continued to worsen in terms of
frequency, severity and management difficulty for the focus person over the previous seven years
respectively. The focus person had no meaningful day activity placement due to the management
difficulty of challenging behaviour.
Measures:
1. The frequency, management difficulty and severity of behaviour were established using the
subscales from the Challenging Behaviour Checklist (Harris, 1993).
2. An observational measure of both service user engagement in meaningful activity and staff
contact and assistance to service users (EMAC-R, Mansell and Beadle-Brown, 2005), was
collected using momentary time sampling (MTS).
3. The quality of staff support was measured using the Active Support Measure (ASM: Mansell and
Elliott, 1996; revised Mansell, Elliot and Beadle-Brown, 2005).
4. The Quality of Life Questionnaire (QoLQ: Schalock et al., 1989) was used to assess QOL at
baseline and at follow-up.
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5. A measure of user needs, characteristics, participation and opportunities for choice making was
conducted via questionnaires. These questionnaires were made up of the short form of the
Adaptive Behaviour Scale Part 1; the Aberrant behaviour Checklist
6. The amount of medication administered to the focus person was monitored from the
medication kardex at the last day of every month.
7. The Periodic Service Review (PSR: LaVigna et al.,1999) was implemented as a quality assurance
system that yields a self-report measure of the proportion of an overall behaviour support plan
that has been implemented. At the end of each month a PSR score records the number of
interventions implemented that meet a specified criterion.
Results
Outcomes for the focus person
Figure 1 illustrates the changes in percentage of time spent in meaningful activity, and receiving
assistance from staff. The average percentage of time the focus person spent engaged in any
meaningful activity nearly doubled. This was explained by the increase in the amount of facilitative
assistance provided by staff. There was also a 93% decrease in self-injurious behaviour and a
reduction in stereotypic and repetitive behaviours from 51% to 16% as measured by the Aberrant
Behaviour Checklist.
Figure 1: Percentage of time spent in Engagement and Receiving Assistance
In addition to direct assistance increasing significantly, there was also a significant 86% increase in
the quality of staff support as measured by the active support measure.
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Figure 2 presents the percentage scores on the measures of participation in domestic life (IPDL),
involvement in community living (ICI) and opportunities for choice making (CMS). As can be seen,
opportunities for choice increased significantly as did participation in daily life.
Figure 2: Changes on Participation in daily life, community involvement and choice
making
Figure 3 presents a monthly summary graph of frequency of challenging behaviours displayed by the
focus person. The data was collected over the 13 month period prior to implementation of person
centred positive behaviour support and data was continually collected once implementation of the
support plan had commenced. Reductions to near-zero levels in the monthly rates of behaviour
were observed following the implementation of the positive behaviour support plan. Monthly
ratings of the implementation of the behaviour support plan using the Periodical Service Review
were also conducted. The implementation of the plan increased to 95% over three months therefore
assisting with the gradual reduction in the frequency of the challenging behaviour.
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Figure 4: Presents the percentage of units of use of Paracetemol, Ativan, Chloropromazine (CPZ) and
placebo used to manage the focus person’s challenging behaviour. Overall levels of medication were
reduced to near zero levels to manage challenging behaviour after the implementation of the
support plan.
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Figure 5 presents the results of the Quality of Life Questionnaire (QoLQ). The focus person’s quality
of life score had significantly improved over the 12 months. The focus person had previously no
social activities within the local community due to behavioural problems. Following implementation
of the support plan the focus person has now joined a local gym, enjoys grocery shopping in the local
supermarket, enjoys going to the cinema, enrolled in dance classes in the local community college
and now owns a pet dog. Through these activities and others, the focus person is building a network
of support and establishing a profile within the local community.
Conclusions:
It is clear that the introduction of Person Centred Positive Behaviour Support in the Community
Residential Service has been very successful overall and has made positive changes in the lives of
those in the service. The focus person in this case study presented with behaviours of sufficient
severity to require admission to an out of area placement in a special treatment facility. Because no
such facility was available, it was necessary for the service to provide systems of support to maintain
the focus person’s placement within the community residential service. This not only resulted in the
dramatic reduction of challenging behaviour by the application of a low arousal environment but
also significant improvements in the focus person’s Quality Of Life.
This case study illustrates that people with severe challenging behaviour and complex needs can
maintain their place in the community if given the right supports.
Organisational and managerial commitment has been the foundation of the success of this approach
so far. The Manager continues to lead and co-ordinate the implementation to ensure maintenance
and interventions continue and develop.
Staff Training within the service ensured a greater degree of ownership, understanding and
motivation with the support team. It is therefore important to ensure that there are systems in place
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to train new staff through induction and training as soon as possible to their start date to ensure a
smooth transition for the people we support.
The Periodical Service Review plays an important role in the maintenance and development as it
assists staff in setting their own standards and reviewing their progress.
It is important to develop support systems by which staff are given an opportunity to seek support
on issues by sharing success stories regarding the impact of positive behaviour support on people’s
lives. Staff could be nominated for awards for their commitment and enthusiasm to improving the
quality of life of the people they support. Finding ways by which good practice is recognised and
rewarded is important in maintaining staff motivation in the current health care climate.
The process of implementing Person Centred Positive Behaviour Support in this service and the
evaluation of its effectiveness provides the Daughters of Charity with invaluable information which
informs the way in which they will continue to deliver services.
The impact it can have in terms of improving and maintaining the quality of life of the people we
support is clearly evident.
References:
Harris, P. (1993) “The nature and extent of aggressive behaviour amongst people with learning
difficulties (mental handicap) in a single health district”, Journal of Intellectual Disability Research,
Vol 37, pg 221-242
LaVigna, G.W., and Willis, T.J. (1994) The Periodic Service Review: A Total Quality Assurance System
for Human Services and Education. Paul Brookes Publishing, Baltimore
Mansell, J and Beadle-Brown J.(2005), Engagement in Meaningful Activities and Relationships:
Tizard Centre
Mansell and Elliott (1996) Active Support Measure: Tizard Centre.
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Schalock, R.L., Keith, K.D., Hoffman, K and Karan, O.C. (1989) “Quality of Life:It’s measurement and
use”. Mental Retardation, Vol 27 pg 25-31.
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