Visit any community care provider website and you will probably read somewhere on their website that they are able to support individuals with ‘challenging behaviour’ or ‘individuals that other providers have declined’. However, there is often a lack of detail about the actual approach used by the organisation to enable them to successfully support individuals with behaviours perceived to be challenging. So, if you are a referrer or family member looking for community support for an individual with complex needs and behaviours perceived to be challenging, how do you determine which community provider to use?
As a provider of community support to individuals with particularly complex needs, we explain the approach used by Gray Healthcare to support adults with behaviours perceived to be challenging and the clinical outcomes we are achieving because of our approach. There is also a helpful list of questions that we advise you to ask of any community provider who claim they can support individuals with behaviours perceived to be challenging.
What are behaviours perceived to be challenging and why do people develop these behaviours?
Challenging behaviour is defined as ‘behaviour…of such intensity, frequency or duration as to threaten the quality of life and/or 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 et al 2007.pg 14)
These behaviours can arise from interactions with social and physical environments. They are functional, learnt behaviours developed and maintained within the context of an individual’s abilities, needs and circumstances and, for many, these behaviours act as a method of communication to try and exert control and influence over their lives.
People develop these behaviours to meet a specific need. This might be to seek attention, or to receive a specific item or even to avoid doing something they do not wish to do. Some examples of behaviours perceived to be challenging include:
- Physical aggression for example, hitting or kicking.
- Self-harm, for example head banging
- Destructiveness, for example, throwing or breaking things.
- Eating inedible objects
- Absconding
- Abusive language, shouting, screaming
How do Gray Healthcare support individuals with behaviours perceived to be challenging?
The approach we use at Gray Healthcare is PROACT-SCIPr-UK®. PROACT-SCIPr-UK® stands for ‘Positive Range Options to Avoid Crisis and use Therapy – Strategies for Crisis Intervention and Prevention.’ It is an approach to support that looks at the whole person, not just their behaviours.
This approach was pioneered by Marion Cornick, Founder of the Loddon School, a specialist residential home for children aged 8 – 19 with profound autism, who are non-verbal and have severe learning disabilities, resulting in behaviours perceived as highly challenging. There are now more than 700 instructors teaching this approach in schools, care settings and community homes across the UK and courses are accredited by the British Institute of Learning Disability (BILD) Physical Intervention Scheme (PIAS).
PROACT-SCIPr-UK® works on the principle that many behaviours perceived to be challenging can be managed using proactive rather than reactive support strategies and the use of de-escalation methods. Best clinical practice informs that restrictive interventions are only used as a last possible resort and for the least amount of time, and only after all other forms of intervention have been tried to ensure the safety of all concerned.
What is restrictive practice?
Restrictive practice is defined as ‘any practice or intervention that has the effect of restricting the rights or freedom of movement of a person’ (Section 9, National Disability Insurance Scheme Act, 2013). It has also been defined as ‘making someone do something they don’t want to do or stopping someone from doing something they want to do’ (Skills for Health, 2014).
The use of restrictive practices is most commonly associated with mental health hospital environments, but its use does occur in other settings as well. Best clinical practice informs that restrictive practice techniques should only be used as the last possible resort in response to risk of harm to a person or others and only after a provider has explored and applied evidence-based, person-centred and proactive strategies.
The focus of our clinically-informed framework has always been to provide the least restrictive package of support possible. We use the PROACT-SCIPr-UK® framework, a ‘whole approach’ to supporting individuals with complex needs or who may present with behaviour perceived to be challenging, focussing on three core aspects: the individual, staff and organisation. Physical interventions would only be used as a last resort.
What are the types of restrictive practices?
There are six types of restrictive practice. These are:
Chemical: the use of medication to address behaviours of concern. It does not include the use of medication prescribed by a medical practitioner to treat a mental health condition.
Environmental: restricting a person’s access to all parts of their environment, to items or to activities. Examples might be locking a door to prevent a person’s access or denying a person access to their mobile phone.
Mechanical: the use of a device or item to address behaviours of concern. Examples include use of helmet to prevent head butting behaviour and gloves to prevent skin picking.
Physical: the use of physical force to prevent, restrict or subdue movement. This form of restraint should only be used for serious behaviours of concern to prevent harm to self or others when other methods have failed. Physical restraint can range from holding a person’s arm down to prevent them from harming others to full prone restraint.
Seclusion: the confinement of a person in a room or physical space.
Psychological: depriving a person of choices, controlling them through not permitting them to do something, making them do something or setting limits on what they can do, without physically intervening. It includes the use of threats and coercion.
What is the PROACT-SCIPr-UK® Gradient ?
The mission statement for PROACT-SCIPr-UK® is ‘to minimise the use of physical interventions and emphasise sound behavioural support strategies based upon an individual’s needs, characteristics, and preferences. This is achieved by providing support to individuals utilising proactive, active and reactive interventions, referred to as the PROACT-SCIPr-UK® Gradient. These interventions are developed through applied behavioural analysis which aims to understand the function of each behaviour and ultimately develop positive, holistic approaches for each person.
The Department of Health Positive and Proactive Care: reducing the need for restrictive interventions states that: “The legal and ethical basis for organisations to allow their staff to use restrictive interventions as a last resort is founded on eight overarching principles”.
These are:
- Restrictive interventions should never be used to punish or for the sole intention of inflicting pain, suffering or humiliation
- There must be a real possibility of harm to the person or to staff, the public or others if no action is taken
- The nature of techniques used to restrict must be proportionate to the risk of harm and the seriousness of that harm
- Any action taken to restrict a person’s freedom of movement must be the least restrictive option that will meet the need
- Any restriction should be imposed for no longer than necessary
- What is done to people, why and with what consequences must be subject to audit and monitoring and must be open and transparent
- Restrictive interventions should only ever be used as a last resort
- People who use services, carers and advocate involvement is essential when reviewing plans for restrictive interventions
The PROACT-SCIPr-UK® gradient works on the premise that 70% of the support provided will be proactive, 20% active and 10% reactive.
Many behaviours perceived to be challenging can be managed through proactive support strategies and the use of de-escalation methods. Extreme circumstances may require measures to ensure the safety of all concerned. This may necessitate in extreme instances of risk or potential risk, a ‘hands-on’ approach to prevent further escalation or continuation of danger.
PROACT-SCIPr-UK® restrictive physical interventions are only used as a last resort for the least amount of time after all other forms of intervention have been tried to end a truly dangerous situation where injury may occur to the individual or others. Physical restraint is defined as: any direct physical contact, where the intention of the person intervening is to prevent, restrict, or subdue movement of the body, or part of the body of another person.
Proactive Strategies (70%)
Proactive strategies are intended to make sure that the person we support always has what they need and these strategies teach the person we support appropriate life and communication skills, thereby removing any need for the person to behave in a way perceived to be challenging. Examples of proactive strategies vary from one person to another based on their individual interests, but some examples from the people we currently support include going for a drive or walk or simply going out, listening to music, looking at family photographs, gardening or playing football.
Active Strategies (20%)
Active strategies might be chosen when an individual starts to show some signs that all is not well. These signs vary from one individual to another and can range from subtle changes such as the use of a specific word or phrase, to more obvious signs such as changing facial expressions or restlessness. As our staff teams receive training tailored to the individual they are supporting, they know exactly what signs they need to look out for. Active strategies are generally activities our staff know the person they support enjoys, but they are used as a distraction or as a redirection technique.
Reactive Strategies (10%)
Reactive strategies are only used when the individual has reached a crisis point and is showing signs of aggression, verbal or physical, or any other behaviour perceived as challenging. All the people we support have a Positive Behaviour Support Plan that details exactly what that individual person needs their staff team to do at that moment in time to manage the situation safely. Strategies vary from one person to another, but some examples include giving the person physical space and/or disengaging for a short period of time.
As part of our training programme, all our staff teams are taught five basic interventions. Any further interventions are prescribed by our clinical trainers based on an individual’s needs.
Frequently asked questions
Why have you chosen PROACT-SCIPr-UK® as your preferred approach for managing behaviours perceived to be challenging?
As an organisation, we have chosen PROACT-SCIPr-UK® as our preferred approach as it has been proven to support positive outcomes and to reduce the need for the use of restrictive practices for people with behaviours perceived to be challenging. The benefits are twofold. By using a proactive approach, we can empower the people we support to become involved in their care by helping them learn how to appropriately handle situations they find difficult, which in turn helps them gain independence and control. From a staff perspective, with our rigorous training programme, our staff teams learn techniques that help them develop a positive therapeutic relationship with the people they are supporting, resulting in a better working environment for all and better clinical outcomes.
What training do your staff receive?
As part of our induction week, our staff teams receive two full days PROACT-SCIPr-UK® training delivered by our specialist trainers. Our curriculum is certified by BILD Association for Certificated Training against the Restraint Reduction Network Training Standards (RNN). Following induction, our new staff members meet with the manager of the package of support where they will be working. The purpose of this meeting is to provide detailed information based on the individual, including their likes, dislikes, their goals and their care plan.
We also offer annual refresher courses on PROACT-SCIPr-UK® for all staff. Our specialist trainers also visit packages of support to offer further support and training to individual teams, if needed.
Our specialist training covers the communicative function of behaviour, problem solving skills, support strategies and keeping staff and the individual safe and secure and promotes the PROACT-SCIPr-UK® gradient the PROACT-SCIPr-UK® gradient, a framework that helps identify the appropriate strategy to use when working with people with behaviours perceived to be challenging.
Compliance with our PROACT-SCIPr-UK® training programme is consistently high at over 95%.
Reference:
https://www.bild.org.uk/wp-content/uploads/2020/01/RP-tool-RRN-with-all-included.10.18.TT_.pdf
Who delivers your PROACT-SCIPr-UK® training programme?
Our training programme is delivered in person by our full-time in-house training team. Our trainers have each attended the initial four-day intensive course on PROACT-SCIPr-UK® delivered by the Loddon School. This initial training is then followed by six months of teaching the course to others.
During these six months, the attendee is required to create and maintain a portfolio of the training they have delivered and demonstrate that they have the taught the course successfully. They are then invited back to Loddon School to share their portfolio and to sit a competency exam.
Each year, our trainers attend a full day at the Loddon School with their portfolio of training for the preceding 12 months. They present their training and sit another competency test.
Every three years post qualification, a representative from either the Loddon School or from the British Institute of Learning Disability (BILD) sit in on a training session to assess the quality of the training delivered.
How do you identify the training requirements for each package of support?
Following referral, a member of our clinical team meets with the individual and their care team in their current setting to undertake a full clinical person-centred assessment. As part of our assessment, we review both the number and frequency of incidents for that person during the last two years. This data enables our Multi-Disciplinary Team (MDT) to identify what physical intervention training our staff teams will need to support the individual. Based on our assessment we assign a RAG (Red, Amber, Green) rating for the individual based on their history of incidents. A ‘Red’ rating indicates that we need to train our staff in person-specific intervention techniques, a ‘Green’ rating indicates that this high level of training is not necessary at the present time.
How do you evaluate the effectiveness of your PROACT-SCIPr-UK® training programme?
Our physical intervention data enables us to monitor the success of our training programme as well as evidencing that we are delivering support that uses the least restrictive package of support as possible. Each year we report on our physical intervention data as part of our annual Clinical Outcomes Report. You can see how we’re successfully reducing the use of restrictive practices in our latest clinical outcomes report.
What questions should you ask community providers about supporting individuals with behaviours perceived to be challenging?
What approach do you use to support individuals with behaviours perceived to be challenging?
What training do you deliver to your staff teams who work with individuals with behaviours perceived to be challenging?
Who delivers your staff training programme? What is your training compliance percentage with your course?
Can you give me some examples of how your company has successfully supported individuals with complex behaviours in the past?
What does a good day look like for the people you support?
What percentage of people are classified as ‘red’ in terms of their behaviours when they come to you?
What percentage of people are still classified as ‘red’?
‘For me, PROACT SCIPr UK® is the best approach to physical interventions/restraint currently available. It is completely person-centred and looks at the reasons why an individual behaves the way they do and not just how to manage their behaviours. Every day we see the positive impact that a consistent team with good knowledge of PROACT-SCIPr-UK® has on the people we support in terms of the quality of their life, and we can evidence the efficacy of our training programme through our incident data.’
(Craige Jones, Instructor)