Using Positive Behaviour Support (PBS) to reduce the use of restrictive practices

What is PBS?

PBS is a comprehensive, evidenced-based, values-led approach which starts with a good understanding of each individual, their strengths, needs and wishes. It provides a personalised and enduring system of support to meet needs, build upon strengths and enhance an individual’s quality of life.

It is an inclusive approach which depends upon the involvement of the individual themselves and the key people in their lives, including families and social care workers.

PBS is not a single-way of working as it includes the full range of therapies and interventions required to meet people’s unique needs and achieve long-term improvements in quality of life. These can change behaviour and reduce the use of restrictive practices.

PBS is a practical way of responding to people with behaviours that challenge by:

• developing an understanding of why an individual presents with behaviour that challenges
• making changes to the environment to reduce the need for an individual to use challenging behaviour to control their life
• teaching the individual new skills and alternative ways to communicate their needs
• creating the cultural change necessary for services to respond positively and respectfully to the individual.

What are the different components?

There are three stages to PBS:

Primary prevention
This is the most important part of PBS because it has the greatest impact on the quality of people’s lives. Primary prevention supports people to get what they need which leads to a reduction in behaviours that challenge and reduces or even eliminates the use of restrictive practices.

Primary prevention includes five key strategies:

• changing the environment in which an individual lives or spends time to meet their needs
• changing triggers that lead to behaviours that challenge
• changing reinforcements that maintain behaviours that challenge
• supporting people to participate to achieve a typical lifestyle
• teaching skills to increase independence and ability to cope.

Secondary prevention
The focus of secondary prevention is to support people, when they are becoming distressed or agitated, to relax and prevent behaviours from becoming challenging. The emphasis is on calming, redirecting, distracting and problem-solving to avoid the need for physical restrictions and interventions.

Secondary prevention has three elements:

1. Knowing the early signs – All of us show signs when we are getting distressed or angry- for example going very silent, avoiding eye contact, pacing the floor and so on. Identifying the individual’s early signs is the first important step in helping them to avoid becoming too agitated.
2. Active listening – Closely monitoring their mood to note any early signs of agitation.
3. Taking action – Intervening early by removing triggers, distracting the individual with something they enjoy, giving them some space and, if necessary, moving other people away. It is important not to rush in, panic, threaten or challenge people when they are showing signs of agitation.

Another important thing is for carers themselves to remain calm to prevent the situation escalating and getting out of control, and to ensure they can get a safe distance from the individual if they need to.

Reactive strategies
Reactive strategies are not a treatment but are sometimes necessary when primary and secondary strategies have not prevented an individual from presenting behaviour that is challenging. Reactive strategies are safe and ethical responses that are put in place after the behaviour has occurred. They should be agreed by a multi-disciplinary team, and wherever possible the individual and recorded within their behaviour support plan.

There are four levels of reactive strategy, and the least intrusive one necessary for each incident should be used:

1. Increasing personal space – People often need more space around them when they are agitated, and providing this space serves to keep both them and the worker safe.
2. Self-protective and breakaway procedures – These are to minimise the chance of the social care worker being hurt.
3. As required medication – This should be offered to the individual if the first two strategies have failed.
4. Minimal restraint – This should only be undertaken as part of an agreed care plan. Techniques should be designed for an individual’s specific behaviours and should be checked out with the individual’s GP before they are used, as any physical restraint can be dangerous. Such techniques must use minimum force, not cause pain and be used for the shortest possible time only to keep the individual safe from harm.

What needs to be in place to support its use?

Several elements need to be in place for PBS to be delivered appropriately:

1. Functional analysis – To clearly identify the reasons an individual presents behaviours that challenge, their strengths and preferences, their health and communication needs.
2. PBS plan – To specify all that social care workers need to know and do to support the individual, based on the results of the functional analysis. This should focus mainly on primary prevention and also include the secondary prevention and appropriate reactive strategies that have been identified for the individual.
3. Training for social care workers – To ensure they understand the PBS plan and are skilled in all the things they need to do to support the individual. Training should be in three stages: verbal competence (they can explain what is in the plan); role-play (they can act out what they need to do); in vivo (they can carry out the plan in real life).
4. Practice leadership – Team leaders need to be skilled in supporting the individual so they can act as role models for workers and give them regular feedback on how well they are carrying out the PBS plan.

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