How RNLDs and BCBAs can support taking forward Positive Behaviour Support

This is a brief sum up of thoughts relating to how Learning Disability Nurses (RNLDs) and Board Certified Behaviour Analysts (BCBAs) can help take forward high quality PBS, following on from a #pbs4 tweet meet on this topic. By focussing on these two professions I am not excluding that other professions also have a key role, but BCBA’s are trained to the highest level of Applied Behaviour Analysis and many RNLDs are going on to do MSc’s or further studies in this. Both professions are in a very good position to set the expectations and raise standards.

Why is this important? There is a huge drive to increase the availability of PBS at the moment, and still there remains confusion about what PBS is. Most of the confusion is around the word “positive”. You may have seen in the last blog┬áthat we don’t use “positive” to judge if we think a behaviour is good/bad – who are we to judge this anyway! It is about “adding” behaviours, increasing independence. It is cognitive shifts like this that require skilled oversight to put in practice in my view. A lot of the attention at the moment is on how do we skill up support workers in PBS. This is great, but there are risks with PBS and if not overseen as a clinical intervention could make behaviour worse or create problems. It needs skilled oversight.

Here are my main thoughts on how RNLDs and BCBAs can help take PBS forward:

Promoting and growing the evidence base

PBS is underpinned by Applied Behaviour Analysis. There is a growing evidence base to its effectiveness. Nurses and Board Certified Behaviour Analysts have a code they work to that says we need to know the evidence and promote it. It is a core duty.

We have to challenge practice that isn’t in line with the evidence base. There is a lot of opinions about what PBS is. If it doesn’t fit with the evidence our codes say we should challenge it.

We also have a responsibility to grow the evidence base. PBS is a data driven approach. We need to write up our data, even if it is for one person, and publish it. We need to keep sharing what good should look like.

An educator

We should be educating teams and others about what PBS is. Sharing our knowledge. Helping other people to understand what PBS is about. There are always concerns about the terminology we use. But compare it to a cancer nurse who talks about hepatic malignant carcinomas. This may be gobbledegook to us, but they need that science to understand the evidence behind what they do. They may not use that language with patients and families. It is the same for us. We need to promote the use and understanding of the science, make it accessible, but avoid watering it down and deviating from what the science means.

Assessment

We have the skills and competence to complete full and accurate functional analyses of complex behaviours. Most behaviours won’t need a full functional analysis, you can understand a lot of behaviours just by listening to what people are trying to say. But sometimes people with learning disabilities, particularly without verbal communication, can be complex. For example, if a man starts hitting himself in the face his support might assume this is to gain attention. But if it is really because he has tooth ache this goes unresolved, but he has also learnt a new way to gain attention. The behaviour now has two purposes for the person. By not having a good assessment at the start the behaviour now has two purposes, and has become harder to stop.

Skilled assessment by competent professionals can avoid well intentioned support unintentionally making a bad situation worse.

Monitoring implimentation

Many people with learning disabilities and challenging behaviour will have more than one person that provides support for them. Each person may adopt what works for them. Imagine having a shower and one person puts the soap on the sponge and leaves you to it, the next day a different person gives you a full wash. You wouldn’t know what to expect. It is much easier for 5 people to learn to do something one way than a person with learning disabilities to learn 5 ways something is done.

Consistency is key in achieving real change and as clinicians, RNLDs and BCBAs are in an ideal place to design and monitor interventions are being completed accurately.

Measuring effectiveness

PBS is a data driven approach. We can subjectively review the data collected and identify whether the intervention is effective, what is and is not working, and what changes may need to be made. Without this skilled review you may as well lick your finger and stick it in the air to judge whether what is being done is any good.

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PBS has a lot of potential to improve quality of support services for people with learning disabilities. But if it is to be effective it must be done correctly. If it is bodged together on the cheap and pushed through as something that can be done without clinical leadership it won’t work. It will be ruled out as another fad people have tried and been let down by. That would be bad for PBS and awful for people with learning disabilities to be let down again. We wouldn’t accept an unqualified professional to do any other clinical intervention unsupervised. Why should this be ok to accept for people with learning disabilities?

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Positive? Who are we to judge the behaviour of others

The conflict between the scientific description of behaviour and everyday values about behaviour is one that those trained in PBS will be all too familiar with.

I have smoked cigarettes since I was 11 years old. It’s not something I am particularly proud of but I enjoy it. Does this make it a positive thing?

Society says smoking is bad. It is banned in most public places, they are hidden from view in shops now, and it is not that uncommon to get scowling glances from passers by. Does this mean smoking is negative? As I started at 11 the disapproval of others was probably a motivating factor and maybe something I still secretely enjoy, so positive right?

What we are talking about here is values and opinions. In reality, what I think about a behaviour or what you think about a behaviour will do nothing to change it. And who are we to judge the behaviour of others, saying what we think is positive or negative anyway? This isn’t how behaviour is changed, and it isn’t how Positive Behaviour Support works.

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When scientifically describing behaviour positive means adding to, negative means taking away. Just like how you don’t have a good side and a bad side of a battery. Some will scowl at me using the word “scientifically” (is their scowling positive or negative?), but we need to dissuade those in caring/supporting roles from making opinionated judgements about behaviour and promote an objective, evidence based approach.

Smoking is technically subject to negative reinforcement. Inhaling smoke takes away the pangs of nicotine withdrawal. It has probably picked up some other deviant reinforcements along the way, which is what makes us as humans complex, what makes behaviour so fascinating, and ultimately what makes behaviours like smoking hard to change.

Traditional approaches to stopping smoking, similar to approaches to challenging behaviour, have largely been focussed on how do we take this behaviour away. From going cold turkey to sticking patches all over yourself to wean you off the nicotine.

Positive Behaviour Support would look to help the person achieve the same function in different ways, and those ways have to be easier/more efficient than the behaviour you want to make redundant. This partly explains why e-cigarettes have been credited in the news this week with helping achieve the lowest smoking rates in the U.K. ever recorded. You use the same behaviours of inhaling and blowing out “smoke” to remove the nicotine withdrawal pangs, its cheaper, it has a pleasant(er) smell, and can be done in more places with no mess and less risk of burns.

I’m not making any promises to give up smoking anytime soon. But your judgements about whether smoking is a “positive or negative” thing won’t be what changes my behaviour. It will be understanding the reinforcement/function and providing functionally better options.

Peer pressure and opinions can act as a motivator to change behaviour but won’t change it in itself. I think I’ll save that for another blog though.