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 that 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.
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.
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.
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.
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.
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?