This is the first in a series of four Behaviour Support Planning Blogs. In this initial blog I will briefly describe the problem of behaviours of concern in residential aged care settings, and use an illustrative example from the Royal Commission into Aged Care Quality and Safety (Aust. Gov. 2020). I will focus on one particular recommendation (No: 17) from the Royal Commission, and the subsequent regulatory requirement for residential aged care facilities to establish Behaviour Support Plans for residents. I will define a “Behaviour Support Plan”, and briefly explore the initial steps in the process of behaviour support planning (collaborate and identify, assess and set goals).
Behaviours of Concern
Behaviours of concern are frequently observed in older people living with dementia and/or mental illness. These behaviours can lead to dangerous and difficult situations for the person and others in the environment. By 2050 the prevalence of dementia in Australia will grow to more than 1.1 million, and will account for 11% of health and residential care spending by the 2060’s. Over 90% of residents with dementia manifest one or more challenging behaviour over the course of the illness.
A Sydney based Behaviour Assessment and Intervention Service (BASIS) found 38.5% of a sample of nursing home residents presented with physical aggression, 23.1% with verbal aggression and 19.2% with disruptive vocalisation (Turner & Snowdon, 2009). These behaviours caused significant stress for residential care staff and adversely impacted care planning and service delivery.
Example from the Royal Commission into Aged Care Quality and Safety
The Royal Commission into Aged Care Quality and Safety heard testimony that older people are frequently treated with psychotropic medication to manage these behaviours of concern; and they noted there has been an increasing reliance on this form of restraint in residential aged care facilities.
As an example of these concerns, the Royal Commission heard testimony from Ms DF (let’s call her Dianne), regarding her mother Mrs CA (let’s call her Carol). Carol was 82 years old and living with Alzheimer’s Disease in a Dementia Unit in a residential aged care facility in country NSW. Carol regularly wandered around the Dementia unit and entered other residents’ rooms and picked up their belongings.
In a serious incident of June 2018, Carol sustained a head injury causing bleeding on the brain and fractures to her pelvis and clavicle. The Royal Commission heard testimony that Carol was put to bed for the night in the early evening. She then wandered into the communal area. Staff “directed and escorted” Carol from the communal area to her room, and then left her unsupervised. There were two staff on duty in the dementia unit at the time.
Carol subsequently entered another resident’s, Mr CB’s, room (let’s call him Charlie) while he was present in the room. Charlie’s room was across the corridor from Carol’s. There was no supervision of them by staff at this time. Inside Charlie’s room, Carol’s head and body made forceful contact with the floor, but it is not clear whether this was the result of a push or hit by Charlie (as Carol alleged) or a fall (as Charlie alleged). No staff observed the events in Charlie’s room. Charlie was then observed by staff to drag Carol out of his room by her arms into the hallway (Aust Gov. 2020. Volume 4a, page 121-127).
The Royal Commission noted that there were 3 behaviour assessments prior to this serious incident.
“The third behaviour assessment includes some additional information and was prepared after staff at …. Village had consulted with the DBMAS and an in-house dementia advisor. However, much of the additional information in the third behaviour assessment was copied from the pre-existing extended care plan for Mrs CA dated 31 May 2018″.
(Aust Gov. 2020).
Notably, this incident occurred despite the involvement of the Dementia Behaviour Management Advisory Service (DBMAS) who had already initiated a “behaviour care plan”, and an “in-house dementia advisor”. There are no details provided about whether the care staff were engaged in the entire process of behaviour support planning, particularly in the implementation.
The Commissioners stated that “this case study illustrated the challenges providers of aged care face when accommodating people who live with behaviours associated with dementia”.
In relation to dementia care, the Royal Commission made a number of recommendations, including recommendation 17, regulation of restraints.
This recommendation stated:
“The Quality of Care Principles 2014 (Cth) should be amended by 1 January 2022 to provide that the use of restrictive practices in aged care must be based on an independent expert assessment and subject to ongoing reporting and monitoring. The amendments should reflect the overall principle that people receiving aged care should be equally protected from restrictive practices as other members of the community”.
(Recommendations, Page 221).
The Commissioners recommended restrictive practices should be prohibited unless recommended by an independent expert. This expert must be accredited for the purpose by the independent Quality Regulator, as part of a behaviour support plan.
An outcome of this recommendation was the recent publication of a regulatory bulletin from the Aged Care Quality and Safety Commission announcing increased regulation around restrictive practices and the creation of a new role, Senior Practitioner Restrictive Practices (Aust. Gov. RB 2021-13, 2021).
It details that “from the 1st July 2021, approved providers must have updated and specific responsibilities under the Aged Care Act 1997 and the Quality of Care Principles (2014) relating to the use of any restrictive practice in residential aged care and short-term restorative care in a residential care setting” (Aust. Gov. RB 2021-13, 2021, page 1).
It states that “from 1st September 2021, providers are required under the Principles to have a Behaviour Support Plan in place for every consumer who exhibits behaviour of concern or changed behaviours, or who has restrictive practices considered, applied, or used as part of their care” (page 4).
What is a Behaviour Support Plan?
So, what exactly is a Behaviour Support Plan? It is a plan that assists a person in building positive behaviours to replace or reduce behaviour of concern. It includes positive (preventative and responsive) strategies and interventions. This plan may include teaching new skills, changing contingencies, improving communication, improving relationships, modifying the environment, and using other evidence-based clinical interventions eg. cued-recall interventions, positive reinforcement systems, and the identification of functionally equivalent replacement behaviour (FERB).
Positive behaviour support has been defined as:-
“an applied science that uses educational methods to expand an individual’s behaviour repertoire and systems change methods to redesign an individual’s living environment to first enhance the individual’s quality of life and, second, to minimise his or her problem behaviour”.
(Carr et al. 2002, p. 4).
The Process of Behaviour Support Planning
With over 25 years’ experience providing behaviour support services in residential aged care environments, we have developed a process that ensures that each person receives individualised specialist positive behaviour support that is appropriate to their needs, person-centred, incorporates evidence-informed practice, and complies with relevant legislation and policy frameworks.
“The person-centred approach is founded on the ethic that all human beings are of absolute value and worthy of respect , no matter their disability, and on a conviction that people with dementia can live fulfilling lives”.
The process is as follows:-
1. Collaborate and Identify
The development of the behaviour support plan for each individual is best done in collaboration with the providers implementing the behaviour support plan. To be effective, behaviour support planning starts with an initial meeting. This meeting should include significant others involved with the individual, including carers, family, providers who will be implementing the plan, and any allied health staff involved. This collaboration ensures high levels of commitment, consistency, and good communication by all involved parties. All parties work together to identify the behaviour of concern. Different perspectives are inevitable. All perspectives are valid, and will further inform the planning process.
Each older person has a unique combination of biological/physical, psychological and social features. These all need to be assessed, starting with a thorough medical review by the medical practitioner. We need to develop an understanding of the person, including an understanding of their personal history, background, cultural factors, personality, ways of coping and relating, and likes and dislikes.
a) The Biopsychosocial Model
This model is used as a framework when providing individuals with behaviour support services. This model assists with identifying all the relevant underlying causal and contributing factors of the presenting behaviour, and guides the design of goals and interventions.
b) Functional Analysis is Performed
Positive behaviour support recognises that all human behaviour serves a purpose, including those behaviours that are considered to be behaviours of concern. In order to bring about adaptive change, it is vital to understand the purpose of the existing behaviours, the person’s aspirations/goals and the range of their personal strengths, knowledge and skills.
The behaviour of the individual should be adequately and specifically described. This happens best when observing the behaviour on multiple occasions. Information about antecedents and consequences is collected, as are measures of frequency and intensity. This information includes what was happening at the time, and provides details of the context of the behaviour.
Private events (non-observable variables) are also considered in the functional analysis. These private events may include pain, mood, flashbacks to frightening images. It’s easy to see how private events could act as antecedents to a behaviour eg. a flashback to a frightening image may be an antecedent of screaming.
c) Environmental Assessment is Crucial
In order to develop effective behaviour change intervention strategies it is important to understand the context in which any behaviours of concern occur and the environments in which the person lives and needs to learn to use more adaptive behaviours. In order to assess this, we also need to consider the care environment. In particular, we absolutely must assess the staff approach and response to the person and their behaviours.
There will be no progress with behaviour support planning unless the care staff are fully engaged in the process. This will depend upon the willingness of management to prioritise such engagement. This is a huge challenge due to the workforce issues. These are discussed in more detail in Part 3 of the Amazing Ageing Psychology Blog Response to the Four Corners programme about abuse and neglect in aged care facilities.
3. Design of Goals
Goals are for the individual. Goals need to be person centred and address causal factors identified in the assessment.
Recognising and meeting the needs of the individual means improving their quality of life (often by reducing drug and restraint use), and maximising independence.
Behavioural goals are the most obvious, and describe, but are not limited to:
- The behaviour that needs to decrease (i.e., the behaviour/s of concern)
- The behaviour that needs to increase (the functionally equivalent replacement behaviour)
Best-practice goals focus on the following:-
- Attempt to meet the person’s needs.
- Assist in reaching their personal goals.
- Improve communications for the person.
- Improve relationships for the person.
- Maximise functional independence.
- Promote the development of more adaptive behaviours.
- Improve quality of life
From these, more specific and measurable goals can be set for the older person.
In this blog I have taken you on a brief journey into the realm of behaviour support planning in residential aged care settings. I started with the behaviours of concern, illustrated with an example from the Royal Commission, and progressed to Recommendation 17, with the subsequent regulatory guidelines now in place. The initial steps of behaviour support planning were discussed (collaborate and identify, assess and set goals).
Stay tuned for more in this series of Behaviour Support Planning Blogs. Part 2 will focus on the design of interventions, Part 3 will delve deeper into implementation, and Part 4 will focus on evaluation and review.
Behaviour support planning is part of our core business. If you are committed to provide best-practice behaviour support for your residents, while meeting regulatory requirements; or if you would like to learn more about behaviour support planning, please contact us at Amazing Ageing Psychology on 9844-5403, or send an email enquiry through our website here.
Senior Clinical Psychologist
Amazing Ageing Psychology
Copyright © Jane Turner 2021
Images in this blog are used under license from Shutterstock.com.
Aust. Gov. (2020). Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect. Volume 4A: Hearing overviews and case studies. Adelaide Hearing 1 to Darwin and Cairns Hearing
Aust. Gov. Regulatory Bulletin 2021-13, (2021). https://www.agedcarequality.gov.au/sites/default/files/media/rb-2021-13-regulatory-bulletin-regulation-restrictive-practices-role-snr-practitioner.pdf
Alzheimer’s Australia NSW. Alzheimer’s Advocate 2009; Edition 2, April.
Carr, E.G., Dunlap, G., Horner, R.H., Koegel, R.L., Turnbull, A.P., Sailor, W., et al. (2002) Positive Behaviour Support: evolution of an applied science. Journal of Positive Behaviour Interventions, 4(1), 4–16.
Kitwood, T (1996). Building up the mosaic of good practice. Dementia Care 3:12-13.
Turner J, & Snowdon J (2009). An innovative approach to behavioral assessment and intervention in residential care: A service evaluation. Clinical Gerontologist 2009; 32:260-75.