Following the Winterbourne View incident in 2011, positive behaviour support (PBS) gained more attention in the care of people with challenging behaviour (Care Quality Commission, 2018). PBS is a framework that provides a structured approach to care where the dignity, human rights and values of vulnerable service users are safeguarded.
Baker and Allen (2012) discussed PBS being an evidence-based intervention. In essence, they distinguished between PBS and applied behaviour analysis (ABA); this separation is important for the future practice of PBS (Baker and Allen, 2012). PBS is a model that ensures and maintains the human rights and values of individuals, whereas ABA offers treatment interventions that can be specific to circumstances (Smith and Nethell, 2014).
A wealth of evidence supports PBS and confirms it is an extensively used model that is value based, bearing all the hallmarks that improve individuals' quality of lives (Hanley et al, 2003; LaVigna et al, 2005; LaVigna and Willis 2012; Hassiotis et al, 2014). The person-focused, individualised approach of PBS makes it favoured over other interventions (Weiss and Konster, 2008). In addition, a number of studies have validated PBS as a scientific model in the management of challenging behaviour (LaVigna and Willis, 2012; Gore et al, 2013; MacDonald and McGill, 2013; McClean and Grey, 2016). Similarly, a recent study has shown wide approval of PBS by parents, who have described the practice as a positive, collaborative approach to address behaviours of concern in children with complex needs (Botterill et al, 2019).
Background
While PBS is described as a multicomponent framework that is delivered through an multidisciplinary team (MDT) approach, nurses' views of PBS were lacking in literature until recently (Savarimuthu, 2019). Savarimuthu (2019) explored the experience of six nurses of using PBS in practice.
Nurses are often seen as important players in the day-to-day implementation of PBS plans, with other professionals, such as clinical psychologists and occupational therapists (OTs) taking more of a leadership role (Davies et al, 2019). However, nurses' experience of PBS is central to how it is implemented in practice and their input potentially ensures it is delivered effectively. Nurses are well known for their abilities and skills to establish therapeutic relationships with service users. This rapport means that nurses develop a trusting relationship with service users, which has helped in engagement with them and in the co-production of PBS plans. These qualities are useful in the context of PBS.
Because of nursing's troubled history, with it being seen as a vocation with training based in hospitals rather than university, it was difficult for nursing to gain recognition and validation as a profession. Being accepted as a profession is still challenging for nursing. Although it is now a graduate profession, nurses continue to find it difficult to explain their roles in an MDT setting (Willetts and Clarke, 2014). The discourse around nursing identity therefore remains current, especially as nurses are gradually becoming key players in the delivery of evidence-based practice.
This paper reviews nurses' views of PBS in relation to it being a psychology-dominated intervention and the implications of this in current clinical practice, as well as nurses' role in the future of PBS. This theme emerged in a previous study by the author (Savarimuthu, 2019).
Positive behaviour support
PBS is a model of care that is non-aversive and non-intrusive. It is a behavioural approach that is used in areas of challenging behaviour and was recommended by the Department of Health (2014) following the Winterbourne View incident, where service users with learning disabilities and behaviours of concern were abused. PBS focuses on a functional assessment that informs the development of strategies to support individuals with complex needs.
Participants, methodology and method
Six nurses from both mental health and learning disability inpatient settings took part in semistructured interviews for the study.
Registered nurses were invited to take part through an email from the trust. They had to have received some form of training in PBS, used it in practice and been involved in delivering it in mental health or learning disability services. Student nurses and other nursing trainees, nurses who were unaware of PBS and non-employee bank staff were excluded.
There were four mental health and two learning disability nurses; four women and two men.
The interviews were each an hour long and were uninterrupted. They were conducted on the trust premises to ensure meeting rooms were set up to maintain confidentiality.
Data were collected during the semistructured interviews and analysed through thematic analysis.
The study used hermeneutic phenomenology as described by Heidegger and data analysis was by thematic analysis (Braun and Clarke, 2006). The hermeneutics circle, as endorsed by Heidegger, promotes the view that ‘understanding and interpretation of [a] phenomenon is gained through shared knowledge and shared experience’ (Reiners, 2012: 3).
Ethical approval was sought from the University of Salford where the author is undertaking a doctoral programme. No other ethical approval was required for this project.
Results
Six themes emerged: training; resources; psychology-led practice; restrictive practices; communication; and effectiveness (Table 1) (Savarimuthu, 2019). This paper explores the theme of ‘psychology led-practice’.
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Nurses' views of PBS
One of the six themes was ‘psychology-led practice’, which had subthemes of ‘clinical psychologists seen as PBS experts’ and ‘barriers’.
The six nurses interviewed in Savarimuthu (2019) see clinical psychologists as the experts who often lead PBS. Clinical psychologists embrace the leadership role in coordinating delivery, and the nurses felt this created tensions and challenges to team cohesion and collaborative working (Savarimuthu, 2019). This potential conflict may arise from a perception that PBS has become a psychology-dominated model mainly because of nurses being passive and too often the minions of a medically and psychologically influenced chain of command (Grant, 2001; Santangelo et al, 2018). These issues can become barriers to the effective implementation of PBS.
Clinical psychologists seen as PBS experts
Clinical psychologists are seen as the leading figures in PBS and the experts with overall dominance and influence over how PBS is planned are designed and applied. One nurse reported:
‘[Clinical] psychologists are the leads; they develop the plans and they pass them on to the team. They are the ones who decide what to include in PBS plans.’
Another participant, who has a psychology background, explained that psychologists and OTs share joint responsibility in ensuring PBS is in place and is effective. PBS was well received by this group of highly committed nurses in clinical practice. However, nurses are seen as facilitators rather than leaders:
‘Psychologists and occupational therapists are the main people taking a lead in PBS but nurses are very much engaged in the process in ensuring PBS is being delivered.’
Similarly, another was of the view that nurses are able to deliver and lead PBS provided there was adequate training:
‘We don't have to rely just on psychologists; nurses can do this. I could go out and help put a PBS plan [in place] and, in actual fact, probably we are more suitable to deliver PBS—but we need to have the education.’
Although there is recognition of the contribution from clinical psychologists in the advancement of PBS, one nurse argued that psychologists might not be the most appropriate colleagues to take the lead; this was based on the amount of time that clinical psychologists spend with service users. Consequently, psychology colleagues may not be in a position to build therapeutic relationships as nurses would be. One participant said:
‘Of course, clinical psychologists do a good job but they come to the ward once or twice a week and see the patients for half an hour or 45 minutes and they just go off to write a PBS plan.’
When asked about their views of why psychologists are often the leading figures in PBS, one nurse said:
‘I think purely [from my perspective] it is the training that psychologists have had. Their education helps them better understand interventions like PBS. Nurses are doers; they will get on with it by helping with the implementation of PBS. In terms of taking a lead in doing behavioural plans, it's always been the psychologist.’
It was claimed that behavioural approaches have always been psychologists' areas of expertise, which is why PBS is led by clinical psychologists:
‘If you look at the current environment, [clinical] psychologists are the ones who lead on matters involving behaviours [of concern]. Psychiatrists deal with mental health issues and, us nurses, we are the one who follow the instructions, which is unfortunate.’
One nurse is of the view that psychologists are eager to hold high-profile responsibilities and be involved so are at the forefront of the development of PBS plans compared to nurses who are seen as passive members of the MDT:
‘Psychologists are very willing to learn and develop strategies. Nurses are somewhat reluctant to do so. This could be because of a lack of opportunities, lack of confidence or just a lack of interest.’
Barriers
The second subtheme that arose under ‘psychology-led practice’ was ‘barriers’. The majority of nurses felt there were barriers and challenges at play when using PBS:
‘Patients were not necessarily involved in the PBS programme. By me saying this, I mean patients may have a meeting with the psychologist without the involvement of a nurse. He [the clinical psychologist] may not know what was discussed at a handover; but I think it is essential to engage nurses in the process. An absence of nurses may mean a lack of leadership from them.’
One nurse believes senior MDT members such as psychiatrists play an important role in deciding who should lead PBS:
‘If we have a situation where the psychiatrist suggests nurses should take a lead, then nurses will be more engaged with this. You will find people who would want to be involved. There are a few nurses who are very good at PBS but never had the chance to be involved at that level.’
Comments were also made about psychologists' positions within the MDT, the role of psychiatrists and nurses' attitude and engagement in PBS. One participant reported:
‘Once psychologists have positioned themselves as leaders—and this being acknowledged by senior members of the MDT [psychiatrists]—nurses find it difficult to become interested in or even taking the role of leader. There is a degree of unwillingness to engage. This is not necessarily being unprofessional but there is a lack of cohesion.’
Psychology-led practice
The six participants who took part in this study described PBS as a psychology-dominated intervention (Savarimuthu, 2019). Nurses from the study perceive clinical psychologists as experts in PBS, but feel this could create a barrier that hinders the full potential of PBS. The view of clinical psychologists as leaders of PBS may have stemmed from the origin of PBS (Carter et al, 2011). PBS was initiated with a psychological backdrop in both the US and UK (Positive Behavioural Support (PBS) Coalition, 2015). Bambara et al (1994) epitomised the original use of PBS initially driven by psychologists in a school environment where they were supporting teachers who in turn were supporting children with challenging behaviour.
Nurses may have developed some resistance because PBS is a psychological framework but have remained central to its development and practice. However, clinical psychologists are seen to be taking prominent roles in developing PBS plans and leading its delivery in current practice. In such a case, there is the perception that PBS is applied through a top-down approach with nurses often finding themselves at the lower end of the hierarchy, seldom given the primary role of monitoring how the plans are working.
Interestingly, nurses view clinical psychologists as an unknown group whose input in providing healthcare is uncertain (Osborne-Davies, 1996). Furthermore, clinical psychologists have been described as occasional workers with indeterminate roles who have momentary contact with service users (Saar and Trevizan, 2007). Undoubtedly, some of these observations have impelled nurses to think it is appropriate that clinical psychologists work in partnership with the nursing team alongside service users to co-produce PBS plans rather than working in silos (Ham and Davies, 2018).
Nevertheless, there are arguably positives of having one profession assigned to lead PBS. One benefit is around achieving consistency from having one profession deliver the practice (Gore et al, 2015); this is an important consideration as otherwise PBS runs the risk of failure, particularly if there is a lack of co-ordination or communication between different professions (PBS Coalition, 2015). However, an MDT approach is helpful because sharing knowledge and expertise across disciplines is valued (Webber et al, 2017). A salient component in the successful implementation of the PBS model is a constant MDT presence in areas where it is being practised. This argument is supported by Nancarrow et al (2013), who believe PBS should be practised in a way that crosses interdisciplinary boundaries. The participants in Savarimuthu (2019) also referred to the importance of teamworking and, in their view, working in collaboration with professionals from diverse occupations is important and beneficial, particularly as clinical psychologists may have only occasional contact with service users. Nurses wish to be actively involved and, at best, lead as they interact with service users on a day-to-day basis (Pazargadi et al, 2015).
Professionals other than clinical psychologists are already involved in PBS, including school teachers, social workers and OTs (Perez et al, 2012). Therefore, although PBS remains mainly psychology-led in clinical practice (Dunlap, 2006), it is now evident that leaders of the framework incorporate other disciplines. Perez et al (2012) established the importance of OTs in the implementation of PBS, claiming that because challenging behaviour may be caused by a number of factors, such as social difficulties, sensory modulation challenges and skills deficits, the role of OTs is relevant in addressing behaviours of concern (Webber et al, 2017). Correspondingly, OTs have positioned themselves in a leading role. Similarly, social workers are recognised as implementers of PBS (Leyba, 2010), and the role of speech and language therapists in PBS is now well documented (Webber et al, 2017). It is nurses' position as leaders with regard to PBS that remains unclear.
Nurses need to embrace the PBS model and it is crucial that they feel a sense of belonging with the concept (Karger et al, 2018). This is important step that would ensure a the could take on a leadership role in a smooth, realistic way. In cases where PBS has been successful, there has been a notable commitment from staff to advocating for it while creating opportunities for PBS to succeed through a collaborative working approach (Ham and Davies, 2018).
Recommendations for practice
Nurses have reported teamworking and consistency as two essential requirements for PBS to work and deliver its objectives. Teamwork is very dependent on having both adequate staff and a workforce that has the right skills and competencies. Therefore, training is a key determinant of PBS delivery.
In addition, the nurses in this study referred to the benefits of working with service users and the contribution of the MDT. This collaborative working is useful in the implementation of PBS plans, as the approach requires input from different fields of expertise. Consistency is viewed as fundamental to successful PBS delivery. The participants described the implications of an inconsistent approach and the impact of this on service users and the care provided to vulnerable people. To ensure consistency and the best outcome in the delivery of PBS, a co-produced approach is preferred. This would mean service users, carers and experts by experience would make a significant contributions to the decision-making process.
For PBS to be effectively practised and for service users to enjoy the full benefit of the practice, some areas require further exploration and a number of these are highlighted in Table 2.
| Leadership | Nurses should be empowered to take leadership roles in the practice of positive behaviour support (PBS) and to lead research that informs their understanding of the model |
| Training | PBS training needs to be offered to all staff, in particular nurses, so they are equipped to lead the intervention |
| Collaborative approach | Clinical psychologists, occupational therapists and nurses need to work in partnership with service users |
| Co-production | Service users are the primary stakeholders in any intervention and nurses are best placed to engage them in co-designing PBS plans |
| Resources | Recruitment and retention of nurses is a national issue. NHS organisations should work together to develop strategies so that nursing resources are distributed and used appropriately |
Nurses are considered key players in PBS practice by virtue of their proximity to service users and by often being the frontline staff who deal, manage and be with victims of violence and aggression (Dickens et al, 2013).
These are some of the arguments for nurses to be given opportunities to be empowered to take an active role in leading PBS (Griffiths and Wilcox, 2013). The essence of nursing has meant that nurses have become important stakeholders in care delivery for service users rather than merely implementing plans (Santangelo et al, 2018). Similarly, while clinical psychologists in general are observed to be more open to collaborative working and often offer an alternative to the dominant medical model (Christofides et al, 2012), they have shown great leadership in PBS field; this may have sidelined nurses.
While various factors affect and influence teamworking, hierarchy, power and individual characteristics are some of the dominant themes (Jones and Jones, 2011; Fox and Reeves, 2015; Sims et al, 2015). Nurses and clinical psychologists will therefore need to share responsibilities and accountability towards collaborative working for PBS to succeed (Karger et al, 2018). However, there should be also be a recognition that nurses need to take a leading role in the delivery of PBS.
Conclusion
There is strong evidence that it is important for nurses to take a leading role in the management of challenging behaviour through the facilitation of PBS. Indeed, systematic preparation and training of nurses in PBS are necessary steps to encourage much more engagement from this professional group.
In the current landscape, another issue requires further consideration; for nurses to be able to have a greater involvement in PBS, healthcare organisations need to provide the resources so nurses have the flexibility to take on the role of PBS practice leaders. Extra resources could release nurses from some of their current responsibilities (Redknap et al, 2015). This could be a senior nurse being given protected time off their clinical duties to take on the role of PBS coordinator or PBS champion.
As with any piece of research, this study has its limitations, starting with the sample size. However, there is a paucity of research exploring nurses' experiences of PBS so the views of a small number of nurses are a valuable contribution.
Exploration of a community-based PBS could be useful to fully appreciate the practice. Equally significant would be an investigation of other professionals' experience of PBS. These may include nursing associates, healthcare assistants and graduate mental health workers, as they are all actively involved with the model.