Behavioural Advisory Session EvaluationIntroduction

The behavioural advisory sessions (BAS) were devised in November and December 2010 by the community nurses with consultation with the link behavioural analyst. BAS was developed following analysis of the community nurses waiting list finding a high proportion of service users referred for active work from a CLDN for minor behavioural issues. Historical experience has also shown that there are consistently inappropriate nursing referrals for full behavioural assessments and interventions. The BAS therefore had two main objectives firstly to reduce the amount of service users waiting allocation for a community nurse for behavioural assessment and work without requiring them being placed on the team case list for set piece of work. Secondly to effectively gate keep the allocation of community nurses for active behavioural work.

Prior to the introduction of the BAS the community nursing waiting list was reviewed. 10 service users were identified as awaiting allocation for community nursing meeting the criteria for accessing the BAS process, which are as follows:

o Low impact challenging behaviouro Living in a supported living or

residential placemento Motivated home leader and staff teamo Previously know to teamo Previous professional behavioural

work preferable

In cases where service users present as a significant or high risk to themselves, staff and / or the public will continue to be allocated to a community nurse on receipt of referral. Where cases were found to meet the BAS criteria it was agreed that one member of direct support staff and the senior support work (formally home leaders) would attend. The senior support worker was to be invited via a letter with important information and examination of the BAS process (see appendix 1). It was agreed that these sessions would be no longer than 1 hour, with 30 minutes for information gathering and 30 minutes consultation. These sessions would be held at the CLDT HQ once a month over a maximum of 6 meetings. To start with it was decided that these sessions would be run by two community nurses and a behavioural analyst to increase nurse experience, knowledge and skills, whilst ensuring appropriate implementation of assessment tools and interventions. It was decided that initially the BAS would be run once a month as a pilot and if successful another BAS team would be implemented.

The BAS process is based on the basic principles affecting behavioural function looking at antecedents, reinforcers and environment modification. The nurses and behavioural analyst involved were not to carry out any active work and only provide advice and support to the participants within the session. The participants were then expected to complete a number of aims and objectives identified in the sessions, such as the completion of assessment tools, up-dating or creating of behavioural protocols and making environmental changes. The advice given by the nurses and behavioural analyst must be evidenced based and objectives achievable and given time scales. It was hoped that the process will build and develop the participant’s skills, which should be transferable to the rest of the support team.

It was found through the nursing modernisation meetings that a large proportion of these service users had already had some degree of behaviour assessment and intervention by community nurse and / or the critical needs service. Therefore in most of these cases there should be existing assessments and interventions. It was agreed that many of these individuals’ behavioural needs could be met through reviewing and updating existing behavioural information. The BAS attempts to provide a structured approach for this process with community nurses providing advice and support for project managers and project workers to appropriately up-date behavioural information. Small proportion of the referrals suitable for BAS did not have historical behavioural assessments and in these cases it is important to introduce appropriate assessment tools to ensure that advice and support given is evidence based.

Through discussions in the nurses modernisation meetings it was agreed that service users should not attend as discussion regarding there challenging behaviour can be very anxiety provoking and distressing for them. Also this would enable the community nurses to discuss behaviour proactive and reactive management strategies and how these should be implemented in a much more efficient manner.

The BAS aims is to provide a safeguard to inappropriate referrals for medium to low level behaviour intervention ensuring that cases are only allocated where needed, enabling nurses to have more time to work with complex cases. This gate keeping is completed in the initial behavioural advisory session through an interview and review of existing behavioural information. The first session follows a set format (see appendix 2) with a number of questions regarding behaviour, health, social and lifestyle changes. This information should provide the community nurses enough information to decide if the case is appropriate to continue through the BAS process or if a community nurse should be allocated.

Evaluation

It has now been a year since the BAS has been implemented and an evaluation of the service has been completed. The following document will analysis the evaluation records from the service managers, community nurses and behavioural analyst involved in the process.

The evaluation found the 10 about of cases had been to the initial behaviour advisory session. From these cases 8 went through the full 6 sessions or less. The remaining 2 were allocated for community nursing for team case load. Data from the nurse’s waiting list for behavioural support have shown that there has been reduce from 10 to 0. The sessions are continuing to run on a monthly basis with two BAS teams, however these are not running to capacity and one BAS group a month could meet the current demand.

Service Provider Evaluation

The evaluation sheets were only completed by service managers who had concluded the BAS process. No data has been collected from individuals involved in only the initial behavioural advisory session. The evaluations sheets found that 2 of senior support workers found the BAS had a positive impact on the service user’s behaviour and 2 feeling that it was mostly positive. The remaining two were unable to say due to being moved to the project late in the BAS process.

One senior support worker stated that the BAS should gather much more detailed information in the first meeting and provide more individualised recording tools. She also felt that visual data analysis would be more beneficial for the service user’s staff team. 2 senior support worker stated that the process could be improved the whole staff team having a better understanding of the process. 2 senior support worker became involved in the BAS process near the end and they felt that they were not given enough information on the sessions. They recommended that more information is given to senior support workers that join the BAS mid way through.

Community Nurses Evaluation

Four community nurses were involved with the BAS process working in two teams each reviewing and advising 3 cases once a month on a designated day. The community nurses have reported a number

of positive aspects that the implementation of BAS had brought. All the nurses involved felt that the BAS process encourages and promotes staff teams and management to develop there own protocols leading to a sense of ownership and therefore increasing the likelihood of implementation and consistent approach. The nurses involved also felt that it effectively prevented the inappropriate allocation of community nurses as well as being a very effective use of nursing resources. Another area that the nurse agreed the BAS produced was the development of skills and knowledge of staff and management, which should be transferable to similar projects. Other positive aspects indentified by the nurses were:

Identifying good practice Staff encouragement and building confidence Revisits and developing existing work, interventions and

protocols Clear process Very positive when working with a motivated staff team Encourages team work and increases job satisfaction when

done correctly

The nurse evaluation sheets found that there were a number of areas in which the BAS process could be improved. The major problem that all community nurse found was that the service provider had not fully read or understood the information sent regarding the BAS process and want was expected from the and there staff team. Consequently bringing the service user to the sessions or not bring specified documentation so data analysis could not be completed and therefore interventions and advise could not be given. There was once team that brought the service user to 3 sessions another team did not know that there was a behavioural support plan in place until session 3.

Although the nurses found that BAS is an appropriate use of there clinical time the majority of them found that it was resource intensive with four nurses having to dedicate half a day over the two teams. The nurses also reported that the lack of protected time became a hindrance as important meetings taking presentence over BAS and days subsequently being changes. Once this change had occurred it was difficult to find a day in which all parties could attend.

The nursing team found that commitment and motivation of the staff teams and their senior support worker is essential to the BAS process. The provider must be committed to the process and implement the aims and objectives set in the BAS and bring any data or new documentation to the next session, as without this the BAS ineffective. Unfortunately the nurses did experience poorly motivated staff teams with workers with limited understanding and

experience of learning disabilities. Often these teams have limited communication with there management and consequently work is not completed and / or support staff will want to discuss all of the issues they are experiencing. Poor staffing levels and non-attendance was a major negative aspect of the process often with very minimal warning of cancelation or none at all. Due to the restructuring in Community Living Service the community nurses found that there were regular changes in service user’s support team and management, which very disruptive for the service user and makes it difficult for aims and objectives to be completed.

Some of the nurses felt that the BAS process needed to be more holistic with quality of life being more evident. The current process concentrates on topography of behaviours, triggers and reinforcers without enough emphases level and variety of activities, choice and independence.

Out of the 6 cases that went through the BAS process 5 had already had involvement from a community nurse, with 2 of these having involvement from BST. In these cases it is essential that previous behavioural interventions, protocols and behavioural support plans are brought to the initial session. These will then be reviewed by the community nurses and advice given to the senior support worker and / or key worker to up-date, make changes to behaviour documentation or ensure that current protocols are being implemented appropriately.

Conclusion

Following evaluation by the community nurses there were a number of areas that were found needed improvement. Firstly the BAS pathway was streamlined to be clearer and more coherent. The letter format and information was also simplified in order for team managers to have a better understanding of the process, stressing the vital importance of not being the service user and the need for assessments and data required for each session.

The format of the initial behaviour advisory session has also been changed to incorporate more of a positive behavioural support element. This should make this process more holistic and focus more on quality of life issues and proactive management strategies.

The behavioural analyst attended around 50% of the behaviour advisory sessions due to heavy work load and breakdown in communication; however these sessions still ran very effectively and the community nurses were able to advise appropriately with positive results. Therefore the level of behavioural analyst resource for the BAS process needs to be reviewed. One suggestion is that the behavioural analyst be accessible during these sessions.

Currently both BAS teams are not running at capacity and if this were to continue one team might be more appropriate. Many of the community nurses felt although BAS was an appropriate and good use of there time, it was very resource intensive. Therefore further discussion needs to be had regarding if these sessions could be run by one community nurse with support from the behavioural analyst if required.

Protected time to complete BAS sessions each month is extremely important. This should also incorporate time to write up the minutes for each session. Clinicians need to ensure timely delivery of these minutes as they have clear aims and objectives to be completed.

An important part of the BAS process is the completion of behavioural assessment tools by the individual’s staff team. The nurses involved agreed that it would be beneficial to have access to a number of behavioural assessments tools immediately due to the limited time available. Therefore it is suggested that a file of relevant assessment tools should be compiled and taken to each BAS. A lap top could also be valuable to quickly and effectively write up data provided by support staff and where possible analysis data.

Development of a letter to providers to be sent when BAS instructions have not been followed i.e. service user being brought, no data, DNA. At the beginning BAS process the community nurse must discuss with the provider the importance of completion of work, motivation and ensure that they have fully understood there role within the sessions.

Lastly as breakdown in communication has been an issue for nurses, project workers and senior support worker, it is essential for an information leaflet to be created. This should be aimed at staff teams to help raise understanding of the BAS process and what is expected from all involved.