Positive behaviour support: a systematic literature review of the effect of staff training and organisational behaviour management

Figures & data

Figure 1. Prisma chart presenting the screening process.

Table 1. General and training information.

Authors	Participants	Setting	Country where the study took place	Training	Duration
Crates and Spicer 2012	3 first generation trainees Second generation trainees 32 clients (25 adults, 7 children)	Disability services in Tasmania	Australia	Train the trainer model: Trained trainers who attended courses provided by the Clinical Director of the Institute for Applied Behaviour Analysis (IABA) (LaVigna et al. 2005). The training was replicated in 2006 by the Tasmanian training team to second generation trainees. Tasmanian trainers were prepared, supervised and monitored by IABA. PBS course following IABA’s model (LaVigna et al. 2005) Level 1 (including topics such as IABA’ s multi-element model, functional behavioural assessment, Level 2 (longitudinal Practicum)	4 days (Level 1) 9 days spread over a period of 9 months (Level 2)
Dench 2005	38 students/staff	St. John of God Hospitaller Services (for people with learning disabilities)	UK	Training in Multi-Element Behavioural Support, adapted from IABA, and based on the intensive intervention sequence (Donnellan et al. 1985) Supervisors’ workshop for all staff attending training	9 months
Haberlin et al. 2012	44 direct care staff, (after excluding those not meeting criteria for analysis, 10 staff remained from the consultant-led training and 16 from pyramidal training. 4 supervisory staff	Community based programmes	USA	PBS course delivered either through pyramidal training or through consultant led training Most of the materials came from the manual Positive Behavior Support Training Curriculum: Supervisor Edition (Reid and Parsons 2004) In pyramidal training the supervisors were trained by the consultants	Consultant-led training: 5 training sessions (1 h each) Pyramidal training: 6-7 one-hour sessions within 2.5 weeks. Supervisors: 5 training sessions (1 h each) + 1 h training on how to deliver feedback
MacDonald et al. 2018	72 managers 72 clients Staff managed by managers	Community based social care provider	UK	PBS course ‘multielement model’ (Lavigna and Willis 2005)	1 year (2 days introduction, 8 one-day workshops, 6 weeks apart)
McGill et al. 2018	81 adults with intellectual disabilities Secondary participants: staff and managers	Residential services for adults	UK	Training as part of system wide intervention	11 months intervention
McKenzie et al. 2002	36 staff	Non-statutory residential services	UK	Training on challenging behaviour (described as using the multi-element model)	1 day
O’Dwyer et al. 2017	54 staff 17 adults with disability	Agencies registered with the Victorian Department of Human Services	Australia	PBS course included elements of good practice as recommended in the BSP QE-II guide (recently	4 days in two-day blocks conducted 2 weeks apart 12 months (after training for developing an implementation plan for their team)
Reid et al. 2003	12 supervisors (1st training for a part of the training curriculum) 386 supervisors	Residential Agency in North Carolina	USA	PBS course following the Carolina Curriculum: The curriculum included supervisory skills, developed under the auspices of the South Carolina Department of Disabilities and Special Needs	5 days within 5 consecutive weeks
Wardale et al. 2014	234 staff working in the disability sector	Training course run by the Centre of Excellence for Behaviour Support (training provider)	Australia	PBS course. The Functional Assessment and Positive Behaviour Intervention (FAPBI) training course	4 days course delivered across 6 to 8 weeks

Table 2. Type of outcomes and measurement systems for staff overt behaviour.

Authors	Staff skills	Knowledge	Residents’ outcomes	Other outcomes
Crates and Spicer 2012	Quality of behaviour assessment and intervention plan (Assessment and Intervention Plan Evaluation Instrument, AIEI (LaVigna et al. 2005); Implementation of strategies in the intervention plans (fidelity) (PSR) Quality of reports reached the standards of the previous training (mean AIEI score for the participants trained by the Tasmanian trainers was 79.5% with a range of 44%–94% for Tasmania 2006, and a mean AIEI score of 80.2% with a range of 64%–92% for Tasmania 2008) The mean PSR score was 47% with a range of 19%–86%		Challenging behaviour 27/30 cases demonstrated a reduction in ES of target behaviour at the 3-month follow-up (statistically significant reduction)	Referral data Cost effectiveness There was a reduction in priority of referrals from 100% Priority 1 in the first year of training provision to 25% Anecdotal reports indi- cated that reduction of challenging behaviour led to related cost savings e.g. resulting from a reduction in support hours, staff injury costs, property damage, and administrative costs associ- ated with issues such as complaints management and grievances
Dench 2005	Quality of behaviour assessment and intervention plan, Callan Institute adapted competencies from the Behaviour Assessment Report and Intervention Plan Evaluation Instrument (Willis and LaVigna 1990) For supervisors: intervention fidelity (PSR) Students achieved an average of 91.7% across all units (the success criterion was 85%) Results of PSR are not described		Quality of life Challenging behaviour The Quality-of-Life Questionnaire (Schalock and Keith 1993) appeared insufficiently sensitive to measure some of the anecdotal evidence 56% cases presented with significant improvement of challenging behaviour (defined by reduction to less than 30% of baseline) within three months of implementation	Organisational cost benefit analysis A culture of positive behaviour support in the organisation. Many of the trained staff have been promoted to key managerial positions and continue to advocate and implement positive behaviour support strategies. There were trained behavioural practitioners in all the services. There were indications that staff make a longer-term commitment to the organisation, reducing staff turnover. The course improved response times and results. The course was an accredited programme, recognised both nationally and internationally
Haberlin et al. 2012	For direct care staff: Correct teaching procedures (Checklist with 6 components) For both groups of direct care staff, percentage of correct teaching increased (for pyramidal training group more)	Both groups increased knowledge
MacDonald et al. 2018	For direct care staff: Quality of staff support (momentary time sampling, The Active Support Measure, ASM, completed through observations (Mansell et al. 2005); For both direct care staff and managers: Fidelity of PBS plans and staff performance (PSR) (LaVigna 1994) No significant improvement for staff and manager measures	Significant increase in knowledge for managers for the experimental group	Quality of life Challenging behaviour No significant increase for quality of life Significant reduction in challenging behaviour	Staff challenging behaviour attribution Practise leadership for managers No significant increases for both measures
McGill et al. 2018	Quality of staff support (momentary time sampling, The Active Support Measure, ASM, completed through observations (Mansell et al. 2005) ASM scores increased in 7/9 settings Mean percentage of engagement increased but not significantly		Quality of life Challenging behaviour There was no significant difference between the groups in measurement of quality of life Reduction in challenging behaviour reduced significantly more in the experimental group	Provider’s quality of support Achieved median percentage in last data collection in each setting 80.1%
McKenzie et al. 2002	Staff practice (PSR) (LaVigna 1994) The PSR score increased from 26 percent pre-training to 74 percent at 16 weeks after training	Staff rated their knowledge levels as higher after training		Staff challenging behaviour attribution No significant changes in attributional dimensions
O’Dwyer et al. 2017	Behave support plan quality (The Behaviour Support Quality Evaluation-II (BSP QE-II) (Browning-Wright et al. 2006) The behaviour support quality increased (statistically significant improvement from control group) The quality of the BSPs of the trained group remained below optimal levels		Challenging behaviour Mental health No significant change for severity of challenging behaviour Statistically significant change in client mental health	Frequency of restraints No significant change with the use of chemical restraint
Reid et al. 2003	Competency and performance-based observation and training skills (assessed via checklist during direct observation in classroom setting using scenarios for role play and, on the job for reaching mastery criterion) 85% successfully completed the training by performing all classroom and on-the-job skills checks at mastery criterion
Wardale et al. 2014	Skills in developing PBS plans /behaviour support plan quality (The Behaviour Support Plan Quality Evaluation Guide, Version II, BSPQEII) (Browning-Wright et al. 2006) Positive results from PSPs quality	Significant change in staff knowledge		Staff challenging behaviour attribution Staff evidence-based practise attitude Significant change in causal attributions No significant difference with evidence-based practises

Table 3. Organisational systems in combination with training.

Authors	Antecedent-based				Consequence-based
	Assess	Super roles	Response	Others	Mon/feed systems	Others	Effectiveness	Maintenance/generalization
Crates and Spicer 2012		Second generation trainees: allied health or nursing professionals, individuals with degree qualifications or adult education qualifications working in leadership roles within government and nongovernment service provision organisations	First generation trainees were asked to train the second-generation trainees		PSR used for the intervention plans (as part of the longitudinal practicum)		Staff: Quality of Behaviour Assessment and Intervention Plans: positive Fidelity of Plans: negative Residents: Challenging behaviour: positive Others: Referrals: positive Cost effectiveness: anecdotal positive	Generalization: positive
Dench 2005		Supervisors of trainees-staff are attending a supervisors’ workshop			PSR used by supervisors		Staff: Quality of Behaviour Assessment and Intervention Plans: positive Fidelity of Plans: no information Residents: Challenging behaviour, positive Quality of life: no information (only anecdotal) Others: Organisational cost benefit analysis: positive
Haberlin et al. 2012		4 supervisors in one group	Pyramidal training (train the trainer program) for one of the groups		Training supervisors on how to deliver feedback		Staff Correct teaching procedures: positive for both groups (higher results for pyramidal group) Knowledge: positive for both groups	Generalization: Positive Maintenance: Positive for pyramidal group only
MacDonald et al. 2018		72 managers first level managers	Manage and review staff practise was one of the objectives of the course		Training in PSR		Staff Quality of staff support Fidelity of PBS plans and staff performance: negative Knowledge: positive for the experimental group Residents: Challenging behaviour: positive Quality of life: Negative	Generalization: Positive Maintenance: Positive for pyramidal group only
McGill et al. 2018	Assessing provider’s score on defined social care standards	Managers and direct care staff were trained together by the researchers.		3 h briefing session	Using traffic light system to evaluate performance (researchers faded their support and managers carried on the responsibility)		Staff: Quality of support: Positive (ASM scores) Negative (Mean percentage of engagement) Residents: Challenging behaviour: positive Quality of life: negative Others: Provider’s quality of support: positive	Maintenance: positive for reduction in challenging behaviour
McKenzie et al. 2002							Staff: Staff practice: positive Knowledge: positive Others: Staff challenging behaviour attribution: negative	Maintenance: positive for staff practice and staff knowledge
O’Dwyer et al. 2017		Staff at a team leader level	Staff responsible to create an implementation plan for the team, after the training.		Training for using BSP QE-II		Staff: Behaviour Support Plan quality: positive but the quality of the BSPs of the trained group remained below optimal levels Residents: Challenging behaviour: negative Mental health: positive Others: frequency of restraint: negative	Generalization: positive Change (quality of BSPs Remained below optimal Levels)
Reid et al. 2003		All trainees were supervisors	Through teaching supervisors feedback skills		Supervisors were taught feedback skills		Staff: Performance based training skills: positive	Generalization: the Impact on the trainees of The supervisors was not Measured
Wardale et al. 2014		25.9% of the sample were allied health professionals (psychologists, occupational therapists), 24.6% direct support workers, 22.4% service managers, 20.6% service coordinators or team leaders 6.6% ‘other’ (such as educational staff).					Staff: PSP quality: positive Knowledge: positive Others: Causal attributions: positive Evidence-based practises: negative

Table 4. Quality assessment according to Reichow et al. (2011).

	Essential quality indicators						Desirable quality indicators
	PART	IV	CC	DV	LRQ	STAT	RA	IOA	BR	FID	ATR	G/M	ES	SV	Quality of study
Crates and Spicer 2012	U	H	U	H	H	H	No	No	No	No	No	No	Yes	Yes	Weak
Dench 2005	U	A	U	A	H	U	No	No	No	No	No	No	No	No	Weak
Haberlin et al. 2012	U	H	H	H	H	A	No	Yes	No	No	No	Yes	Yes	Yes	Weak
Macdonald et al. 2018	H	H	A	H	H	H	No	Yes	No	No	No	Yes	No	Yes	Adequate
McGill et al. 2018	H	H	H	H	H	H	Yes	Yes	No	No	Yes	Yes	Yes	Yes	Strong
McKenzie et al. 2002	A	A	U	A	H	H	No	No	No	No	No	Yes	Yes	Yes	Weak
O’Dwyer et al. 2017	H	H	U	H	H	H	No	No	No	No	No	No	Yes	Yes	Weak
Reid et al. 2003	U	H	H	H	H	U	No	Yes	No	No	No	No	Yes	Yes	Weak
Wardale et al. 2014	A	H	U	H	H	H	No	Yes	No	No	No	No	Yes	Yes	Weak

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