Behaviour support plans: will they make a difference for people living with dementia?

Professor Christine Bigby

Director, Living with Disability Research Centre, La Trobe University, Melbourne

I recoiled with horror on hearing that behaviour support plans (BSPs) were to be mandated for people with dementia in residential care who displayed challenging behaviours.

One reason was the history of abject failure of similar legislated plans for individuals with intellectual disabilities to deliver on their promises – general service plans, individualised participant directed plans, behaviour support plans, and then Restrictive Practices and Behavioural Support Rules. All are predicated on assumptions that plans lead to person-centred support practices and better outcomes. This is seldom the case. Planning processes are frequently compromised by haste or poorly skilled planners. Mandated plans too often remain unformulated, becoming ends in themselves rather than means to a better quality of life.

Service systems would do better to focus attention on the universal foundation of behaviour support, providing respectful, enabling person-centred everyday support responsive to each individual’s needs. This alone, as shown by the impact of Active Support practice in intellectual disability services, attends to many unmet needs particularly related to engagement, and reduces incidents of challenging behaviour.

In disability services, BSPs are synonymous with Positive Behaviour Support (PBS). But PBS cannot simply be imported into dementia care – elements such as teaching new functionally-equivalent replacement behaviours will not work. Additionally, the many support staff working across disability and aged care will be challenged to distinguish the practice implications stemming from the subtle differences underpinning BSPs in each sector. As the disability sector demonstrates, much more must be done than mandating plans to achieve quality care.

The new BSPs in aged care risk confounding different theoretical approaches to behaviour support, confusing an already under-skilled workforce and diverting their attention from care to paperwork of plan preparation.

Associate Professor Steve Macfarlane

Head of Clinical Services, Dementia Centre, HammondCare

While legislation requiring providers to develop and implement behaviour support plans (BSP) for every person who is experiencing changed behaviours or where a restrictive practice is being used, reviewed, or being considered is relatively new, the practice of developing care plans to support a person with changed behaviour has been part of normal care planning for many providers.

Evidence from our publication, Evaluating The Clinical Impact Of National Dementia Behaviour Support Programs On Neuropsychiatric Outcomes In Australia (Macfarlane et al 2021), showed restrictive practices are not the most effective way of supporting a person who is experiencing changes in behaviour.

A change in behaviour is often the only way for the person to express themselves and let the care worker know how they are experiencing what is currently happening to them. It is important to understand and identify the contributing factors, which can then be addressed and potentially modified. There is a requirement under the Act that providers include such an assessment in their BSP.

If BSPs cause a paradigmatic shift away from the use of restrictive practices, whether they be chemical or physical, to a person-centred approach focusing on non-pharmacological strategies, then this will surely improve the quality of life of the person with dementia.

Colin McDonnell

Dementia and Wellbeing Consultant, Calvary Care Group

The concept of behaviour support plans is not new. The best form of behaviour support is that championed by dementia care pioneer Professor Tom Kitwood and others: building meaningful relationships. This is the foundation of person-centred care, and is premised on the values of individuality, respect, dignity, independence, choice, rights and partnerships.

For behaviour support plans to work and make a difference, staff must have effective communication skills, the knowledge required to foster meaningful relationships and know the person with dementia’s life story in order to prevent responsive behaviours.

Having designated and sufficient staffing, education, staff awareness of the impact of pain and the built environment, will help prevent responsive behaviours.

The use of validated frameworks for analysing behaviours, such as the Need-Driven Behavioural model and the A_B_C model, as well as documenting the frequency of responsive behaviours, are necessary to establish the correct response to the behaviour. Staff must understand the difference between a ‘behaviour’ and a person with dementia who is simply exercising their right to make choices and decisions. They must also understand that denying that person’s right to make a decision may trigger a behavioural response – as would happen with all people.

Behaviour support plans are necessary for people living with dementia who have a diagnosis of a psychosis, aggression, or agitation. All staff must be aware of the triggers, the best intervention, and evaluation. If all staff don’t follow the same interventions, behaviour support plans will not work.

Garrie O’Toole

Team Leader, Dementia Australia Centre for Dementia Learning

With the introduction of additional provider responsibilities to minimise the use of restrictive practices in residential aged care, including behaviour support plans, it is crucial that the aged care sector supports the workforce to deliver quality, person-centred dementia care.

This needs to include a strong focus on developing dementia practice leaders who can provide mentoring and coaching within the workplace to support the ongoing application of learning to practice. This strong leadership should effectively engage staff, families, carers and people living with dementia when it comes to developing individual behaviour support plans.

As outlined in Dementia Australia’s position statement on restrictive practices (https://bit.ly/dementia-restrictive-practices), providing the aged care workforce with the skills and knowledge to identify unmet needs, such as understanding pain relief and responding appropriately to changed behaviours with individualised, psychosocial interventions, will be critical to minimising the use of chemical restraint in residential aged care.

It is essential that we include the views of people living with dementia when we discuss these issues. If we get the care right, we will find we need to use behaviour support plans less often, as people living with dementia will be living purposeful, meaningful lives.

Professor Elizabeth Beattie

Director, Dementia Training Australia (QUT), gerontologist and psychogeriatric nurse

What we know about dementia-related changed behaviours and how best to respond continues to evolve. Some changes in behaviour are short lived, cause minor resident distress and can be reduced, and sometimes eradicated. Other changed behaviours are persistent, without easily identifiable triggers, intractable even with optimal management, and deeply distressing to the resident and others.

Prioritising behaviour change by legislation is an important step towards the goal of minimising restrictive practices across the sector. Yet legislation alone will not change practice. Many complex factors, beyond resident characteristics, coalesce in residential aged care, impacting the quality of support a BSP can provide: governance and leadership, funding, infrastructure, location and environment, care philosophy and enactment, staffing and skills mix, staff training, family and community involvement.

Providing effective, sustained support to residents experiencing changed behaviours, especially those with more complex issues, is sophisticated clinical practice. At least three critical things must be broadly present and sustained over time for BSPs to be the useful tool they have the potential to be: proactive sector leadership that makes dementia education, training and staff support a critical priority; excellent evidence-driven sector training specific to changed behaviour practice, tailored to staff roles and responsibilities; and robust sector data to benchmark progress in the use of BSPs and other strategies in mitigating the impact of changed behaviours.