‘We struggle and muddle.’ A qualitative study exploring community ABI therapists’ experiences of using, training in and implementing behaviour interventions

A window into the reality of families living long term with challenging behaviours after a TBI

Challenging behaviours are a long-term burden for people with traumatic brain injury (TBI) and their families. Families frequently shoulder the responsibility alone, but little is known about the strategies they use to manage these behaviours. This study aimed to 1) identify the coping strategies used by people with TBI living in the community and their family caregivers to manage challenging behaviours; and 2) describe the similarities and differences between strategies used by people with TBI and caregivers. In this qualitative descriptive design, individual semi-structured interviews were conducted with adults with TBI and their caregivers and were inductively analyzed. The sample included 10 dyads and two triads, totalling 12 caregivers (8 women) and 14 individuals with TBI (6 women; 21.71 ± 10.84 years post-injury). Participants' strategies were proactive (prevention), reactive (response), or retroactive (aftercare). Most strategies were described by caregivers. Some of them were effective and lasting, others not, reflecting how they adapted their approaches over time. Families put in place various strategies in their life's journey, such as giving feedback or adapting the environment. Despite these strategies supporting long-term community living, the need for ongoing support is underscored, as crises may still occur, impacting families' quality of life.

Challenging behaviour, activity, and participation following acquired brain injury: a scoping review of interventions delivered by allied health professionals

Background This scoping review aimed to identify literature describing allied health interventions used to address challenging behaviour for adults with an acquired brain injury (ABI) living in community settings and identify the impact of these interventions on outcomes across the domains of behaviour, activity, and participation. Methods The Polyglot Search Translator for scoping reviews guided the search of six databases: (1) Ovid Medline®, (2) EmCARE (Ovid), (3) CINAHL Complete, (4) Embase (Ovid), (5) Scopus, and (6) Cochrane Library to identify literature published between 1990 and 2023. Results Of the 1748 records screened, 16 articles met the inclusion criteria. Studies commonly described therapeutic, least restrictive approaches to challenging behaviour founded on a positive behaviour support framework. Interventions were individualised, combining multiple elements to effect change in the environment, behaviour of the people providing support, and/or skills and behaviour of the person with ABI. Although most studies reported clinical gains from intervention, study designs used a range of methods and either single cases or mixed populations. Conclusions The findings of this review suggest that allied health interventions have the potential to reduce challenging behaviour experienced by people with ABI. However, further research addressing the impact of interventions on activity and participation is required to inform clinical practice and improve long-term outcomes.

Communication between rehabilitation staff and people with traumatic brain injury: A systematic review

This systematic review aimed to synthesize barriers and facilitators in communicative interactions between staff and people with traumatic brain injury (TBI) in the rehabilitation context. Searches captured published evidence up to November 2022 in MEDLINE, Embase, SCOPUS, Web of Science, CINAHL, AMED, and PsycINFO. Eligible studies reported on the communicative interaction between rehabilitation staff and adults with TBI. In total, 31 studies were included in the review; including quantitative, qualitative, and mixed-methods designs. Quality assessment was carried out using standard checklists. Quantitative studies and quantitative components of mixed-method studies were synthesized descriptively according to reported communication barriers and facilitators. Qualitative studies and qualitative components of mixed-method studies were analysed through an inductive thematic meta-synthesis; generating six main themes with four subthemes. Themes were categorized as barriers or facilitators to communicative interaction. Findings demonstrated that cognitive-communication disorders of people with TBI challenge the communicative interaction between rehabilitation staff and people with TBI. However, the extent to which these disorders create a communicative barrier is closely related to staff's communicative approach. While staff holding a collaborative and acknowledging approach and using supportive strategies may facilitate successful communicative interactions, staff using the opposite approach may exacerbate communication barriers.

Co-designing positive behaviour support (PBS+PLUS) training resources: a qualitative study of people with ABI, close-others, and clinicians' experiences

Background Challenging behaviours are often a significant difficulty faced following acquired brain injury (ABI), for which PBS+PLUS (a Positive Behaviour Support framework) is an effective intervention. Clinicians report experiencing a range of barriers to supporting behaviour change for individuals with ABI and require tailored resources to support the implementation of PBS+PLUS. This study aimed to describe the process of co-designing a PBS+PLUS intervention guidebook and podcast series together with individuals with ABI, close-others, and clinicians, and qualitatively examine co-design experiences. Methods The Knowledge-To-Action Framework was followed to support the translation of PBS+PLUS into clinical practice. Participants with ABI (n  = 4), close-others (n  = 7), and clinicians (n  = 3) participated in focus groups contributing to the development of a PBS+PLUS intervention guidebook and podcast series. Following completion of the groups, qualitative interviews were conducted to understand participants' perspectives of the co-design experience. Transcripts were analysed using reflexive thematic analysis. Results Co-design processes are described, and participants provided practical suggestions for co-design and the dissemination of developed resources. Two core themes encapsulating four sub-themes were identified. Firstly, 'Esteeming Experiences ' described the person-driven approach of co-design whereby participants felt supported and connected with other contributors and facilitators through sharing their perspectives. Secondly, 'Empowerment ' reflected participants' increased confidence and skills in applying PBS+PLUS. Conclusions Overall, participants endorsed the therapeutic benefits of co-design engagement and high utility of PBS+PLUS resources. This study adds to the growing literature supporting the use of co-design methodology within clinical implementation, and is inclusive of individuals with ABI, close-others, and clinicians.

Behaviour support for people with acquired brain injury within the National Disability Insurance Scheme: an Australian survey of the provider market

BACKGROUND AND OBJECTIVES

People with acquired brain injury (ABI) may experience behaviours of concern that require therapy services, including behaviour support. In Australia, the implementation of a National Disability Insurance Scheme (NDIS) and development of the NDIS Quality and Safeguards Commission, has led to significant changes to behaviour support workforce processes, and the way behaviour support is funded, regulated and delivered to people with ABI who are Scheme participants. The aim of this study was to explore the current and future provider market of professionals providing behaviour supports to Scheme participants who experience ABI.

METHOD

An anonymous survey was designed and distributed via social media channels, an email listserv and professional association newsletters to professionals working within the NDIS in Australia. Data were analysed using descriptive statistics and content analysis.

RESULTS

One hundred and two surveys responses were analysed. A majority of professionals had an average understanding of the NDIS Quality and Safeguard Commission rules and policies on behaviour support. Responses to current and future registration as an NDIS Practitioner indicated the workforce gap could increase by between 17 and 26%. Respondents also raised concerns about the lack of training and experience of allied health professional students and graduates in addressing behaviours of concern. Responses to the open-ended question highlighted additional issues in the provision of behaviour support within the NDIS.

CONCLUSIONS

This research highlighted the need for an NDIS behaviour support workforce strategy and supply-side market intervention to ensure a viable and sustainable workforce for people with ABI who need behaviour support.

"I've never been positive … I am now": Participant perspectives of a Positive Behaviour Support intervention (PBS + PLUS) for community-living individuals with ABI and their close others

Challenging behaviours are common following moderate to severe acquired brain injury (ABI). These behaviours cause relationship and community participation difficulties and are a significant source of stress for many individuals with ABI and their close others (COs). A Positive Behaviour Support intervention, PBS + PLUS, was implemented to assist individuals with ABI to collaboratively build meaningful lives and self-regulate their behaviour. This study explored the perspectives of individuals with ABI and COs (family members, friends, and carers) who had completed an individualized 12-month PBS + PLUS intervention. Fifty-two individuals participated in semi-structured interviews, and a thematic analysis of interview transcripts identified the interrelated themes of Openness to Change, Embeddedness, Clinician Connection, and Preparedness for the Future. Participant perceptions of, and engagement with, PBS + PLUS were influenced by an attitude of openness to new ideas and by the intervention itself. Achieving contextual relevance allowed the intervention to become embedded in participants' lives, and the client-clinician relationship was central to participants' positive experiences. While most participants felt better equipped to cope with the future, some experienced difficulties transitioning to post-intervention life. These results suggest PBS + PLUS may assist individuals with ABI to lead meaningful lives and more confidently overcome behavioural challenges, while encouraging supportive and empowered COs.