A Survey of Safety Skills Training Used by Behavior Analysts in Practice

Abstract

This survey study examines the clinical practices and opinions of Behavior Analyst Certification Board (BACB) certificants regarding safety skills training with their clients with neurodevelopmental disabilities. This article focuses on five safety threats: abduction, sexual abuse, poisonous substances, firearms, and fire-starting agents. Respondents were asked to rate the importance of teaching their clients safety skills for each of these safety threats. Furthermore, the survey included questions pertaining to the use of behavioral interventions, notably behavioral skills training. Results from this preliminary survey of BACB certificants (N = 695) are included and we provide a discussion of current practices and recommendations for future research related to safety skills training among practitioners in clinical settings.

Thousands of children die from unintentional injuries each year (West et al., 2021). The leading causes of death are road traffic accidents, poisoning, drowning, and fires (Centers for Disease Control & Prevention [CDC], 2021; World Health Organization, 2008). Although children engage in safety skills on a daily basis such as pedestrian skills and wearing a seatbelt in a vehicle, there are other safety skills for which they do not have frequent opportunities to practice. Children may encounter a variety of low frequency safety threats in their environments. These safety threats can be characterized as those that come from the physical environment (e.g., firearms and poisonous substances) and from the social environment (e.g., abduction and sexual abuse lures). Although some of these safety threats might occur infrequently, they are harmful and potentially fatal. For example, the CDC reported that in 2019, 275 children died of fire or burn related injuries and 700 children were killed by poisoning. In addition, Everytownresearch.org reported that 141 children were killed due to unintentional shootings in 2021 (Everytown, 2021). Finally, according to the Office of Juvenile Justice and Delinquency Prevention (2016), over 100 children experienced abduction by strangers in 2016.

Parents and caregivers are responsible for minimizing exposure to these safety threats. For example, caregivers can safely store firearms and poisonous substances and keep children at close proximity when in public spaces. Although it is the responsibility of adults to minimize safety threats as a preventative approach, children must be taught the skills to respond safely when they encounter safety threats. Informational programs are passive learning approaches that consist of instructions and modeling and have been shown to be ineffective for teaching safety skills (Beck & Miltenberger, 2009; Gatheridge et al., 2004; Himle, Miltenberger, Gatheridge, & Flessner, 2004b). These approaches do not involve practicing the skills and receiving feedback. Researchers have demonstrated that when children’s behaviors are assessed in simulated situations in the natural environment following an informational approach to training, these children did not execute the safety skills (Beck & Miltenberger, 2009; Gatheridge et al., 2004; Himle, Miltenberger, Gatheridge, & Flessner, 2004b). In-situ assessments are simulated situations wherein the child is presented with a safety threat without their knowledge in the natural environment to assess how they behave. In-situ assessments are the only valid form of assessing safety skills because the child’s responses are assessed in a situation that closely simulates a real safety threat (Baruni & Miltenberger, 2022).

Unlike informational approaches, behavioral skills training (BST) is an active learning approach that is often effective for training children safety skills (Baruni & Miltenberger, 2022; Miltenberger, 2008; Miltenberger et al., 2020). Researchers have evaluated BST to teach children to engage in three safety responses: avoid the safety threat by not making contact (e.g., when encountering a firearm) or by stating “no” (e.g., when presented with an abduction lure); moving away from the safety threat; and reporting the safety threat to a trusted adult (Gunby & Rapp, 2014; Himle, Miltenberger, Flessner, & Gatheridge, 2004a). During training, children are given opportunities to practice the safety skills in the presence of the safety threat within a controlled setting and receive feedback for correct and incorrect execution of the skills. Thus, repeated trials of rehearsal and feedback must occur for the child to execute the skills in the presence of the safety threat. Researchers have evaluated BST for teaching various safety skills, such as abduction prevention skills (Johnson et al., 2005; Ledbetter-Cho et al., 2021), sexual abuse prevention (Egemo-Helm et al., 2007; Lumley et al., 1998), firearm safety (Miltenberger et al., 2004; Novotny et al., 2020), fire safety (Houvouras & Harvey, 2014), and poison prevention (Dancho et al., 2008; Morosohk & Miltenberger, 2022). This research has shown that BST is not consistently effective for all participants (Baruni & Miltenberger, 2022). When BST does not produce the desired outcomes during in-situ assessments, in-situ training (IST) has been shown to promote the use of the safety skills (Gross et al., 2007; Gunby et al., 2010; Himle, Miltenberger, Flessner, & Gatheridge, 2004a; Johnson et al., 2005). IST is similar to BST whereby the child has the opportunity to rehearse the skill and receive feedback from the trainer; however, some researchers have implemented IST after a child fails to perform the safety skills during an in-situ assessment. In other words, the trainer intervenes and turns the assessment into a training opportunity. In contrast, other researchers have demonstrated the effectiveness of BST and IST as a combined intervention package (e.g., Miltenberger et al., 2005; Miltenberger et al., 2009).

Some limitations of safety skills training procedures are that they are resource-intensive, time-consuming, and usually implemented by researchers. To increase the adoptability of such procedures, researchers have focused on making trainings more accessible by demonstrating that teachers, parents, and peers can be trained to implement such procedures effectively (Carroll-Rowan & Miltenberger, 1994; Gross et al., 2007; Jostad et al., 2008; Novotny et al., 2020; Tarasenko et al., 2010). To our knowledge, no research has evaluated safety skills training procedures implemented by practicing behavior analysts or behavior technicians. The majority of behavior analysts work with individuals with neurodevelopmental disorders (NDD) such as autism spectrum disorders (ASD; BACB, 2021) in the areas of skill acquisition and reduction of challenging behaviors. Because individuals with NDD are at greater risk for harm than neurotypical children due to their limited social and communication repertoires (Dixon et al., 2010; Tekin-Iftar et al., 2021), there should be an emphasis on including safety skills training in behavioral programming for individuals with NDD. Equipping behavior analysts with the skills to design, implement, and monitor safety skills assessment and training programs may help to reduce unintentional injuries that are potentially fatal in this subset of the population. We do not know to what extent behavior analysts include safety skills training within their services and if so, to what extent they use evidence-based practices when doing so. To develop a better understanding of the current practices employed by behavior analysts, the purpose of this survey was to obtain the opinions and assess the practices of behavior analysts and behavior analysts in training.

Method

Participants

Participants were board certified behavior analysts (BCBA), board certified assistant behavior analysts (BCaBA), and registered behavior technicians (RBT). Only behavior analysts and behavior technicians whose job entailed developing, overseeing, and/or implementing behavior analytic programs for individuals with NDD proceeded to the survey. Participants were recruited through the Behavior Analysis Certification Board, Inc. (BACB) email blast, social media sites (e.g., Facebook sites for Applied Behavior Analysis Ireland, Florida Association for Behavior Analysis, and Ontario Association for Behaviour Analysis, Reddit for Applied Behavior Analysis, and other behavior analysis groups), emails to professional email lists for behavior analysts, and word of mouth. The total number of individuals who received the invitation to participate is unknown, therefore a corresponding rate of responding is unavailable. Of the 853 participants who responded to the survey, 714 selected “yes” to continue to the survey, 2 selected “no” to continue to survey, and 137 did not complete the entire survey. Of those 714 respondents, 695 indicated that they were currently practicing behavior analysis with individuals with NDD and proceeded to complete the survey. The other 19 respondents indicated that they were not currently providing clinical services to individuals with NDD. Therefore, 695 respondents were included in the final analysis.

Instrument

The authors developed questions based on their knowledge of safety skills research. Once we compiled a list of questions, we created a Qualtrics survey to obtain feedback on the specific questions. We received feedback from nine behavior analysts (four master's level practitioners and five PhD level behavior analysts with experience in safety skills research) to assess the content and quality of questions. Thereafter, we made changes to the questions accordingly and developed and distributed the final survey using Qualtrics. The survey was comprised of 27 selection-based questions and 1 free response question, for a total of 28 questions. The first question provided an opportunity for respondents to consent to the information being collected. Twelve questions gathered demographic information on the respondents (see survey items 1–12 in Appendix A), eight Likert-scale questions were related to perceived importance of safety threats and reported client experiences (See survey items 13–20 in Appendix A), and seven questions asked about current practices to teach safety skills (see survey items 21–27 in Appendix A). The final question was a free response for which respondents could provide additional comments (see survey item 28 in Appendix A). The Likert-scale questions consisted of a 5-point scale ranging from 1 = strongly disagree to 5 = strongly agree.

The survey included six dichotomous questions for which respondents selected “yes” or “no” (see survey items 1, 18, 20–22, and 26 in Appendix A). For example, one question asked if their job entailed developing, overseeing, and/or implementing behavior analytic programs for children or adults with NDD. Respondents who selected “no” were directed to the end of the survey and were not presented with any further questions. In another example, some dichotomous questions such as “I include behavioral intervention programs for safety skills training with my clients related to at least one of the given safety threats addressed in this survey” resulted in the respondent being asked a follow-up question; “If you do not use or have not used behavioral intervention programs to teach safety skills, have you considered implementing safety skills interventions?” Furthermore, the survey covered topics related to the perceived importance of teaching specific safety threats (e.g., abduction lures, poisonous substances, firearms), types of behavioral intervention programs employed in current practice, and potential barriers. We arranged the settings in Qualtrics so that respondents whose job responsibilities involved solely implementing behavioral programming for their clients (i.e., RBTs) did not proceed to questions pertaining to designing and supervising of behavioral intervention programs. These respondents were asked if they would like to provide additional comments, and they were directed to the end of the survey. We reviewed the data sets for any duplicate responses based on the IP addresses; however, no action was required because we did not find equivalent responses. Survey topics corresponding with data can be found in Tables 1, 2, 3, 4, 5, 6, 7 and 8. A complete list of survey questions can be found in Appendix A.

Table 1.

Respondent characteristics

Characteristic	n	%
Country
United States	618	89
United Arab Emirates	28	4
Canada	25	4
Australia	5	1
16 Other Countries	19	3
Gender
Female	615	88
Male	66	9
Nonbinary/third gender	8	1
Prefer not say	5	1
Prefer to self-describe	1	0
Race/ethnicity
American Indian/Alaskan	5	1
Asian	38	5
Black/African American	45	6
Hispanic/Latino	90	13
Native Hawaiian/other Pacific Islanders	3	0
White (not Hispanic/Latino)	474	68
Prefer not to say	15	2
Prefer to self-describe	25	4
Age
18–20	12	2
21–30	298	43
31–40	212	31
41–50	103	15
51–60	50	7
61 or older	20	3
Current certification level
RBT®	316	45
BCaBA®	31	4
BCBA	322	46
BCBA-D®	26	4
Florida CBA®	0	0
Highest degree earned
High school diploma	48	7
Associates	34	5
Bachelor’s	199	29
Master’s	371	53
Doctorate	43	6
Primary rolea
Clinical director / program director / administrator	140	20
Developing and overseeing behavioral programs	340	49
Implementing behavioral programs for clients	440	63
Years active
0–1	153	22
2–5	242	35
6–10	163	23
11+	137	20
Population serveda
Young children (0–4 years old)	475	68
Children (5–11 years old)	601	86
Adolescence/teenagers (12–18 years old)	407	59
Young adults (19–25 years old)	178	26
Adult (26+ years old)	72	10
Primary work setting
Public or private school	261	38
Center (day program)	253	36
Outpatient clinic	80	12
Residential facility	58	8
Inpatient clinic	12	2
Home-based program	440	63
Other	29	4

N = 695

^aRespondents were given the option to select more than one item

Table 2.

Mean scores for the importance of teaching clients safety skills by safety threat

Safety threat	M
Abduction	4.69
Sexual abuse	4.67
Poisonous substance	4.61
Fire-starting agent	4.49
Firearm	4.22

N = 695. Rating scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree

Table 3.

Percentage of clients who have experienced each safety threats as reported by practitioners

Safety threat	%
Finding a poisonous substance	35
Finding a fire-starting agent	23
Experiencing a sexual abuse lure	14
Experiencing an abduction lure	6
Finding a firearm	4

N = 695

Table 4.

Percentage of practitioners reporting their clients having the skills to respond safely to each safety threat

Safety threat	%
Finding a fire-starting agent	25
Finding a poisonous substance	24
Experiencing an abduction lure	15
Finding a firearm	13
Experiencing a sexual abuse lure	12

N = 695

Table 5.

Percentage of practitioners reporting the use of behavioral interventions by safety threat

Safety threat	%
Poisonous substance	72
Abduction lure	62
Sexual abuse lure	45
Fire-starting agent	40
Firearm Overall	16 55

N = 225

Table 6.

Percentage of practitioners reporting the use of different behavioral interventions

Program	%
Behavioral skills training	67
Discrete trial training	55
Prompt and prompt fading procedures a	52
Tangible or highly preferred reinforcers	49
Video modeling	46
BST and in situ training	42
Other	8
Virtual reality	4
Commercially available program	3

N = 225. BST = behavioral skills training

^aProcedures other than instructions and modeling within BST

Table 7.

Percentage of practitioners reporting the use of behavioral interventions for teaching safety skills by setting

Setting	%
Client’s home	73
Center (day program)	38
Public or private school	26
Residential facility	16
Other	12
Outpatient clinic	10
Inpatient clinic	4

N = 225

Table 8.

Percentage of reported barriers to using behavioral interventions for safety skills training

Barriers	%
Concerns about liability	43
Lack of expertise	41
Other	36
Lack of time	36
Lack of approval from caregivers	24
Lack of space or materials	22
Lack of staff	16
Lack of funding from insurance companies	13
Lack of approval from supervisors	12
Lack of approval from administrators	11

N = 129

Procedure

Before distributing the survey, we obtained approval from the university’s institutional review board and then submitted the survey to the BACB for review and approval. The BACB sent the survey through their mass email service to individuals at all levels of certification. At the same time, the first author distributed the survey using the anonymous online link available through Qualtrics via email and social media sites. Recruitment and data collection remained open for 5 months. Thereafter, the first author closed the survey and exported all related data to Excel for further review and analysis.

Results

Respondent Characteristics

Surveys were completed by 618 individuals residing in the United States (89%) and 77 individuals residing outside of the United States (11%; see Table 1 for the top three countries for which completed surveys were returned). Table 1 provides a summary of respondent characteristics. The majority of respondents identified as female (88%), white (68%), and between the ages of 21 and 30 (43%). In addition, most respondents were certified as a BCBA (46%) and indicated that they had a master’s degree (53%). The majority of practitioners also reported that they have been active in the field for 2–5 years (35%), and that their primary role involved implementing behavioral programs for clients with ASD (63%), providing services to children between the ages of 5–11 years (86%), and working in home-based programs (63%).

It should be noted that when comparing our sample to that of the BACB’s sample there are similarities and differences. This study included BACB certificants only if they reported that they develop, oversee, and/or implement behavior analytic programs for children with NDD, so our sample differs from the BACB’s sample. Based on the BACB data, 30% of certificants are BCBAs and in our study 50% were BCBAs. Further, 3% of certificants are BCaBAs and in our study 4% were BCaBAs. Finally, 67% of certificants are RBTs and in our study, 45% were RBTs. When we compared our respondent characteristics such as gender, we found some correspondence. For example, according to data from the BACB, 85% of certificants are female, 13% are male, 0.49% are nonbinary. In the current study, 88% were female, 9% were male, and 1% were nonbinary. When we compared data for race, we found the characteristics of our sample differed somewhat from the characteristics of BACB certificants. For example, according to data from the BACB, 53% of certificants are White, 21% are Hispanic/Latino, 11% are Black, and 7% are Asian. In contrast, in our study, 68% were White, 13% were Hispanic/Latino, 6% were Black, and 5% were Asian. Our age category could not be compared due to the differences in age groups reported by the BACB.

Teaching Clients Safety Skills

Responses to five questions related to the perceived importance of teaching individuals with NDD safety skills for each safety threat are depicted in Table 2. All respondents identified the five safety threats as important by providing a rating of “4 = agree” or “5 = strongly agree.” The mean scores by safety threat for abduction, sexual abuse, poisonous substance, fire-starting agent, and firearm are 4.69, 4.67, 4.61, 4.49, and 4.22 respectively.

Clients’ Experiences with Safety Threats and Safety Skills

Participants responded to questions pertaining to whether their clients have experienced each safety threat (see Table 3). Of the five safety threats, 35% of participants reported that their client had encountered a poisonous substance (e.g., bleach, rat poison), 23% reported that their client found a fire-starting agent (e.g., lighter, matches), 14% reported that their client experienced a sexual abuse lure, 6% reported that their client experienced an abduction lure, and 4% reported their client encountered a firearm. When asked if their clients have the skills to respond safely to each safety threat (see Table 4), 25% reported that they believed their clients have the skills to respond safely to finding a fire-starting agent, 24% for finding a poisonous substance, 15% for experiencing an abduction lure, 13% for finding a firearm, and 12% for experiencing a sexual abuse lure.

Practitioners’ Use of Behavioral Interventions

When respondents were asked if they include behavioral programs for safety skills training with their clients to at least one of the five safety threats addressed in the survey, 55% selected “yes.” Further, the survey presented three questions on the use of behavioral interventions; responses are depicted in Tables 5, 6, and 7. Of the respondents who reported using behavioral interventions to teach safety skills (55%), 72% reported using behavioral interventions to teach poison prevention. Furthermore, 62% use behavioral interventions to teach abduction prevention, 45% teach sexual abuse prevention, 40% teach fire safety, and 16% teach firearm safety. When asked about specific behavioral intervention programs (see Table 6), 67% of respondents reported that they use BST. Others reported using discrete trial training (55%), prompting and fading procedures (52%), tangible or highly preferred reinforcers (49%), video modeling (46%), BST and IST (42%), virtual reality (4%), and commercially available programs (3%). For respondents (i.e., 8%) who selected “other,” social stories were the most common approach to teaching safety skills. Finally, respondents were asked to report the setting in which they teach their clients safety skills (see Table 7) and 73% of participants selected client’s home. Other settings that were selected included center (38%), public or private school (26%), residential facility (16%), outpatient clinic (10%), and inpatient clinic (4%). Finally, 12% of respondents who selected “other” reported “community” as the training setting.

Barriers to Using Behavioral Interventions

When asked what they viewed to be barriers to using behavioral interventions for safety skills training, 43% of respondents reported concerns about liability. Other barriers included lack of expertise (41%), lack of time (36%), lack of approval from caregivers (24%), lack of space or materials (22%), lack of staff (16%), lack of funding from insurance companies (13%), lack of approval from supervisors (12%), and lack of approval from administrators (11%). For respondents (i.e., 36%) who selected “other,” several barriers were reported such as prioritizing the treatment of severe problem behavior, prioritizing skill acquisition for early learners, cultural concerns, having clients who are young children, not having clients who experience safety threats, and the perception that teaching safety skills is the caregivers’ responsibility.

Discussion

This study aimed to obtain the opinions and assess the practices of BACB certificants as they pertain to safety threats and safety skills training. The results of the survey indicated that practitioners rated all safety threats as important. It is worth noting that although the mean scores for the five safety threats were above 4, the range of scores was 1 to 5. These data suggest that some respondents did not identify these safety threats as important to teach. On another note, 55% of practitioners indicated that they use behavioral intervention programs for safety skills training. These results indicated that 45% of practitioners reported that they do not use behavioral intervention programs to teach their client’s safety skills even though individuals with NDD are more likely than neurotypical children to be harmed when encountering a dangerous situation (Lee et al., 2008; Tekin-Iftar et al., 2021). Given that practitioners typically provide services to multiple individuals on their caseload, it is unclear how many of their clients receive the training. That said, it is likely that the percentage of individuals with NDD who received safety skills training is far lower than 55%. It is important that practitioners proactively program for safety skills training for all their clients. It should be noted that 67% of practitioners who teach safety skills reported that they use BST to teach their client with NDD safety skills. Given that BST is an evidence-based practice for teaching safety skills (Baruni & Miltenberger, 2022; Miltenberger et al., 2020), this finding is promising.

The highest rated barrier to conducting safety skills training was concerns about liability (43%). We included this item in the survey based on the recommendation of one of our expert reviewers who wrote, “People might also be concerned about liability issues related to teaching safety skills. If something happens following your safety skills program, will the caregivers sue? Will they report you to the board?” Unfortunately, we do not know specifically what the liability concerns of the respondents are based on the survey results. This is an issue worth further investigation.

The second highest barrier selected in the survey was lack of expertise for using behavioral interventions for safety skills training (41%). The findings of this survey study highlight a gap in the training of behavior analysts as it relates to implementing safety skills training with their clients. Behavior analysts learn how to implement numerous behavior-change procedures during their graduate training (BCBA Task List [5^th ed.]). It is unclear if all these individuals receive training for how to implement BST given that it is not a requirement outlined in the current BCBA Task List (5^th ed.). Moreover, the upcoming changes in the BCBA Test Content Outline (6^th ed.) does not include BST within the Behavior-Change Procedures domain. Although BST procedures are not explicitly outlined in either of these BACB documents, it is important that future BCBAs are trained to implement evidence-based practices for teaching safety skills as a part of ongoing professional development. It should be noted that implementing an evidence-based safety skills training program not only involves BST but in-situ assessments as well to evaluate the effects of training and incorporating IST when needed (Baruni & Miltenberger, 2022; Miltenberger et al., 2020). In fact, research shows that BST is effective for 48.3% of participants suggesting that IST may be needed 51.7% of the time following BST (Baruni & Miltenberger, 2022). Perhaps, as part of graduate training, programs should ensure that students are learning about different applications of BST, including safety skills training and assessment by offering more formal and explicit training related to BST and assessment for behavior analysts in training. Furthermore, it is unknown if behavior analysts and technicians have the skills necessary to implement a complete safety skills training protocol that includes in-situ assessments and IST. It should be noted that in-situ assessments are unlike other assessments insofar as the child is unaware that the assessment is taking place thus requiring careful planning with the caregivers. Like many other skills behavior analysts learn when teaching clients with ASD, executing an in-situ assessment correctly requires explicit training. Future research should continue to evaluate approaches to increase behavior analysts’ skill set to implement safety skills training and assessment.

One approach to training a safety skills protocol can involve using technology such as the interactive computerized training method (ICT; Shapiro & Kazemi, 2017). The ICT approach has been employed successfully to train professionals a variety of skills such as discrete trial instruction (Gerencser et al., 2018) and mand training (McCulloch & Noonan, 2013). ICT programs can make training more accessible and efficient thereby increasing widespread adoption of behavior analytic procedures (Shapiro & Kazemi, 2017). Future research should evaluate using ICT methods to train behavior analysts and technicians to implement safety skills training.

There are several limitations of the study that warrant discussion. First, the sample size was small relative to the number of BACB certificants. In addition, the sample size predominantly consisted of respondents from the United States (i.e., 89%). Respondents from other geographical areas, besides the United States, may view safety threats differently. For example, the United States has a higher prevalence of unintentional injuries due to firearms than any other developed country (Solnick & Hemenway, 2019). In fact, some respondents in the survey stated that the issue of firearm safety does not affect their geographical location. Therefore, the survey questions related to firearm safety may not have been as applicable to those respondents. However, questions pertaining to the other physical safety threats such as fire safety and poison prevention, are likely relevant to respondents from other countries.

Another limitation is that the survey did not consist of questions related to in-situ assessments. Behavior analysts should always evaluate the effects of BST with in-situ assessments. During an in-situ assessment, a trainer or researcher sets up a simulated scenario in which the child encounters the safety threat (e.g., a disabled nonfunctional firearm, empty medicine bottles that contain innocuous substances, a confederate playing the role of an abductor) and the child is not aware that their behaviors are being observed. Researchers have demonstrated that in-situ assessments are the only valid form of assessment because they assess behavior in a situation that appears to be realistic, thereby minimizing the effects of reactivity (Baruni & Miltenberger, 2022; Gatheridge et al., 2004; Himle, Miltenberger, Gatheridge, & Flessner, 2004b). By not including survey questions related to in-situ assessments, it is unclear that if respondents were asked about a complete safety skills training protocol (i.e., BST, in-situ assessment, and IST) whether there would be even fewer practicing behavior analysts reporting that they employ BST for safety skills training. To clarify, many behavior analysts (i.e., 55%) reported the use of BST to teach safety skills however, without assessing the effects of training (under naturalistic conditions) it is unknown if the client in fact benefited from the training. The value of teaching safety skills is to ensure the child can perform the skills in a real safety threat situation.

This survey study is a preliminary attempt to identify current practices of safety skills training among behavior analysts and behavior technicians. Future directions for research should include a larger sample size across other geographical areas. In addition, the findings of the current study highlight the importance of developing a program to teach behavior analysts and behavior technicians how to implement safety skills training. Moreover, considering some of the barriers identified in this survey study, it would be important to explore concerns related to liability of training safety skills. Finally, assessing parents’ willingness to participate in safety skills training and factors that may influence their willingness to participate may help to increase caregiver buy-in.

Appendix A: Survey Items

Authors’ Contributions

All authors contributed to conceptualization and writing.

Data Availability

Data will be made available on request.

Code Availability

Not applicable.

Declarations

Conflicts of Interest/Competing Interests

None.

Ethics Approval

Study exempt from university Institutional Review Board review.

Consent to Participate

Respondents provided consent.

Consent for Publication

All authors consent to publishing this article.