Barriers and Facilitators to Staff's Implementation of Behaviour Support Plans in Community Settings

ABSTRACT

Background

Behaviour supports plans (BSP), if accurately implemented, have been found to increase skills and decrease behaviours that challenge for individuals with intellectual disabilities. However, skills acquired by staff during trainings on BSPs often fail to transfer into effective implementation. The current study aimed to examine barriers and facilitators to BSP implementation.

Method

Focus groups were conducted with four staff teams (n = 21) and semi‐structured interviews were carried out with each team's respective team leader (n = 4). Thematic analysis, involving inductive and deductive approaches, was used to analyse the data.

Results

Environmental context and resources (e.g., compatibility of environment) and social influences (e.g., level of team communication) were the predominant domains impacting on implementation.

Conclusion

Findings emphasise the importance of service providers aligning with the core values of positive behaviour support, which acts as a facilitator for effective BSP implementation. These include integral social processes such as collaboration across key stakeholders and person‐centred planning.

Summary

• The views of frontline staff and team leaders reflect that the environmental context and resources, and social influences are key domains impacting BSP implementation, both as barriers and facilitators.

• The study provides a roadmap of strategies at an organisational and individual level, as well as process factors that can be adopted to enhance behaviour support plan implementation.

• The overarching factors impacting implementation.

• This research aligns with the advancement of services for people with intellectual disabilities, contributing to the field's understanding of barriers and facilitators to the implementation of BSPs.

Individuals with an intellectual disability may be at increased risk of engaging in behaviours that challenge, which may negatively impact their quality of life (such as aggression), the prevalence of which may be as high as one in five to six adults (Bowring et al. 2019; Emerson 2001). Personal relationships and employment opportunities can be impacted, and individuals with antisocial behaviours are at greater risk of placement breakdown and social exclusion (Bigby 2012; Phillips and Rose 2010). Therefore, identifying and adopting evidence‐based behaviour support practice is integral to providing the support necessary to ensure quality of life outcomes.

A framework of support that is legislated both internationally and nationally is Positive Behaviour Support (PBS; Health Act 2007; IDEA 2004). PBS is a person‐centered, multi‐component framework, which when applied as a ‘whole systems approach’ involves three tiers of support (Fisher and Kelly 2024; Gore et al. 2022). Tier 1 (universal supports) and Tier 2 (supports for at risk individuals) offer preventative supports. Tier 3 offers highly individualised support and entails developing a detailed understanding of a person's behaviour (i.e., the underlying reason for its occurrence) through a comprehensive functional assessment. The interventions developed from this assessment are function and evidenced based behavioural interventions, directly aimed at addressing the underlying cause of the behaviours. These behavioural and lifestyle interventions are compiled within a behaviour support plan (BSP) (Gore et al. 2022; LaVigna and Willis 2005; NHS England and Local Government Association 2014). Interventions offered in Tier 2 are function based but may be based on briefer assessment methods. Within community settings in the Republic of Ireland, the PBS framework is most commonly delivered at Tier 3 (McClean et al. 2023).

Integral to the effectiveness of a BSP is how feasible is it to implement the components of the BSP within the individual's current environment and how well these ‘fit’ with the values, needs, skills and resources available within the context (Albin et al. 1996; Allen et al. 2013). Implementation of the BSP needs to be feasible across the environment that it is designed for within a person's community or home, or day service. Another fundamental factor, which impacts on the effectiveness of a BSP, is procedural fidelity, the degree to which the recommended plan is implemented as proposed.

Within community settings, primary responsibility for the implementation of BSPs is held by front‐line staff (Hastings and Brown 2000). Staff training is typically the first port of call following the introduction of a BSP as it is assumed that a skill gap needs to be met and to ensure staff are aware of how the intervention is to be individualised to meet the unique needs of the individual they support (Campbell 2010; Reid et al. 2019). However, in practice, the delivery of training may not directly translate to accurate implementation (Novak et al. 2019). Furthermore, consideration is needed for other factors which may impact on staff's ability to implement a BSP such as other responsibilities held by staff (i.e., high volumes of administrative activities (i.e., paperwork) may reduce the time available for direct work with individuals being supported; Quilliam et al. 2015; Fisher et al. 2024), or stress and burnout which are related to increased risk of staff turnover and absenteeism and may result in poorer performance of duties (Jenkins et al. 1997; Hastings 2002, 2010; Hastings et al. 2004; Hasselhorn et al. 2003; Hatton and Emerson 1998; Hatton et al. 1999; Robertson et al. 2005). Given the complex system in which BSP implementation functions, it is integral to gain staff's insights on what helps and hinders implementation.

To date, a small body of literature exists which examines barriers and facilitators to the implementation of PBS in adult services in the community for individuals with intellectual disability (Bambara et al. 2001; Inchley‐Mort and Hassiotis 2014; Woolls et al. 2012). These studies have focused on perceptions of PBS as a framework of service delivery from all levels of staff including directors (Bambara et al. 2001), clinicians and behaviour support practitioners (Dunworth et al. 2024; Fisher et al. 2024; Woolls et al. 2012), and front‐line staff (Bambara et al. 2001; Woolls et al. 2012). Woolls et al. (2012) also specifically asked about experiences of implementing a PBS plan. More recently, Fisher et al. (2022) asked frontline staff and family members (n = 46) to complete a survey, gathering their perspectives on ‘accessibility’ and ‘usefulness’ of BSPs, as well as implementation support needs. While the survey found that over half of the respondents indicated that plans were accessible, technical language, the length of plans, lack of individualization, and out of date content were highlighted as issues. Areas of needs identified were collaboration in plan development, more training, follow‐up and support throughout the ‘PBS processes’ (Fisher et al. 2022).

Barriers and facilitators to BSP implementation have been more widely researched within the educational sector (Karger et al. 2018). An important distinction highlighted by Lawson et al. (2022) is how barriers and facilitators may differ within frameworks of support that involve more than one tier. This recommendation was specific to behavioural classroom management interventions, but the same premise applies to community settings. Identifying similarities and differences between tiers within the PBS framework may enable organisations and practitioners to identify suitable supports to assist staff in achieving greater implementation at each tier. Given the importance of contextual fit and the environmental differences between schools and community‐based services, further research is required in this area. It is essential to have a full understanding of the barriers and facilitators to change within the context and with the specific approach seeking the insights of those directly implementing interventions. A method which enables clarity on barriers and facilitators is the Theoretical Domains Framework (TDF).

The Theoretical Domains Framework (TDF) is a theoretical framework which uses a theory informed approach to identify key determinants (i.e., barriers and facilitators) to evidence‐based practice implementation. The TDF enables broader consideration of barriers and facilitators including cognitive, affective, social, and environmental influences on behaviour. The framework consolidates 33 behaviour change theories into 14 theoretical constructs and has been widely used to explore implementation (Atkins et al. 2017). The TDF may have utility in clarifying the key factors impacting the implementation of BSPs for individuals with intellectual disabilities in community settings.

The current study aims to address the research question: what are the barriers and facilitators to the implementation of BSPs for individuals with intellectual disability in community settings? A secondary research question seeks to explore whether frontline staff teams and their team leaders perceive barriers and facilitators differently. This study aims to develop and expand on the work of Bambara et al. (2001), Inchley‐Mort and Hassiotis (2014), and Woolls et al. (2012) by focusing solely on the implementation of BSPs (Tier 3) and by using the Theoretical Domains Framework to identify the facilitators and barriers among staff teams that are both successfully implementing and struggling with implementing BSPs.

1. Method

1.1. Design

A qualitative research design was used, underpinned by a constructivist epistemological paradigmatic framework. During data analysis the research adopted an epistemological lens and viewed language ‘as implicit in the social production and reproduction of both meaning and experience’ (Byrne 2022, p. 1395). The consolidated criteria for reporting qualitative research (Tong et al. 2007) guided the study write‐up and the Theoretical Domains Framework (TDF) lead the development of the interview guides.

1.2. Participants

The inclusion criteria for participants were as follows: (a) staff teams working in residential houses supporting individuals with intellectual disabilities that engaged in behaviours that challenge, for whom a BSP was developed and currently being implemented and (b) Team leaders of the staff teams who participated in focus groups. Teams were identified based on the clinical expertise of the organisation's PBS Group staff teams, where (i) the BSP was successfully being implemented in the setting (high implementation, referred to as ‘successful teams’) or (ii) there were challenges with implementation of the BSP (low implementation, referred to as ‘struggling’ with implementation). There were no specific criteria for individual staff within the team in order to gain insights from typical staff teams within the organisation. The exclusion criteria were staff teams who provide care for individuals with intellectual disabilities, but for whom a BSP was not in place.

1.3. Setting and Recruitment

The research was conducted within one region of a charity organisation in the Republic of Ireland which provides multidisciplinary support for individuals with intellectual disabilities across residential, day and respite services. The organisation provides a two‐day theory‐based training in PBS, which is not mandatory. Ethical approval was granted by both the academic institution and the organisation (Ref: 18‐Jun‐11).

A purposive sampling strategy was used to identify staff teams. The PBS Group within the organisation (composed of management, psychologists and behaviour therapists) was asked to nominate staff teams which met the inclusion criteria. This strategy was used to gain an in‐depth comparative analysis within and across staff teams. Key within the recruitment process was an emphasis that taking part was voluntary so that participants fully understood there was no organisational obligation to take part. Recruitment occurred in phases, with an additional set of staff teams identified by the PBS Group if further recruitment was required, which was not necessary.

Once a staff team was nominated by the host organisation PBS Group, all members were offered the opportunity to participate. This involved the first author and the team leader jointly meeting with the staff team in order to provide them with information sheets and consent forms, at which point it was highlighted that participation was completely voluntary.

Participants took part in the research during their time at work and received no reduction in pay. If consent was received from four members of a team (the minimum participation requirement), their respective team leader was then offered the opportunity to take part using the same process and consent sought.

1.4. Interview Guide

The interview guide (for focus groups and interviews) consisted of 14 questions related to each domain of the TDF (please see Data S1 for an explanation of each domain). The behaviour of interest was the implementation of BSPs, and the interview guide aimed to identify the barriers and facilitators to implementation. The interview guide was piloted in a focus group with two people working in the area of PBS (a front‐line staff member, and a team leader) and a mental health clinical support worker. Feedback was incorporated to adapt the interview guide.

1.5. Procedure

1.5.1. Focus Groups and Interviews

In 2019, four focus groups were conducted with frontline staff teams working with adults with intellectual disabilities in residential settings. Following each focus group, a semi‐structured interview was conducted with the team leader of the participating staff teams (n = 4). Data was collected across staff teams and their respective team leaders to identify if both cohorts shared the same beliefs. Focus groups were conducted by the first author with each staff team in a private room, both on‐site in residential settings and off‐site (in a local training venue) until the principle of saturation of data was met (the focus groups were providing no new information; Carlsen and Glenton 2011). Focus group sizes varied from four to six staff, and all were audio recorded and transcribed by the first author. Duration of focus groups ranged from 48 min 30 s to 106 min 06 s.

Interviews were conducted by the first author with the team leader of the respective staff team at a convenient time, in a private room on‐site, and were audio recorded and transcribed. Duration of interviews ranged from 51 min 42 s to 108 min 40 s. Transcriptions for both focus groups and interviews were crosschecked for accuracy by the first author, with spot checks from random scripts against audio recordings, which were then deleted.

1.6. Data Analysis

In line with the constructivist epistemological paradigmatic framework, while the recurrence of codes was viewed as important within the coding process, the central criterion was the meaningfulness of the codes to answer the research question (Byrne 2022).

1.6.1. Reflexive Thematic Analysis

Reflexive thematic analysis (RTA) was conducted separately across interview and focus group data by the first author using Braun and Clarke's (2006) guide, with NVivo version 12 (International Pty Ltd 2018) software used to facilitate data organisation. “TA is a method for identifying, analyzing, and interpreting patterns of meaning (‘themes’) within qualitative data” (Clarke and Braun 2017, 297) while acknowledging the subjectivity of the researcher. The six phases include: (1) researcher familiarisation with transcribed data, (2) generating initial codes (called open coding), (3) placing codes into categories; generating themes, (4) reviewing identified themes, (5) defining and refining themes, and (6) the report itself. Twenty percent of both focus group and interview transcripts were analysed independently by the second author to facilitate in‐depth reflective discussions about coded data and theme development, differences in interpretation, which were discussed with the fifth author who has extensive experience in PBS. This was facilitated by providing access to focus group and interview transcripts and involved discussions on codes and developing and developed themes. To facilitate discussions on the depths of themes (i.e., the richness of coded data by the first author) the second author accessed and made notes on both the coded data and memos (corresponding first authors thought process) in NVivo, see Figure 1. The reflexive thematic analysis enabled the development of a thematic map by narratively linking over‐arching themes identified across focus groups and interviews highlighting both agreement and differences.

FIGURE 1.

Diagrammatic representation of the data analysis process.

1.6.2. Theoretical Domains Framework

As Braun and Clarke's (2006) method is a flexible inductive analysis, (i.e., not tied to a pre‐existing theoretical framework) it also enabled deductive analysis of data (i.e., using a pre‐existing theoretical framework) into the relevant TDF domains.

Firstly, clear definitions were developed of each domain within the TDF which is outlined in Data S1. Secondly, the first author deductively developed beliefs for both interview and focus group transcripts separately by placing open codes into relevant domains. For example, any open code referring to the compatibility of the setting for the individuals supported was placed within the Environmental context and Resources Domain. Frequently mentioned responses were only outlined as beliefs if they were impacting on the implementation of BSPs (see Figure 1). From this, the predominant domains (a domain was identified as a predominant domain if it had a high instance of data coded (beliefs) to this domain), and key barriers and facilitators were identified. The second author independently mapped all identified beliefs into TDF domains to facilitate discussion on the depth of beliefs (Francis et al. 2009).

Agreement and differences across interview and focus group predominant TDF domains and determinants (i.e., facilitators and barriers) were narratively summarised. The first and second authors discussed predominant domains (the most data coded to these domains) and key barriers and facilitators across domains and their relation to identified themes. This enabled clarity on the key factors impacting on BSP implementation.

2. Results

2.1. Participants

Participants were from four staff teams, including 21 front‐line staff, and the respective team leaders for each of the staff teams (n = 4). A front‐line staff member fulfilled the duties of a social care worker/care assistant, which involved supporting individuals with intellectual disabilities and implementing elements of BSPs. Each front‐line staff member reported to their respective team leader, who may or may not have been directly implementing BSPs. Team leaders' primary responsibility was to oversee the work of all front‐line staff within a team, ensuring that duties and responsibilities to the individuals supported were fulfilled. For information on participant demographics, see Table 1. Team A (n = 6) supported one individual in an apartment. Team B (n = 5) supported three individuals across one house and one apartment, Team C (n = 6) supported six individuals across one house and two apartments. Team D (n = 4) supported 6 individuals across one house and one apartment. Teams A and D were identified as ‘successful teams’ and Team B and C were identified as ‘struggling’ with BSP implementation in their setting.

TABLE 1.

Demographic table of participants academic qualifications, duration in organisation and current role (in years).

Team	Academic qualifications	Duration in organisation	Current role	Duration in current role
A
Mary	Undergraduate in related degrees	> 5	Frontline care roles	< 5
Sarah	Undergraduate in related degrees	> 5	Frontline care roles	< 5
Molly	Undergraduate in related degrees	< 5	Frontline care roles	< 5
Nicole	Undergraduate in related degrees	< 5	Frontline care roles	< 5
Mathew	Undergraduate in unrelated degree	< 5	Frontline care roles	< 5
John	Not specified	< 5	Frontline care roles	< 5
B
Jack	Undergraduate in related degrees	< 5	Frontline care roles	< 5
James	Postgraduate and advanced degrees	< 5	Frontline care roles	< 5
Rachel	Undergraduate in related degrees	> 10	Frontline care roles	< 5
Luke	Not specified	> 5	Frontline care roles	> 5
Lily	Undergraduate in related degrees	> 10	Frontline care roles	< 5
C
Kim	Undergraduate in related degrees	< 5	Frontline care roles	< 5
Jill	Undergraduate in related degrees	< 5	Frontline care roles	< 5
Minny	Undergraduate in related degrees	< 5	Frontline care roles	< 5
Laura	Undergraduate in related degrees	< 5	Frontline care roles	< 5
Elizabeth	Undergraduate in related degrees	> 10	Frontline care roles	> 5
Gemma	Not specified	> 10	Frontline care roles	> 5
D
Miley	Vocational and other certifications	< 5	Frontline care roles—assistant level	< 5
Monica	Postgraduate and advanced degrees	> 5	Frontline care roles—assistant level	> 5
Merideth	Undergraduate in related degrees	> 10	Frontline care roles	> 5
Christina	Undergraduate in unrelated degree	< 5	Frontline care roles	< 5
Team leaders
Joanne	Undergraduate in related degrees	> 10	Supervisory and leadership roles	> 5
Cara	Postgraduate and advanced degrees	> 5	Supervisory and leadership roles	< 5
Blake	Undergraduate in related degrees	> 10	Supervisory and leadership roles	> 5
Jane	Undergraduate in related degrees	> 10	Supervisory and leadership roles	> 5

Note: Related disciplines include: BA Psychology and Sociology, Denominated Psychology, and BA in Early Childhood Studies and Practice; unrelated disciplines include: BA in Fine Art; the roles and responsibilities of social care workers, support workers, and care assistants are similar. The primary differences between social care workers and support workers are the qualifications; social care workers must have an applicable degree to be able to register as such with the national requirements, while support workers are required to have qualifications related to the intellectual disability field. For care assistants, a relevant degree is an advantage rather than a requirement.

Abbreviations: BA, Bachelor of Arts; BSc, Bachelor of Science; FETAC, further and higher education qualifications; ID, intellectual disability; MA = Master of Arts.

2.2. Reflexive Thematic Analysis Explanatory Themes

The three over‐arching themes were organisational level, process factors and individual level. The organisational level theme was broken down into the subthemes of clarity of BSP, sharing the details of BSP, informal training, environment, resources and client factors. Process factors were broken down into the subthemes of the creation process, staffs' relationship with the individual they support and team communication (including team dynamics, collaboration with MDT, and level of communication). Individual level included understanding, experience and buy‐in. Many of the subthemes exist on a continuum, acting as either barriers or facilitators depending on their level of presence or absence within the context. A further distinction was made on how these subthemes were identified as both barriers and facilitators across three time points: acquiring knowledge and skills, implementation on the ground and consistency of implementation (see Figure 2). Firstly, acquiring the knowledge and skills includes how staff are first introduced to the BSP. Secondly, implementation on the ground relates to when staff are first trying to implement the BSP. Finally, consistency of implementation encompasses both implementation across the staff team and level of implementation by individual staff. Consistency is distinct from implementation as two staff teams highlighted that they were ‘ticking a box’ to indicate they had tried to implement or wrote lifestyle notes. A thematic map across these three time points indicating whether identified subthemes were at an organisational level, individual level or were related to process factors was developed and represented in Figure 2.

FIGURE 2.

Factors impacting on the process of behaviour support plan implementation.

2.3. Organisational Level

2.3.1. Clarity of BSP

The clarity of a BSP was reported to impact on skill acquisition. Structured (e.g., a step‐by‐step day routine), simplified (e.g., working on one target behaviour at a time), and individualised BSPs were outlined as facilitators to implementation. In contrast, large documents with multiple components which can be interpreted differently by each staff member were seen as a barrier to implementation.

2.3.2. Sharing the Details of the BSP

MDT providing a presentation and incorporating collaboration with the staff team on which elements to prioritise first was identified as a facilitator for acquiring knowledge and skills (Teams A and D). Team C highlighted the need for this input. However, solely reading a plan where there is a lack of clarity on what elements to prioritise without collaboration with MDT (Teams B and C) is a barrier to implementation.

And when it comes down on the floor, for the, psychologists to come and give us a presentation. Just to clarify what is in the PBS. So everybody knows the part, that element of oh ____, that element of subjectivity is the key now. So everybody understands what it's about. Gemma—Team C

2.3.3. Informal Training

For staff members who joined a team after a BSP is put in place (i.e., new staff), informal training, observation, and discussions with other staff members, as well as feedback from other staff members, were identified as facilitators to acquiring knowledge and skills. A barrier to implementation for new staff is not having access to informal training due to staffing levels and solely reading the plan (Team B).

I think when I say vague, it's how you interpret it, I might look at it and say, Oh, this is what it means and someone else might look at it and go maybe we should, do you know, maybe we should try it another way. Kim—Team C

2.3.4. Environment

Other factors impacting implementation on the ground were the compatibility or incompatibility of the environment. A compatible environment meeting the individuals needs was identified as a facilitator for implementation. Whereas staff teams supporting more than one individual (Teams B, C and D) discussed this heavily as a barrier.

2.3.5. Client Factors

For three staff teams' the level of CB (high) was outlined as making BSP implementation a priority and therefore a facilitator for implementation on the ground. In contrast, client's motivation, a long history of CB and if individuals are in crisis or engaging in elevated levels of CB were reported as barriers to implementation. This was particularly evident for settings supporting more than one individual, with workload, and prioritising the individual in crisis. Team B discussed that it was not possible to implement the BSP when safeguarding for the individual, managing the individual's behaviour, and ensuring they are kept safe during an incident. Descriptions indicated that ‘managing behaviour’ was implementation of the reactive elements of the plan, however a direct link was not made to BSP implementation.

They take turns. Like one person could be [good] for a good few days and then someone else takes over having a bad week, at this stage the BSP takes the back seat to just managing behavior, keeping at an even keel and just getting through the day, rather ticking boxes, trying to get through without any incidents. James—Team B

2.3.6. Resources

Access to adequate resources (e.g., staffing levels for activities in the community) was also discussed comprehensively. Having the availability of adequate staffing (two to one staffing in this instance) was a facilitator to implementation on the ground and consistency of implementation. Staffing levels were only emphasised as a barrier if supporting more than three individuals, with daily responsibilities and finding time to implement elements such as skills building elements reported as the greatest challenge. This was also linked to new staff putting regular staff under pressure or not enough staff on duty to implement.

And then also, you have the fact that people come in there, and we have new staff quite a lot. So we have quite a high, I suppose, rotation of newer staff, which can impact on certain people's behaviors, and can escalate behaviors, so that doesn't help and that, that makes it difficult, doesn't it? Jill—Team C

Consistent input from MDT, including consistent review meetings with feedback, on the ground support and having access to support (i.e., available on phone: Teams A and D) facilitated consistency of implementation. The need to have access to support to discuss qualms was emphasised as integral. One specific member within Team C mentioned ethical qualms with an intervention that had a long‐term focus, where short‐term requests were in certain instances denied. While other members of the team did not share this perspective, they indicated that they felt that the restrictive intervention was in the best interest of the individual.

Not having the availability of support from MDT, lack of feedback, and cancelled or inconsistent periods between meetings (Teams B and C) were identified as barriers. One of the ‘successful teams’: Team D, indicated that they also had difficulty with resources, supporting more than one individual, but had strong communication across the team, day service and with family members.

This is where the more consistent reviews need to come in where you're not annoying someone, making them do something that they've made it clear they're not that interested in but that you still feel like that because you haven't been told let's just drop it. It's not working, we're still doing it until the next meeting, and we can say it's been tried. Lily—Team C

2.4. Process Factors

2.4.1. Creation Process

Staff Collaboration and on‐site observations to inform the plan were a facilitator to buy in and subsequent implementation. On the other hand, Teams B and C felt that components of plans were random and highlighted a need for more individualised plans. They also emphasised that the lack of MDT observations during the creation process was a barrier to buy‐in.

so we can tweak it as a team like you know, it will have to be tweaked, because I think with the behavior, the psychologists, like they don't do it case specific, you know. our ladies are complex, if we were part of the whole process, you know, what the final end here's the draft, yeah. And then we all sit down as a team or maybe that wouldn't work. And then it's tweaked, so we're all in. Elizabeth—Team C

2.4.2. Relationship With Individual

Teams A, C and D and two team leaders emphasised the importance of staff members relationship with the individual they support for implementation on the ground. A strong relationship with the person supported was identified as a key facilitator for implementation. In opposition to this, the time it takes to build rapport at the beginning is a barrier for implementation, during which time it is challenging to implement the plan.

From my own experience, it took six months, when I came here first, to even engage that person…so to implement a BSP would be impossible for me at that time. Jill‐Team C

2.4.3. Team Communication

An integral factor that impacts the consistency of implementation is team communication and whether staff check in with each other, which shifts may not always allow. Consistent communication across the team, checking in with each other, was identified as a facilitator.

Team dynamics in turn impacts on level of implementation, through consistency of implementation across the staff team. One team leader specifically labelled this ‘staff attitudes’. Lack of collaboration with MDT both during the BSP creation process and not receiving feedback and praise from MDT was indicated as impacting on buy‐in.

Resources were identified as a barrier to team communication for Teams B and C. Level of communication was heavily linked to implementation monitoring. Team C discussed how communication at team meetings can be subjective, as can individual notes. Similarly, staff may forget to write something down which is a barrier linked to lack of MDT input. In contrast, Team D, that primarily used lifestyle notes, never mentioned subjectivity, however this team had high levels MDT involvement. While Team B did not mention communication at all, they monitored implementation through a tick chart to show they ‘tried’. Team A reported, with MDT being involved in all team meetings, they didn't feel they had as much of an opportunity to check in with each other. Further highlighting the importance of communication within a staff team.

And I think it can be, there's good days and bad days and I suppose like that, the 5 min that it takes to go okay, this happened that happened, are we all okay? I think that's really good to be able to get on with the shift and be able to go no I'm not happy with something or I'm a bit concerned or maybe we need to look into this. Molly‐Team A

2.5. Individual Level

2.5.1. Understanding

Three team leaders believed understanding or a lack of understanding had the potential to be a facilitator or a barrier for acquiring skills. A specific facilitator would be formal PBS training in terms of understanding and knowledge for all team members. Staff who had received this training indicated that it had not provided them with skills for implementation. Across staff teams, 57% (n = 12) of staff had received a 2‐day Introduction to PBS Training provided by the organisation; six (26%) staff members (one staff team) had received additional theory‐based bespoke training on a specific individual's BSP. Forty‐three percent (n = 9) of staff members had not received any PBS‐specific training.

2.5.2. Experience

Two team leaders highlighted experience without knowledge of PBS or intellectual disability as a barrier to acquiring knowledge and skills, with one team leader describing this as ‘the wrong experience’, linking this to a generational gap in terms of education.

If you can't help that staff to understand why we're doing this change (PBS) or then you're always going to have a barrier, because you're not going to have the consistency. Cara—Team Leader

the wrong type of experience around supporting people with behaviors that challenge. Joanne—Team Leader

However repeat, refresher training in PBS was outlined as a strategy by team leaders for how ‘the wrong experience’ could be overcome (a facilitator).

Yeah, the training will definitely be a facilitator, just to refresh, refresh staff's memory on, you know, just to keep it alive. We keep so many other pieces of training alive. And I think, you know, this is definitely one that we should be. Cara—Team Leader

2.5.3. Buy In

Whether staff teams were directly seeing the effects of the plans for the individual they were supporting also impacted buy‐in (reinforcement). Staff teams believed that buy‐in did not impact on their level of implementation, which was at odds with three team leaders that indicated both the level and whether elements were implemented at all were impacted.

So if it's something that they know will work with, ____, if it's something they're not sure that ____ will pass any heed of or have no immediate response again, and they're less inclined to want to implement it. Joanne—TL

Three of the four team leaders highlighted that understanding or lack of understanding can negatively impact on individual staff members' buy‐in and level of implementation, which impacts on team dynamic.

The reflexive thematic analysis enabled a rich understanding of how the barriers and facilitators to implementing BSPs were experienced differently by the teams that were indicated as successful and unsuccessful in implementation. The TDF analysis enabled clarification on the predominant domains and specific beliefs which staff and team leaders believed to be impacting BSPs on implementation.

2.6. Theoretical Domains Framework

The predominant domains believed to be impacting on BSP implementation are presented separately for frontline staff and team leaders, with a commentary on whether there were differences across beliefs for both groups. Table 2 outlines specific beliefs within each domain, and domains are presented in order, from domains with the highest frequency of meaningful utterances to the lowest frequency.

TABLE 2.

Key beliefs in each TDF domain and key quotes.

Domain	Specific beliefs	Key quotes
Environmental context and resources	Barriers and facilitators
Structure of environment impacts implementation	“the environment, so it's a purpose‐built apartment for this individual, so that helps us to implement the Behaviour Support Plan” Molly—Team A “incompatibility issues in this house, and we only have one main living room on large living room space, and you know, you're trying to help four individuals manage positive you know try and implement a positive behaviour plan, all in one room” Kim—Team C
High levels of challenging behaviour impacts implementation	“It's easy enough to implement it when this individual is in a good place, but obviously when mental health deteriorates, and they are in an episode or crisis phase then it's quite difficult to implement the Behaviour Support Plan” Molly—Team A
Clarity of Behaviour Support Plans impacts implementation	“I feel like it's quite a difficult piece of paper to implement, the ones we have here” “they're really large documents with a huge amount of options and information. And it can be difficult to get clarity” Kim—Team C
Workload (supporting more than one individual) impacts on implementation	“Yeah, it's hard for moral to stay high. And then it's a needs basis. So, if there's an imminent need the PBS Yeah, you become takes a bit of a backseat.” “because of practicalities of running the home, come first, or keeping people safe” Jill—Team C
Having availability of support/not having access from Multi‐Disciplinary Team impacts implementation	“But this is where the more consistent reviews need to come in where you're not annoying someone, making them do something that they've made it clear they're not that interested in but that you still feel like that because you haven't been told lets just drop it. It's not working, we're still doing it until the next meeting and we can say it's been tried” Lily—Team B
Level/consistency/availability for Multi‐Disciplinary Team review/support impacts on implementations	“I think we're fortunate because we have a lot of supports, it could be very easily be a team where we haven't seen the Multi‐Disciplinary Team in 6 months and what do we do now we're in crisis. We've never had to you know look anything, help is never far away” Mathew—Team A
Level of feedback from experienced colleagues and Multi‐Disciplinary Team and on the ground support impacts on implementation	“I felt getting stuck in and looking and observing, I suppose I was with it from the start but I felt it was more beneficial to the new staff that came in if they did it experienced it, and took pointers from the staff that were there watching them” John—Team A
Barriers Motivation of Client can hinder implementation	“There's sometimes the idea, that you know the individual will say that sounds brilliant but we know or someone knows that this will absolutely not work, the person will not have any interest in it and then you still try to do it and but know from the get go that it might not work or there is a good chance it won't work” Jack—Team B
Staffing levels/relief staffing hinders implementation	“So we have quite a high, I suppose, rotation of newer staff, which can impact on certain people's behaviours, and can escalate behaviours, so that doesn't help and that, that makes it difficult, doesn't it? Because that kind of send it quite extreme” Jill—Team C
Social influences	Barriers and facilitators
Having or not having a voice with Multi‐Disciplinary Team and or availability of support from Multi‐Disciplinary Team impacts on implementation	“because it shows that they've autonomy, and they can get their voice is as important as anyone else's, which it is in a place like this. Everybody's equal in that sense” Blake—TL a
Level/consistency/availability for Multi‐Disciplinary Team review/support impacts on implementations	“Well, at our team meetings, the Multi‐Disciplinary Team come, they all have their insights into the behaviours, they get information from us” “when we talk back to them, they do up analysis and we do up the plans together” Monica—Team D
Level of feedback from experienced colleagues and Multi‐Disciplinary Team, need for regular support and on the ground support impacts on implementation	“I suppose new staff come in as well between those periods who might read the Behaviour Support Plan but if they haven't worked with them before mightn't really understand what's expected of them and because it takes so long to decide if something is not working or whatever am someone could be doing something doesn't work that we've already established doesn't working” Lily‐ Team B
Team Dynamic impacts on implementation a	“if you have some staff that are all about Positive Behaviour Support, it's great.” “But then if you have another staff that thinks, that's a load of rubbish” “well you can do it if you want to but I'm not” “it can then bring the whole” “positive bit, out of the Positive Behaviour Support, you know, so and then you also don't have, you've a dynamic, then where everybody isn't working together” Cara‐TL a
Facilitators
Communication with Multi‐Disciplinary Team essential	“But this is where the more consistent reviews need to come in where you're not annoying someone, making them do something that they've made it clear they're not that interested in but that you still feel like that because you haven't been told lets just drop it. It's not working, we're still doing it until the next meeting and we can say it's been tried” Lily‐ Team B
	“Because we work shift, and I might be working with _ today and I may not see _ again for another month, very hard at times to make sure we're all doing the same thing.” “, _ did something last week, and it worked really well. And I just I didn't get wind of what it was” “it's hard sometimes to filter down the information through it” Elizabeth—Team C
“There at the end of a phone really every day, they have specific days but realistically if we need _support. If you need them, because you wouldn't be making contact unless it's important” Blake—TL a
Communication across team during day and at team meetings facilitates implementation	“I think communication is key as a team” Monica—Team D
Caring for people they support facilitates implementation	“Everybody cares, they want what's best for the well‐being of the people” Jill‐ Team C
“Because we're working with them so long, like we really care about these guys and want things to work” Laura—Team C
Relationship is essential for implementing Behaviour Support Plans.	“we're learning all the time, you know, and yeah, am, so important that you have a good relationship” Merideth—Team D
Barrier
The time it takes to build a relationship is a barrier for implementation	“From my own experience, it took six months, when I came here first, to even engage that person” “so to implement a positive behaviour support plan would be impossible for me at that time” Jill—Team C
Behavioural regulation	Informal feedback from team leader, feedback from Multi‐Disciplinary Team, feedback from other staff facilitates implementation	“The document is handed to you, go implement it, they don't come back to see what's worked what hasn't worked I think that would be good” Gemma—Team C
Beliefs about capabilities	Participants indicated that this domain was not directly impacting. Rather the mental health of the individual supported (i.e., whether in crisis or a good place impacted their ability to implement the plans).
Reinforcement	Seeing the Behaviour Support Plans work as an advantage Time it takes to see change, can be a barrier to buy in a	“Say the girls will do certain things with certain staff quicker than they do for somebody” “it's the people that implement the Behaviour Support Plans generally are that are very familiar with them.” “Because you're consistent, you know, so I think it does work and then motivates you to continue to do it” Jane—TL a “it's a barrier for keeping staff invested and interested at times because it's hard going you know, when you try the same thing every day nothing works may want an immediate, almost immediate feedback” Joanne—TL a
Social professional role and identity	Barrier and facilitator: Level of challenging behaviour impacts on priority of implementing Behaviour Support Plans	“particular behaviour that's causing huge trouble in the house, it's going to be a huge priority. Well if the behaviour is more tepid, well the other things take priority, like food and shopping” Elizabeth—Team C
Skills	Facilitators
Informal training facilitates implementation	“I suppose when you read the BSP, particularly for this individual, it's very hard to not understand it but to put it into context until you go physically into the situation or the environment and see how the team … implement it … the team are so strong out there and have developed such a strong relationship with the individual that the implementation is just second nature, so you're picking up from the team more so” Molly‐Team A
Experience also facilitates implementation a
Education is a facilitator a
Repeated training in pbs as possible facilitator, refresher courses across two team leaders for implementation a	“does it require some sort of regular by annually within teams to go through PBS again and again and again and again until it becomes our norm because it's still relatively new overall, when you say to staff, that's our model. It's not ___ model anymore PBS's our model and why we might have been doing it for a very long time with MDT's. I still think it needs a lot of education” Joanne—TL a
Barrier
Experience without knowledge of PBS as a barrier a	“Whereas the experience, you might have a lot of experience working with people with intellectual disability if you don't have the knowledge to go with it. And the education sort of around this, then you mightn't see the need to implement?” Jane—TL a
Knowledge	Facilitators
	Formal (organisations) Positive Behaviour Support training facilitates understanding (knowledge)	“It's all in theory, you know, it's very hard to apply that in practice but it is a good course” Laura—Team C
	Repeated training in Positive Behaviour Support as possible facilitator, refresher courses across two team leaders for understanding a	“And sometimes maybe the understanding of how we achieve it gets a bit wishy washy” “so if there are steps that we need to do to achieve the goal. Sometimes you need to make sure that you keep in the link of the chain” Cara—TL a
	Education is a facilitator a
	Experience (time) also facilitates implementation (skill) and knowledge a	“I think the most thing everybody needs to be given time to get to know services or services, good time to know them” Blake—TL a
	Barrier
	Experience without knowledge of Positive Behaviour Support as a barrier to knowledge a	“there is a big shift in thinking between the older generation and the younger generation” Jane a “a huge barrier, you know,” “trying to break the culture of the past to change it into what we want it to be in Positive Behaviour Support” Joanne—TL a
Emotional factors	Barriers
	Stress and tiredness from long shift impacts on implementation	“So we work through our shifts. So we eat our meals here with our people we support and you have a lady beside you while you're trying to eat a slice of toast screaming” Kim—Team C
Beliefs about consequences	Barriers and facilitators
Staffs perspective on client motivation to engage with plans may impact on buy in/quality of implementation Knowing plans don't work impacts on buy in	“There's sometimes the idea, that you know the individual will say that sounds brilliant but we know or someone knows that this will absolutely not work, the person will not have any interest in it and then you still try to do it and but know from the get go that it might not work or there is a good chance it won't work” Jack—Team B
Might not always agree plans impacts on buy in	“Sometimes you're implementing something you mightn't agree with and it mightn't be working but you've got to persist with it” Mathew—Team A
Agreeing with plans may impact on implementations/level of implementation a	“So if it's something that they know will work with, ____, if it's something they're not sure that ____ will pass any heed of or have no immediate response again, and they're less inclined to want to implement it” Joanne—TL a
Goals	Improving quality of life for the individuals they support is a key objective	“Assisting the service user to have the best possible quality of life” Christina—Team D
Intentions	Barrier and facilitator Attitude/staff buy in may impact on implementation a	“Willingness, from staff to work” “as a team to work consistently can be a barrier. Maybe it's the willingness, maybe it's the attitude of staff to work consistently” Cara—TL a
Memory, attention and decision processes	Participants indicated that this domain wasn't directly impacting, rather the resource domain, more specifically the clarity of Behaviour Support Plans and workload impacts on ability/decision to implement

Note: Beliefs in bold font serve as both a barrier and a facilitator. Impacts indicate that the belief was acting as both a barrier and a facilitator to implementation.

Abbreviation: TL = team leader.

^a Refers to beliefs that were only highlighted by team leaders; all others were shared beliefs across both team leaders and front‐line staff.

2.6.1. Predominant Domains Impacting on BSP Implementation

The predominant domain identified as impacting (both as a barrier and facilitator) on implementation of BSPs by front‐line staff was Environmental context and resources (e.g., staffing levels and compatibility of living environment), followed by Social influences (e.g., communication across the staff team and support from members of the multi‐disciplinary team). The domains of Beliefs about consequences, Behavioural regulation, Reinforcement, Emotional factors, Goals, and Social professional role and identity were also believed to be impacting on implementation. According to staff, the domains of Knowledge, Skills, Beliefs about capabilities, and memory, attention, and decision processes were not impacting on BSP implementation.

Similar to front‐line staff, the predominant domains identified by Team Leaders were Social influences and Environmental context and resources. Furthermore, Team Leaders identified three additional domains: Knowledge, Skills, and Intentions, which they felt were impacting implementation, see Table 2. All other domains were in line with focus group findings, with additional beliefs identified within the domains of Social influence, Reinforcement domain, and Beliefs about consequences.

3. Discussion

The current research study provides an in‐depth insight into the perspectives of front‐line staff teams that are both struggling and successfully implementing BSPs in an organisation supporting individuals with intellectual disabilities. Respective team leaders' insights enabled richer understandings of factors facilitating or hindering implementation.

Key facilitators identified for ‘successful teams’ were compatible environments, clarity of BSPs, access to on‐going Multi‐Disciplinary Team support, low turnover of staff (organisational level) and consistent communication across the staff team (process factors). Teams ‘struggling’ with implementation did not have access to these facilitators and identified this lack of access as key barriers: incompatible environments, lack of clarity in BSPs, the lack of access to resources, high staff turnover, inconsistent Multi‐Disciplinary Team input (organisational level), and structures not supporting communication across the team (process factors). The continuum across these factors further supports them as key determinants (barriers and facilitators) to BSP implementation. The current findings align with broader residential setting literature, where common issues are resources and environmental factors (i.e., issues of time), lack of supervision and team meetings (Broadhurst and Mansell 2007), the need for staff to have a voice, and using their ‘practice wisdom’ to collaborate on practices within their organisation (Quilliam et al. 2018; Bigby and Beadle‐Brown 2016).

The TDF analysis enabled clarification that staff teams believed Environmental context and resources, and Social influences were the two predominant domains impacting implementation, which were primarily external factors. This was at odds with their respective team leaders, who identified the additional domains of Knowledge, Skills, and Intentions as also impacting. Three team leaders believed that buy‐in and group dynamics can impact both the level of implementation and whether the intervention is implemented at all.

Three psychological conditions originally outlined by Kahn (1990) which impact on staff buy‐in are meaningfulness, safety, and availability. Meaningfulness relates to increased buy‐in when staff find purpose in their role and feel they are contributing. Safety refers to staff feeling that they can show up as themselves at work and express themselves without negative consequences to status and career trajectory within the organisation. Availability refers to staff feeling that they have the emotional, physical, and psychological resources necessary to fulfil their role (Asiwe et al. 2017; Kahn 1990; May et al. 2004).

Meaningfulness and availability of necessary resources were not always indicated for three staff teams where buy‐in was not always achieved. For these teams it could directly be inferred that this may have affected their level and quality of implementation, where a ‘ticking a box’ approach to implementation was discussed. This turn of phrase was used in four different contexts; in terms of individuals supported not engaging with an intervention, frontline staff not believing something is going to work or not seeing it work, and ethical qualms. For one staff team, they were able to bring their ethical qualms to the attention of the MDT after a trial period. The findings mirror those of Fisher et al. (2022) who emphasised that collaboration throughout the creation process, of developing the BSP, was essential to facilitate implementation. Fisher and colleagues described a ‘set and forget’ approach to BSPs, to highlight cases where there was a lack of support and follow up, which they outlined as not aligned with the values of PBS.

Unfortunately, resources for the other two teams did not facilitate this collaborative support (key barrier) and as a result psychological meaningfulness and availability were impacted. These findings emphasise the importance of having a space where staff members can voice their concerns about ethical qualms or disagreements. In addition, staff should be empowered through training on procedural integrity, restrictive practices, assisted decision making, in conjunction with the human rights policy of care providers to air their concerns about BSPs. In the current study, staff indicated that the lack of MDT support was a direct result of lack of resources.

Important context for the current research is that the delivery of PBS was within a caseload model of support where MDT receive referrals and provide support on a priority needs basis. The caseload model faces limitations as support needs (prevalence of behaviours that challenge) are much higher than the available resources of support (practitioners) (McClean et al. 2023). Determining how organisations can align their practices with the key values of PBS is integral. Within the current context the comparative of ‘successful’ teams and teams ‘struggling’ with implementation emphasises that what facilities implementation is alignment with the core values of PBS, collaboration throughout the PBS process with key stakeholders, person‐centered plans, and creating environments that offer choice and predictability, referred to as ‘capable environments’ (McGill et al. 2018). One solution may be to ensure all clinicians within an MDT (i.e., Behaviour Specialist/Psychologist, Occupational Therapist, Clinical Psychologist, Speech and Language Therapist. Paediatrician, Nurse; NCPPD 2023) are collaboratively working from a PBS framework to ensure the most effective delivery of services and alignment with the core values of PBS.

In the current research the key TDF domains (Environmental context and resources, Knowledge, Skills, Behavioural regulation, Reinforcement and Beliefs about capabilities) identified as impacting on implementation of BSPs mirror closely the subscales of the Performance Diagnostic Checklist‐ Human Services (PDC‐HS). The PDC‐HS is a tool developed and preliminarily validated as an indirect method of assessing performance analysis. Performance analysis is similar to a functional assessment but ‘focuses on the assessment of individual performance in organizations,’ (Wilder et al. 2020, 1170). However, one key factor which emerged within the current research which is not captured by the PDC‐HS is social processes (i.e., communication across team, staff team dynamic, relationship with clients). It is recommended that if using the PDC‐HS for a staff member working as part of a team that social processes should also be assessed.

3.1. Implications for Practitioner Working Within a Caseload Model of Service Delivery

The current findings on the barriers and facilitators to BSP implementation link to elements outlined by the PBS Coalition Competency Framework (2015). Taken together, these findings could be used as a “road map” for practitioners within a similar context to enhance implementation at each stage (e.g., BSP creation process, acquiring knowledge and skills, implementation on the ground and consistency of implementation). The findings provide insights both at an organisation and individual level and offer considerations for relevant process factors.

At an organisational level, it is recommended that systems are in place to support PBS: (i) sufficient resources for MDT availability, (ii) release staff for training on: PBS, skills‐based PBS training, self‐reflection, and restrictive practices, (iii) incorporate a person‐focused training approach; (iv) incorporate train‐thethe‐trainer model or practice leadership, enabling on‐thethe‐ground support and key personnel championing PBS could facilitate embedding the model of PBS, (v) if implementation issues arise, conduct the Performance Diagnostic Checklist—Human Services (PDC‐HS) as a source of information related to environmental and resource factors.

When considering Process Factors it is recommended that organisations: (i) ensure MDT collaboration during: BSP creation process, initial introduction of BSP (i.e., what to focus on) and throughout implementation; (ii) assess the contextual fit of a BSP (iii) ensure regular MDT ‘check ins’, so the staff feel heard; (iv) ensure staff are accessing reinforcement: where possible develop achievable short‐term goals, providing direct feedback/praise, a train the trainer model would facilitate this; (v) promote staff‐client relationships through emphasising how staff can develop their own personal relationship with individuals during induction training. Inform staff about the time it may take to build trust and the elements of the plan that will be challenging to implement during that period. If necessary support staff by providing informal rapport training; (vi) plan for strong communication across staff teams through consistent team meetings, a ‘check in’ system throughout the day and at the end of shift; (vii) Collaborate with staff on feasible ways of monitoring implementation within the context of their current workload, (e.g., a checklist incorporated within individual notes); (viii) if staff dynamics are impacting implementation, speak directly to staff, complete direct observation, gain insights from the team leader and use the Team Climate Inventory (Anderson and West 1998).

At an Individual Level it is recommended that: (i) staff are upskilled on their knowledge of PBS, intellectual disability, behaviours that challenge, specific behavioural intervention and skills of implementation and self‐reflection, (ii) if ‘buy‐in’ is impacting implementation, review individual process factors (i.e., access to reinforcement, level of collaboration throughout), (iii) incorporate motivational interviewing as an information gathering tool (Miller and Rollnick 2002).

3.2. Limitations and Future Research

While there were many strengths to the current study, there were also limitations. Member checking with participants would have further enriched findings and was not completed due to the timeline and the COVID‐19 global pandemic (i.e., national restrictions at the time prohibited visits to intellectual disability services). As the research was conducted within one regional area of a charity organisation, the findings are to be interpreted within this context. The findings of this research both expand and further support identified barriers and facilitators across different service contexts that were successfully implementing PBS, such as specialist units in the UK (Woolls et al. 2012) and community settings in the United States (Bambara et al. 2001). Future research could use the key barriers and facilitators identified to inform a survey to assess on a larger scale the needs of organisations in the intellectual disability sector across Ireland on PBS implementation, evaluating if practices are aligned with the core values of PBS and, if not, how this can be achieved.

To date, research has focused on staff teams that support individuals with complex needs and behaviours that challenge (e.g., Bambara et al. 2001). Future research could examine the barriers and facilitators which impact on staff supporting individuals with less complex needs, possibly focusing on Tier 1 and 2 levels of the PBS framework. It is suggested that future research on implementation processes could use a measure such as the PDC‐HS to further supplement findings.

In conclusion, the current research builds on and enriches the knowledge that key barriers and facilitators to implementation of BSPs by frontline staff supporting individuals with intellectual disabilities in a charity organisation were primarily within the domains of Environmental contexts and resources and Social influences. It also enables clarity on how organisations can plan for the success of PBS at both individual and organisational levels and highlights the process factors which require consideration.

Author Contributions

The authors confirm contribution to the paper as follows: study conception and design: Dearbhaile Mahon, Helena Lydon, Jennifer Holloway, Jennifer Holloway; data collection: Dearbhaile Mahon; analysis and interpretation of results: Dearhbaile Mahon, Cayleigh Dunworth, Helena Lydon. Jennifer Holloway, Jennifer McSharry; draft manuscript preparation: Dearbhaile Mahon, Helena Lydon, Jennifer Holloway, Jennifer McMahon. All authors reviewed the results and approved the final version of the manuscript.

Disclosure

The first author was in receipt of a scholarship to undertake her PhD in Applied Behaviour Analysis. The participants within the study were on paid time to take part which was facilitated by the host organisation.

Authors notes: The research was conducted by the first author under the supervision of the fifth author as part of her PhD research in Applied Behaviour Analysis at University of Galway.

Ethics Statement

Ethical approval was sought and received from both the Universities and the Organisations Research Ethics Committees.

Consent

Informed consent was received from all respondents to take part in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1.

Data Availability Statement

The data that support the findings of the current study are available from the corresponding author on reasonable request.