Influence of the organizational environment on challenging behaviour in people with intellectual disabilities: Professionals’ views

Abstract

Background

We examined the influence of the organizational environment on challenging behaviour in people with intellectual disabilities to increase understanding of the quality of support services for people with intellectual disabilities.

Method

Twenty‐one professionals and managers from four specialized Dutch disability service organizations were interviewed. Data were analysed with a grounded theory approach, using Bronfenbrenner's ecological theory as a sensitizing frame.

Results

The organizational environment (i.e., vision, values, sufficient resources) is related via the support service (i.e., providing stability, constant awareness) to residents’ challenging behaviour and is also linked directly to challenging behaviour (e.g., living environment, values). Organizations are restricted by national regulations, negative media attention and changing societal values, which negatively influence quality of support.

Conclusions

The creation of a supportive organizational environment for staff, who in turn can provide quality support services to residents with demanding care needs, was found to prevent challenging behaviour in people with intellectual disabilities.

1. BACKGROUND

People with intellectual disabilities are at increased risk of developing challenging behaviour, defined by Emerson (2001, p. 3) as:

culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or results in the person being denied access to ordinary community facilities.

Challenging behaviour includes physical aggression, problematic sexual behaviour, self‐injury, destructiveness and stereotypical behaviour. These behaviours threaten the quality of life of people with intellectual disabilities and those in their support systems and often lead to exclusion from society. People with intellectual disabilities and challenging behaviour are also at greater risk of ineffective treatment, abuse and high rates of restraint and medication (Allen, Lowe, Moore, & Brophy, 2007; Emerson & Einfeld, 2011; Hamlin & Oakes, 2008; Hastings et al., 2013; Hensel, Lunsky, & Dewa, 2014; Knotter, Stams, Moonen, & Wissink, 2013; Totsika, Toogood, Hastings, & Lewis, 2008; White, Holland, Marsland, & Oakes, 2003).

“Challenging behaviour” has been described as an ecological construct and thus is expected to be influenced by the responses of other people in the social environment. Other people include support service staff and professionals, who must support people with intellectual disabilities in a way that prevents challenging behaviour. This requirement may also apply to the wider support system, given that staff and professionals are supported by facilitating services, management and chief executive officers (CEOs) of disability service organizations. Dilworth, Philips, and Rose (2011) stated that relationships between people with intellectual disabilities and challenging behaviour and people in the organizational environments in which they receive treatment are expected to be dynamic. Although research has pointed towards the importance of a supportive organizational environment in preventing challenging behaviour in people with intellectual disabilities, empirical research is largely lacking (cf. Bigby & Beadle‐Brown, 2018). Studies investigating the role of the organizational environment in the development of challenging behaviour in people with intellectual disabilities, and comparing service delivery types, are expected to increase our understanding of the relationship between the organizational environment and challenging behaviour. These studies should enable the provision of better care and treatment to people with intellectual disabilities (Bigby & Beadle‐Brown, 2018; Bigby, Clement, Mansell, & Beadle‐Brown, 2009; Carr, 2007; Dilworth et al., 2011; Emerson & Einfeld, 2011; Felce, Lowe, & Jones, 2002). This qualitative study examined the influence of the organizational environment on challenging behaviour in people with intellectual disabilities in a sample of specialized residential disability service organizations. We analysed these entities’ organizational and support models from the perspectives of professionals and managers, using ecological theory as a source of sensitizing concepts.

1.1. Ecological theory

The ecological theory of Bronfenbrenner (1979, 1994, 1999; Bronfenbrenner & Morris, 2006) was used as a sensitizing frame for this study. Under this theory, individual human functioning and development are assumed to be the result of complex interactions between an active, bio‐psychologically developing person (the ontosystem) and four nested environmental “layers” consisting of persons, objects and symbols (the micro‐, meso‐, exo‐ and macrosystems). This framework is dynamic: The environment and the person within it interact regularly over time through proximal processes. Furthermore, the systems are interrelated; the person can influence and be influenced by nearby environments. The temporal aspects of these systems constitute an additional ecological element, the chronosystem, in which the person, his or her environments and interrelations between them change over time (Bronfenbrenner, 1979, 1994; Tudge, Mokrova, Hatfield, & Karnik, 2009), resulting in the model shown in Figure 1 (Institut National de la Santé et de la Recherche Médicale, 2016).

Figure 1.

Ecological model developed by Bronfenbrenner (1979, 1994, 1999); Bronfenbrenner and Morris (2006) and adapted by INSERM (2016, p. 982)

1.2. Ecological systems of a resident

The ontosystem includes a resident's personal biological (genetic and physical) dispositions and psychological characteristics, such as skills and experiences (Bronfenbrenner & Morris, 2006; Tudge et al., 2009). The environment around the resident, the microsystem, consists of activities with others, social roles and interpersonal relations in face‐to‐face interactions with family members, other residents and/or staff members. The mesosystem includes interactive connections between microsystems, such as those between the staff of the group home and that of the resident's workplace and/or interactions within staff member teams. The exosystem (in this study, the disability service organization) consists of relationships between, for example, staff members at the resident's group home (the microsystem) and proximate elements which positively or negatively influence the microsystem, such as the organization's upper management and board members. These actors do not interact directly with residents on a regular basis. The macrosystem is formed by societal rules, laws, funding systems and attitudes (e.g., belief systems, budget allocation systems, material resources) which are shared among the ecological systems and characteristics of a culture. The chronosystem encompasses the development of the resident and systems over time.

Thus, a resident's challenging behaviour (ontosystem) is presumed to be influenced by the group atmosphere (microsystem) and by positive interactions between his or her parent and staff member (mesosystem), which may be influenced in turn by the organizational culture (exosystem), which may be influenced by societal values (macrosystem). Furthermore, a resident's behaviour and the ecological systems change over time (chronosystem). These six environmental layers were used as sensitizing concepts in this qualitative study to identify the influences of the organizational environment of residential disability service organizations on challenging behaviour in residents with intellectual disabilities.

2. METHOD

2.1. Design

This study used a grounded theory approach, which is appropriate for the identification and explanation of social processes. This approach consisted of an inductive process in which data were collected systematically through interviews and analysed with respect to our research question, using the six environmental layers drawn from ecological theory (ontosystem [residents], micro‐ and mesosystems [support services], exosystem [organizational environment], macrosystem [society] and chronosystem [changes in the systems]) as sensitizing concepts (Strauss & Corbin, 1990 in Bowen, 2006). Sensitizing concepts are interpretive devices that give a general sense of how to arrange data without prescription (Bowen, 2006; Padgett, 2004 in Bowen, 2006). Data were further analysed through iterative close reading and coding to identify latent patterns in multiple participants’ perspectives (Bowen, 2006). We used constant comparative analysis, which entails continuous examination of and searching for boundaries of themes, segmentation and relationships between themes, to go beyond the sensitizing concepts and further ground the theory. Data were studied in several rounds to enhance external validity, until theoretical saturation occurred (Boeije, 2002; Bowen, 2006; Dunne, 2011). The trustworthiness of qualitative research is associated with the degree of credibility (e.g., use of acknowledged methods, familiarity with the field of disability plus challenging behaviour), transferability (e.g., clear description of participants and interviews) and dependability and confirmability (e.g., use of detailed methodology with constant reflection) (Shenton, 2004).

2.2. Setting and participants

Four specialized residential disability service organizations for people with intellectual disabilities and challenging behaviour in the Netherlands were selected based on variation in region, organizational size and stage of organizational development. An upper manager from each organization was asked to select two locations where residents with intellectual disabilities received specialized support for challenging behaviour. Participants were psychologists (responsible for overall support services, treatment and intervention plans), heads of group (responsible for day‐to‐day support of one or more groups/houses) and managers (responsible for three or more groups/houses). They were selected based on their familiarity with the group of residents and the organizational environment and their ability to discuss the relationship between challenging behaviour and the organizational environment.

2.3. Ethics

The Dutch Central Committee on Research Involving Human Subjects confirmed that this research did not fall under the scope of the Medical Research Involving Human Subjects Act.

2.4. Data collection and analysis

The first author, an experienced psychologist in the field of intellectual disabilities and challenging behaviour, held interviews lasting about 1 hr each on location. The interviews were based on the sensitizing concepts derived from Bronfenbrenner's ecological theory: (a) the ontosystem (characteristics of residents, e.g., age and challenging behaviour); (b) the micro‐, meso‐ and chronosystems (support service characteristics, e.g., interaction staff members with residents and group dynamics); and (c) the exo‐, macro‐ and chronosystems (organizational environment characteristics, e.g., culture, structure and national policies). Questions were open ended and generally used to help participants respond from their own perspectives (Appendix 1). In 2016, data were collected during 21 interviews at seven locations of four organizations. Interviews were taped, verbatim transcripts were generated, and sentences and small text sections were coded with open codes. Each code was compared with the other codes until theoretical saturation was visible, with inductively produced boundaries or code clusters. These clusters were labelled with the overarching theme (Boeije, 2002; Bowen, 2006; Dunne, 2011). The Atlas.ti software (version 7, Scientific Software Development, Berlin, Germany) was used for data analysis.

3. RESULTS

Themes generated from the interviewees’ perspectives are presented in Figure 2. Results are reported according to system layers.

Figure 2.

An ecological model of a person with intellectual disabilities and challenging behaviour, as viewed by professionals

3.1. Ontosystem

3.1.1. Complex and extreme challenging behaviours

Most residents in this study were Dutch men with mild to severe intellectual disabilities: Resident age ranged from 18 to 60 years. Psychiatric diagnoses included autism spectrum disorder, attachment disorder, psychoses and borderline syndrome. Some residents had multi‐morbidity (e.g., with diabetes). Residents displayed extreme, intimidating challenging behaviours (e.g., aggression, self‐injury, disruptive societal behaviour, problematic sexual behaviour), which challenged staff members, and resulted in histories of restrain interventions and frequent changes of group and organization. For example, a head of group stated:

All of our residents come from situations [ed: in our own or other organisations] in which people did not know how to manage their behaviours. One of the residents used to be tied to his bed, for almost two years. The moments in the day that he left his bed, about half an hour each, he had to be supported by four staff members.

3.2. Microsystem

The following microsystem themes were reported by participants: the influence of being anxious, seeing residents beyond their challenging behaviours, constant awareness and providing stability.

3.2.1. The influence of being anxious

Several participants emphasized that challenging behaviour can physically and psychologically damage staff members, resulting in feelings of anxiety, which in turn influence the ways in which staff members try to manage residents’ challenging behaviour. For example, a manager said:

How can I explain the tension between controlling behaviour and treatment? You can imagine that a resident's behaviour, certainly when they just arrive, is dangerous. Of course, there are many incidents, which naturally activate different processes in which the staff have to be or want to be protected. It creates anxiety, which influences how they react to challenging behaviour.

Nevertheless, according to participants, staff members try to keep feelings of anxiety under control and act with confidence, which is not easy due to a resident's history of incidents. A psychologist explained:

R: They mustn't downplay the situation, but act confident; based on previous experiences, it can also turn out to be a positive situation. Yes, of course it is stressful going into a room [ed: with a resident], however, you can always leave.

I: Yes.

R: Dinner wasn't thrown, nor was the table.

I: Nothing happened?

R: No, but if you would know the histories of our residents then you would know this is something very unique: sitting down for dinner.

3.2.2. Seeing residents beyond their challenging behaviours

According to several participants, a staff member must see beyond a resident's challenging behaviours and accept that person for who he or she is. A manager explained:

We try to manage a resident's behaviour, but in such a way that it enables us to learn about how these behaviours have developed and truly understand them. Not in a judgemental, disapproving, or correctional manner. Someone lives here; you are here now and what happened in the past doesn't matter anymore. It is important for the staff to have an attitude of accepting the person. A person is more than his behaviour.

According to participants, seeing a resident as more than just their challenging behaviours, although not easy, is important because challenging behaviour is a symptom of an underlying problem. A head of group stated:

A father can ask for protective clothes, stopping the tearing up of a resident's clothes. We will say, “Yes, but this is no solution because protective clothes is one thing to do, but he will start pulling his hair out or his teeth or something else will come in its place”. So that is just combating a symptom, and we won't do that.

3.2.3. Constant awareness

All participants mentioned that staff members need to have excellent observational skills and be constantly aware of potential changes in residents’ behaviour, as can be seen in a quotation from a head of group:

The staff are extremely aware, they have to be, no matter what happens. They are alert constantly, assessing risks continuously. Because, for example, a walk which you take four times a day can be different every time. You have to constantly assess: how is his [ed: the resident's] mood, state of mind, and how will I manage this?

Furthermore, staff members’ awareness and ability to observe their own behaviour in response to residents’ challenging behaviour is just as important as their ability to observe residents’ behaviour, as illustrated by the following quotation from a head of group:

The resident is who he is, and has experiences and memories of the past. Those are often the reason why a person displays challenging behaviour, and I think the only way to deal with this is by adjusting yourself and seeing yourself and the resident in a different way. When you only focus on changing the resident, you will get nowhere. And that is why you have to observe carefully and watch details of how I can interact differently, or what I can say differently, or how I can sit in another manner. So the resident acts differently.

3.2.4. Providing stability

Participants explained that to provide stability for residents, staff:resident ratios range from 3:1 to 1:3 during daytime hours, a team of 7–24 staff members support a group of four to seven residents, and the number of hours that staff members work is limited. A manager explained:

In order to create stability, we jointly created the rule that everyone has to work at least 24 hr per week but nobody is allowed to work full time. This was decided by all of us together. You have to work a minimum of three days per week with a resident, before residents are able to trust you in that moment and in new situations. Full time is not healthy in the support of this population.

3.3. Mesosystem

Mesosystem themes reported by participants were involving family, staff's sense of safety and providing room for mistakes.

3.3.1. Involving family

All participants reported that staff members have to try to facilitate contact between family members and residents (e.g., by visits, phone calls), and, if possible, to work together with family members in supporting a resident. Achieving this goal, however, is not always easy, sometimes due to family members’ own disabilities or damaged relationships with the resident, as a head of group explained:

R: Their social network are asked to help, however, most do not have a social network.

I: Oh, yes?

R: Dad or mom were also in prison, or the relationship is dysfunctional. Some do have a good social network, those you can involve. Then we work together to organise things.

3.3.2. Staff's sense of safety

Several participants mentioned the necessity of creating a sense of safety for staff members, to enable them to manage residents’ challenging behaviour. Thus, some organizations have intervention teams, as a head of group explained:

You have to create a sense of safety for the staff. We have intervention teams. So, when there is an incident or a distressed resident, other person, or staff member, the staff can send a signal through a pager for help, which is provided by colleagues. I can imagine when the staff do not feel safe because the intervention team members do not come or the pagers are broken, well yes. You have to make certain that the staff can rely on it, because otherwise there will be very serious consequences. The staff have to know if I signal, they will come to help.

However, several participants reported being worried about the lack of feeling safe in the workplace, due to severe incidents and staff members’ helplessness, as explained by a manager:

My first month, there was a severe incident with one of our residents, who threatened the staff of the night shift. Just threatening. But they were very alarmed by it, you must know. The staff said: “he does not belong here”. Such responses are frequently expressed in our organisation.

3.3.3. Providing room for mistakes

Several participants emphasized the need to have room for mistakes. Staff members need support, rather than critique, from their colleagues, but this issue is often a problem in cases of incidents. A head of group explained:

Mistakes will be made. The fact is incidents with a resident will happen with consequences for yourself, the resident, and the setting. You have to accept the population you support, but do you also feel you are supported yourself or are you corrected for an incident?

3.4. Exosystem

Participants mentioned the following exosystem themes: vision guides practice, shared values, everyone matters, control versus trust, allowing staff to explore, finding a good match, the team context, financial limitations and the living environment.

3.4.1. Vision guides practice

Vision was the organizational theme cited most frequently by participants, and it guides staff in providing proper support. It is associated with leadership, the organizational structure and the personnel policy, as illustrated by the following quotation from a psychologist:

But it is from top to bottom, the vision in our organisation. The vision is connected to the way we are organised: care is at the heart and not finances, and what is necessary in order to provide care. If there is a need for extra personnel because the resident needs it, we will provide them. We also believe in the head of group and a type of leadership. We have organised it from top to bottom, this has something to do with vision. It is he [ed: head of group] who can coach and support staff members, because he does the same work.

Some participants stated that acting in accordance with the vision requires schooling and guidance through regular reflection on one's actions. A manager explained:

Organising the translation of the vision [ed: into daily practices], by guiding the staff on how to act in daily practice, and a focus on schooling and de‐escalating incidents. You have to stress that the staff have to manage residents’ behaviours, and sometimes that unfortunately results in sending a resident to his room or a time‐out. However, the staff have to immediately discuss what could have been done differently. It's not a mistake, but they have to reflect, so it won't happen again.

Insufficiencies in vision and a lack of focus on treatment methods affect staff's ability to manage challenging behaviour, according to a head of group:

Differences in vision between staff members or having no clear vision at all, no time for meetings to plan interventions, a lack of focus on care and treatment plans can all result in the staff struggling to effectively manage challenging behaviours.

3.4.2. Shared values

A second organizational theme revealed during the interviews was the importance of shared values to guide appropriate staff behaviour in support services. A psychologist stated:

Well, they say it is a family culture, an organisation in which people are involved. The staff are really involved with each other, most have a great sense of responsibility and make an effort. They are interested and passionate.

A head of group also reported on how values, instead of organizational systems, guide staff behaviour with respect to the management of challenging behaviours:

[ed: Values, such as] custom made, thinking in terms of possibilities instead of problems, and the staff taking responsibility. Because they have to manage behaviours. And which we will try to facilitate by minimising the use of systems to control the staff's actions.

Furthermore, a manager explained how shared values guide behaviour of management towards staff, as well as the behaviour of staff towards residents:

Especially with this population, the way you interact with each other is visible in the way the staff interact with residents. So, there are parallel processes in how you handle your employees as management and how the staff manage [ed: challenging behaviours]. This will determine the culture, a good part of it.

Shared values influence staff's attitudes and residents’ behaviour, as illustrated by this quotation from another manager:

He came here [ed: was transferred from another organisation]. And the manager who came with him told me later, he said, the moment that we were inside, I knew all of the hassle would stop. Because of the new staff's basic attitude “nice, you're here”.

3.4.3. Everyone matters

Many participants emphasized that everyone in the organization matters, which means that members take interest in others (residents and colleagues) and use each other's abilities and perspectives, rather than immediately turning to the manager for help. One manager stated:

The key is to make the others feel they matter. It is important for the staff, if someone does something: does this make a difference, can you go ahead or do you expect I will take over as manager? Well, I'd rather not. They have to see; the organisation is a place where you work together. It is nicer if you have a sense of equality, you can talk about what you observe and bring it all together.

3.4.4. Control versus trust

A few participants stated that staff focus on trusting residents, but also have to control risks to create a safe working environment. A manager explained:

You have to have some appropriate level of distrust, you have to view residents in this way, with respect to safety [ed: of yourself]. If you think: “oh, what a nice man”, and forget to ask first if it is safe to talk in his room. The staff might say: it is okay to talk, but somewhere else. There are always risks you have to think of.

Some participants stated that trusting residents is easily forgotten because arrangements to control challenging behaviour seem difficult to abandon. A head of group stated:

Someone goes to the toilet and a light appears outside the toilet. So I say why is that light there, when they go into the toilet. I say do we need to know this. Once it was necessary. It is a restrictive kind of support and I say: “well, shouldn't we stop this?” When you work a long time in the same way, then some things aren't noticed anymore. I said this has to go. You have to be aware that this is not normal, it has no purpose.

3.4.5. Allowing staff to explore

Several participants reported on the extent to which staff members are allowed to explore and take risks in supporting residents with intellectual disabilities and challenging behaviour. To do so, staff members must develop themselves and take responsibility, as illustrated by a quotation from a head of group:

I think our organisation is very good at making personnel responsible and creative. They are competent, which makes them able to explore, in order to do a good job. The ability to explore leads to excellent results, I think. Of course, you have to be careful. This demands great responsibility, it can't be limitless. But overall, this way people do the best things.

3.4.6. Finding a good match

Most participants emphasized the dynamics related to new staff members, who must be matched with residents, other staff members and professionals, as seen in a psychologist's statement:

A new head of group is needed. Someone on the staff team is capable, but then we have to find a new staff member, creating new dynamics. New dynamics can increase the quality, but can also… [ed: have a negative outcome].

In addition, new staff members must learn about the organization's vision and have specific qualities, as a manager explained:

Professional education is not necessary, but they have to be incorporated by our organisation. You have to know the residents, laws and regulations, knowledge of psychiatric disorders and moderate intellectual disabilities, that is what I mean….Also, involvement, are they unconditional and careful. That is what comes to mind: be in tune with residents, provide feedback, when somebody does something which is inadequate then be direct.

3.4.7. Team context

All organizations have a variety of professionals, such as speech therapists, physiotherapists and specific expert teams, but, according to most participants, the key professional providing staff support is the psychologist, followed by the head of group. A psychologist explained her role:

Accessible, approachable, as a psychologist should act. That is how I do my work. I try to be there [ed: at the group home] a lot of the time, accessible in contact, learn about the residents, which is very important. I must model, set an example.

Furthermore, a close working relationship between the psychologist and the head of group is important in supporting staff, as explained by a head of group:

We have monthly staff meetings, me and the psychologist. We support each other in being informed about what happens in the group home, how residents are behaving, and what is necessary for staff members in order to provide quality support.

Participants also emphasized that managers support staff members by being available to reflect on their work and help to reduce their stress, as a psychologist stated:

The manager is observing on a regular basis residents and staff members at the group home. The staff now know who the manager is, which was unlike before. There is more contact between the staff and management. So you can immediately ask for help from the manager.

3.4.8. Financial limitations

According to all participants, support services for people with intellectual disabilities and challenging behaviour require more financial means (e.g., to repair broken items or to provide more support) than do those for residents without challenging behaviour. This difference leads to rivalry within the organization because budgets are often redistributed, or the intensity of support is reduced. A psychologist stated:

A manager has to facilitate. And this can be difficult when a manager says that this group home does not have the budget for two staff members on the same shift. While the psychologist says it is necessary to accommodate the needs of residents and their support needs. Then we have to discuss this and find some solution.

3.4.9. Living environment

Some participants indicated that residents and their behaviour are affected directly by the number of interactions and stimuli in the living environment, which are larger in large organizations. A psychologist explained:

R: A small cluster of group homes…You can limit stimuli.

I: Okay?

R: I mean, when a resident has a difficult day, they will not go with him to the town centre.

I: No, no.

R: We will monitor when and how it will be possible for the resident. However, in a large institution, when walking from the group home to work, they will already have seen 20 other people.

Furthermore, the furnishing and decoration of residents’ living environments directly influence residents’ behaviour, as reflected in a quotation from a psychologist:

But we feel that a human environment is just as important because it will influence your behaviour. When your living environment has declined, what difference will it make if you kick the door or throw a cup on the ground or whatever. It is already hideous.

3.5. Macrosystem

Participants primarily highlighted governmental regulations and media attention as macrosystem‐level aspects.

3.5.1. Governmental regulations

In the Netherlands, the financing of support services for residents with intellectual disabilities and challenging behaviour is constrained by various regulations linked to the availability of incidental budgets beyond the regular budget, which in turn is linked to the severity of the challenging behaviour and stability of the staff, as illustrated by this quotation from a manager:

It is incidental and you never know, but half of our budget is incidental budget. And this is not good for business. You want to provide stability and continuity, you don't want to hire them for three years and fire them, but a contract for a longer period is not an option, you do not know what will happen with the incidental budget.

3.5.2. Media attention

According to participants, the primary roles of media have been to show low‐quality support services and to inflate problematic incidents, as a head of group stated:

We had an incident in our organisation, which was shown on the news, resulting in contacting parents, Facebook. It became a mutual emphasis on the incapability of our organisation. This was not in accordance with the incident.

3.6. Chronosystem

A few participants mentioned changes over time in the support of persons with challenging behaviour, namely dissatisfaction with the degree of family involvement and the integration of residents into society.

3.6.1. Dissatisfaction with the degree of family involvement

A psychologist explained recent changes, with fewer tasks for staff in supporting a resident because the involvement of family should increase, with which the family was dissatisfied:

R: The family did not take part in supporting the resident, so the staff had taken over and did everything, which they don't do anymore... Yes, now. Fewer tasks are done by the staff, which is not easy.

I: No?

R: Family members have expectations: in the past it was always done by the staff and not by family members, and why has this changed?

3.6.2. Integration into society

A head of group explained how staff have new problems in supporting residents because of the integration of residents into society:

We have new problems, with the years they grew. Now residents also have computers, want to buy something online or want a mobile. But they are not able to handle the information, for example, they will phone their father who is not able to answer, which causes stress. However, they see other people in the nearby village and are involved with the community. They want to be like them, and they have a mobile.

4. DISCUSSION

This study showed that professionals and managers perceive challenging behaviour in people with intellectual disabilities as related to the organizational environment. According to the multiple perspectives of managers, heads of group and psychologists, a pattern is formed in which the organizational environment (i.e., vision, values, sufficient resources) is related via the support service (i.e., providing stability, constant awareness) to residents’ challenging behaviour, and organizational challenges posed by governmental regulations, media attention and changing societal values. Furthermore, our findings suggest that the organizational environment is related directly to challenging behaviour in people with intellectual disabilities, in addition to the indirect relationships (via support services) described by ecological theory (e.g., with the living environment, shared values). The direct link between the organizational environment and challenging behaviour is in accordance with Gillet and Stenfert‐Kroese (2003), who reported that shared values and behavioural norms directly influence the quality of life of residents with intellectual disabilities. These values and norms might provide direction for how to act, think and behave not only for staff members, but also for residents. The reciprocal interactional patterns between all personnel and residents are part of the organizational culture, which directly affects the behaviour (Bigby, Knox, Beadle‐Brown, & Clement, 2015) and quality of life (Bigby & Beadle‐Brown, 2018) of people with intellectual disabilities. Interventions that focus on the environmental context, instead of the individual, may therefore reduce challenging behaviour among residents more successfully (McGill et al., 2018).

This study helped to unravel a variety of organizational themes associated with support services for people with intellectual disabilities and challenging behaviour and relationships among these themes. It adds value to research in this field, as previous studies investigated limited aspects of the organizational environment, such as leadership or culture, without considering their interconnectedness or influences on challenging behaviour in people with intellectual disabilities (cf. Bigby, Knox, Beadle‐Brown, Clement, & Mansell, 2012; Bigby & Beadle‐Brown, 2018; Deveau & McGill, 2016; Dilworth et al., 2011). The organizational environmental themes uncovered in this study partially overlap the themes found in a review by Bigby and Beadle‐Brown (2018), in which the authors concluded that most studies focused on the quality of staff support and the role of front‐line leaders. However, as seen in our study, other themes and their interrelations in the onto‐, micro‐, meso‐ and macrosystems require further research.

This study also demonstrated that the exosystem influences the micro‐ and mesosystems; for example, shared values, the team context and well‐matched staff influence the ability to maintain a positive working atmosphere. However, we detected no reciprocal influence of the microsystem on the exosystem (i.e., of seeing residents beyond their challenging behaviours on employees’ roles and positions), which may reflect the ease with which employees can explain how they are influenced, relative to how they and their residents influence, the organization.

4.1. Limitations

This study has limitations because of its qualitative nature. We gathered data in interviews, which risks the introduction of bias from the interviewer and the participants (i.e., due to social desirability considerations). Second, we studied only the perspectives of professionals and management, disregarding those of residents, who might have raised different organizational themes. In addition, the large amount of data collected was difficult to manage, which was complicated by the lack of clear rules on how to extract themes. Furthermore, interviews were conducted at a single point in time, and participants found oversight of the development of the organization and support services to be difficult, resulting in only limited evidence of changes over time in the support of people with challenging behaviour. Fifth, this study was conducted in the Netherlands, which makes generalization to other countries difficult because of the country's unique care situation.

Finally, the use of Bronfenbrenner's ecological theory as the basis for sensitizing concepts also entails limitations. It may have limited our focus, resulting in disregard of themes and relations between systems in the gathered data. The use of a theory from the field of organizational studies, such as the 7 s model (Waterman, Thomas, Peters, & Philips, 1980), to analyse the dynamics of organizational aspects and their interconnectedness in disability service organizations also entails limitations. Such a model could have aided an analysis based on organizational aspects such as staff, skills and shared values. However, the 7 s model is less helpful in examination of the influences of organizational environmental aspects with respect to challenging behaviour in people with intellectual disabilities (onto‐ and microsystems), given the strong focus on the organization alone. On the other hand, the use of a more detailed concept, such as positive behaviour support (PBS), might also have facilitated data analysis. This concept has shown the importance of a focus on the challenging context in which residents receive support, and not on the challenging behaviour they display (Carr, 2007; Grey & McClean, 2007; McGill et al., 2018). In addition, PBS studies aim to integrate evidence from organizational management, ecological, cultural and positive psychology aspects with biomedical science, which might have provided more structured insight (Carr, 2007). However, PBS as a more detailed concept makes the avoidance of preconceptions more difficult, and it neglects macro‐ and chronosystem themes.

These limitations point to the need for further research on the organizational themes detected and the ways in which they can be influenced. Examination of the perspectives of residents and their family members, the use of a longitudinal study design and the adoption of more observational methods would aid our understanding of how organizations and their support services develop and how this development influences challenging behaviour over time.

5. CONCLUSION

Overall, the provision of high‐quality support to people with intellectual disabilities and prevention of challenging behaviour seem to be complex for residents and employees. The creation of a supportive and positive organizational environment in which staff can provide high‐quality support services to residents with demanding care needs is expected to prevent challenging behaviour in people with intellectual disabilities.

CONFLICT OF INTEREST

No conflict of interest has been declared.

APPENDIX 1. Interview template

INTRODUCTION

What are your name, your role in [this organisation], and your number of working years?

If you could name one word associated with your organisation, what would it be?

Could you briefly describe your organisation? Could you describe the group home(s) briefly?

ONTOSYSTEM, CHRONOSYSTEM (RESIDENTS)

Could you tell me about the residents who live here?

MICROSYSTEM, MESOSYSTEM, CHRONOSYSTEM (SUPPORT SERVICES)

Could you describe the support you provide at this group home? Is there a difference between providing support to people with intellectual disabilities and challenging behaviour and providing support to people with intellectual disabilities without challenging behaviour?

EXOSYSTEM, MACROSYSTEM, CHRONOSYSTEM (ORGANISATIONAL ENVIRONMENT)

Could you describe the characteristics of your organisation? How do these characteristics influence your support and the challenging behaviour of residents?

Could you describe mechanisms in your organisation that are successful or unsuccessful in preventing challenging behaviour? Now, in the past, and in the future?

CONCLUSION

Have we discussed everything necessary in this interview? What was essential to you in this interview? How did the interview go? Do you have any tips for the interviewer?

Olivier‐Pijpers VC, Cramm JM, Nieboer AP. Influence of the organizational environment on challenging behaviour in people with intellectual disabilities: Professionals’ views. J Appl Res Intellect Disabil. 2019;32:610–621. 10.1111/jar.12555