‘Stakeholders are almost always resistant’: Australian behaviour support practitioners’ perceptions of the barriers and enablers to reducing restrictive practices

Abstract

A restrictive practice (RP) is defined as a practice or intervention that has the effect of restricting the rights or freedom of movement of a person, and includes physical, mechanical, and chemical restraint, and seclusion. If misused or overused, RPs may present serious human rights infringements. In Australia, behaviour support practitioners who deliver behaviour support funded by the National Disability Insurance Scheme are responsible for developing positive behaviour support plans that aim to reduce and eliminate the use of RPs. At present, little is known about the barriers that behaviour support practitioners experience when attempting to reduce and eliminate the use of RPs and, conversely, what helps (or enables) them to reduce and eliminate RPs. To learn more, we conducted an online survey consisting of two open-ended questions with 109 Australian behaviour support practitioners to identify barriers and enablers. We found that fear and reluctance on the part of stakeholders were often barriers to reducing the use of RPs. However, we found that having time, funding, and resources for training, supervision, other implementation activities, care team collaboration, and data-based decision-making helped overcome barriers. We provide specific recommendations for addressing identified barriers for individual behaviour support practitioners, service provider organisations, and government and regulatory agencies.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD 2006) is the first international human rights convention which sets out the fundamental human rights of people with disability (PWD). The purpose of the CRPD is to promote, protect, and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all PWD, and to promote respect for their inherent dignity. The CRPD specifies that PWD have a right to be free from violence and abuse, and torture or cruel, inhumane, or degrading treatment as well as rights to physical and mental integrity, liberty, and autonomy (United Nations 2006). In 2008, Australia signed and ratified the CRPD, and in doing so, made a public commitment to develop, implement, and enforce legislation and policy aimed at protecting and upholding the rights of PWD in all aspects of life and society.

However, there have been significant challenges in implementing the CRPD for individuals with intellectual and developmental disabilities who display challenging behaviour (Chan 2016). Emerson and Einfeld (2011) define challenging behaviour as behaviours that occur at a sufficient intensity, frequency, or duration to pose a risk to the safety and wellbeing of the person or others, and that are likely to result in the person experiencing exclusion from the community. Challenging behaviour may include (but is not limited to) self-injury, physical aggression, and property destruction (Bowring et al. 2019, Perry et al. 2018). Such behaviours may at times be life threatening and result in severe trauma or premature death, might also result in the PWD being accommodated in residential facilities or detention centres, and might place the PWD at greater risk for abuse, neglect, or violence (Chan 2016).

Restrictive practices

People with disability who display challenging behaviour are at increased risk of being subjected to restrictive practices (Webber et al. 2011a). In Australia, a restrictive practice (RP) is defined as a practice or intervention that has the effect of restricting the rights or freedom of movement of PWD, and includes physical, mechanical, and chemical restraint, and seclusion (Australian Government Department of Social Services 2014). Many researchers have raised concerns that RPs are overused, misused, and used as the first option to manage challenging behaviour (Richardson et al. 2020, Sturmey 2015, Webber et al. 2010). If misused or used without proper oversight, RPs can cause physical harm (Williams 2009), psychological harm (Bonner et al. 2002), and death (Paterson et al. 2003). Given that the use of RPs can restrict a person’s autonomy and freedom and can pose a risk to long term safety and wellbeing, it is now recognised that the use of such practices may conflict with the human rights of PWD and may contravene Australia’s commitments as outlined in the CRPD (Chan 2016).

Positive behaviour support

Positive behaviour support (PBS) has been proposed as an alternative to the use of RPs when addressing challenging behaviour displayed by PWD. PBS is underpinned by a conceptual model that views challenging behaviour as functional rather than symptomatic of an underlying deficiency, diagnosis, or mental health disorder (Carr et al. 2002, Gore et al. 2013). In other words, for individuals with intellectual and developmental disabilities, challenging behaviour is often learned behaviour that serves a communication purpose (i.e. helps the person express their wants and needs; Hanley 2012). When used as a process for supporting PWD who display challenging behaviour, PBS involves (a) a functional behaviour assessment to identify the unique and personally relevant reasons why challenging behaviour is occurring for an individual, (b) the development of multi-component interventions that focus on changing the environment around the person and teaching new skills, (c) implementation support, monitoring and evaluation of interventions over the long term, and (d) collection and analysis of data to facilitate data-based clinical decision-making at every stage (Gore et al. 2022). Within PBS, a constructional approach (Goldiamond 1974) to intervention is used to increase a person’s repertoire of adaptive behaviour, provide the person with more opportunities to make choices, increase access to preferred and enjoyable life activities, and help the person develop meaningful and positive relationships with others (Gore et al. 2013, LaVigna and Willis 2005). In such an approach, reductions in challenging behaviour and, in turn, the need for RPs, are achieved as a side effect, rather than the primary goal, of intervention (Carr 2002). When implemented with fidelity, PBS-based interventions have been demonstrated to reduce challenging behaviour (Grey et al. 2018, Hassiotis et al. 2009, LaVigna and Willis 2012, LaVigna et al. 2022), and improve some aspects of quality of life (Dunlap et al. 2010, Grey et al. 2018, Kincaid et al. 2002).

Restrictive practices, positive behaviour support, and the National Disability Insurance Scheme

In Australia, personalised supports for PWD are now funded through the National Disability Insurance Scheme (2021). The National Disability Insurance Scheme (NDIS) was introduced in 2013 by the Australian government and represented a significant change in how disability services and supports were funded and accessed for PWD. Of note, the NDIS upholds the principle that PWD should be provided with choice and control about how to use their funding based on their unique needs, preferences, and goals. The NDIS is underpinned by a human rights framework and enacts several key provisions outlined in the CRPD (Australian Government Department of Social Services 2016). Its primary stated purpose is to respect and uphold the rights of PWD, including the right to dignity and respect, to live free from abuse, neglect, violence, and exploitation, and to participate and experience inclusion in the community. The NDIS Quality and Safeguards Commission was established to support the roll-out of the NDIS by protecting and preventing harm to PWD receiving NDIS-funded services through a variety of planning, implementation, and review processes (such as providing funding for advocacy services, identifying suitably qualified practitioners, and receiving and responding to complaints).

The NDIS Quality and Safeguards Commission promotes PBS as a service model for PWD who experience restrictive practices. Under the NDIS Behaviour Support and Restrictive Practices Rules (Australian Government 2018), NDIS-funded behaviour support services are to be provided by a behaviour support practitioner who has been considered appropriately suitable to undertake behaviour assessments (including functional behavioural assessments) and to develop positive behaviour support plans that may contain the use of RPs. Practitioners are expected to self-assess their suitability to deliver PBS at different levels of competency (core, proficient, advanced, and specialist) and compile a portfolio of evidence to support their self-assessment (NDIS Quality and Safeguards Commission 2021). In addition, practitioners are required to submit an endorsement from a supervisor as part of the application process. The most recent NDIS Quality and Safeguards Commission Activity Report (NDIS Quality and Safeguards Commission 2022) states that 8,715 practitioners are considered provisionally suitable to deliver behaviour support. Of these, 4,361 practitioners have submitted self-assessment evidence against the framework since its implementation in 2021. Currently, 2529 behaviour support practitioners have been assessed and are considered suitable to deliver NDIS behaviour support services. Behaviour support practitioners are expected to be able to recommend regulated RPs as part of behaviour support plans as an option of last resort to reduce the risk of harm to the PWD or others, and to follow appropriate authorisation and reporting processes related to the use of the RP.

Challenges related to reducing restrictive practices

Despite recent government policy and practice initiatives designed to support the provision of safe and effective behaviour support to PWD who display challenging behaviour, the use of RPs remains commonplace. For example, PWD, families of PWD, advocacy organisations, and professionals who provided evidence as part of a recent Royal Commission into Violence, Abuse, Neglect, and Exploitation of People with Disability (2020) reported that, although there is limited data on the prevalence of use of RPs, they perceived that such practices continued to be widely used on PWD in Australian home, community, healthcare, and educational settings, often in the absence of therapeutic supports. Webber et al. (2010) analysed data on the use of RPs for a one-year period in Victoria and found that approximately 9% of people who were receiving a disability service experienced one or more RPs. Almost all people who experienced RPs were reported to have an intellectual disability and/or an acquired brain injury, and the majority were men between the ages of 25 to 44 years who lived in a supported accommodation setting (e.g. residential institutions or group homes). In a follow up study, Webber et al. (2014) evaluated characteristics associated with the use of seclusion and found that age of the person or a diagnosis of autism or psychiatric condition, or placement in supported accommodation, were predictive of its use. Richardson et al. (2020) conducted a longitudinal study to identify the factors associated with long term restraint in the state of Victoria. The authors found that, of a sample of 1,180 people with intellectual disabilities who experienced RPs at baseline, 870 (74%) were still experiencing RPs three to five years later. The factors associated with the long-term use of restraint included the use of psychotropic medication at baseline and a diagnosis of autism or speech delay.

More recently, the NDIS Quality and Safeguards Commission reported that, for the 6-month period ending June 30, 2022, it had received 688,163 reportable incidents related to the use of an unauthorized RP on a PWD, the majority of which involved the use of chemical or environmental restraint (NDIS Quality and Safeguards Commission 2022). Although accurate reporting of the use of RPs should be encouraged, the frequency with which RPs are being used suggests that the Australian disability support workforce may not be well prepared to address the needs of PWD using less restrictive alternative interventions and that RPs may be overused. Indeed, Dowse et al. (2016) and Fisher and Kelly (under review) raised significant concerns about the skills and qualifications of behaviour support practitioners, and the methods by which practitioners and organisations are considered suitable to deliver PBS. Fisher and Kelly argued that a ‘self-assessment is a concerning entry point to a significant clinical role in the disability sector’ (p 13) and note that appropriateness or effectiveness of the self-assessment model of professional registration has not yet been demonstrated. In addition, there is no minimum tertiary education standard, professional training standard (such as a period of supervised internship or practicum), professional qualification, or objective assessment requirement for registration as a behaviour support practitioner (Fisher and Kelly, under review; Hayward et al. 2019). Thus, the degree to which behaviour support practitioners have participated in (a) planned and verified coursework aligned to defined competencies in PBS or (b) supervised interactions with recipients of PBS-based services via internship or fieldwork experiences, particularly with recipients who experience RPs, is unknown.

Additionally, although PBS has been endorsed by the NDIS Quality and Safeguards Commission as a best practice framework for supporting PWD who display challenging behaviour and may experience RPs, there is a paucity of research demonstrating a direct link between the implementation of positive behaviour support plans and reductions in the use of RPs (Hayward et al. 2022). Studies that have demonstrated the effectiveness of approaches for reducing the use of RPs have primarily focused on staff training and other organisational change approaches, rather than on the provision of individual positive behaviour support plans alone. O’Dwyer et al. (2017) evaluated the effects of a structured staff training program on the principles and practices of PBS on the challenging behaviour displayed by PWD, the use of RPs, and the quality of behaviour support plans developed by practitioners. The authors found an improvement in the quality of behaviour support plans and small reductions in both the severity of challenging behaviour and the use of RPs for PWD who were supported by practitioners who received the training when compared to practitioners who did not. Sanders (2009), Craig and Sanders (2018), and Leoni et al. (2018) demonstrated larger and sustained reductions in the use of RPs across human services organisations through the use of an organisational change approach. Drawing on literature describing common components of organisational interventions in human services (Larue et al. 2018, Sturmey 2015), these studies implemented a multicomponent organisational change intervention, in addition to individual positive behaviour support services to PWD, that consisted of leadership development, data collection and analysis to facilitate data-based problem solving, workforce development, specific restraint reduction tools, peer support, and debriefing. Over several years, the researchers demonstrated a significant reduction in the frequency of RPs, a decrease in staff injury and workers compensation claims (which was associated with significant cost savings), an increase in the number of consumers with evidence-informed behaviour support plans including prevention strategies, and an increase in staff participation in regular professional development and supervision activities. These findings suggest that systemic organisational change that uses PBS as a framework (incorporating the organisational interventions described above) may be warranted if the Australian behaviour support practitioner workforce is to achieve long-term, sustained reductions in the use of such practices as an express aim of the provision of positive behaviour support.

Purpose of the current study

At present, the behaviour support practitioner workforce in Australia is still in its infancy but is growing rapidly, and little is known about the barriers related to the provision of behaviour support from the perspectives of this workforce. However, behaviour support practitioners now have a critical role to play in reducing the use of RPs and protecting and upholding the rights of PWD. Behaviour support practitioners may come from diverse backgrounds and have a range of skills and experiences related to the use, reduction, and elimination of RPs as part of the provision of behaviour support. Therefore, the aims of the present study were to identify and describe the barriers that behaviour support practitioners experience when attempting to reduce and eliminate the use of RPs and, conversely, what helps them to reduce and eliminate RPs.

Method

Design

We developed an online survey to examine the experiences of Australian behaviour support practitioners who design and deliver behaviour support plans that include the use of RPs. The study was approved by the Monash University Human Research Ethics Committee (Project 31448).

Participants and recruitment

Participants were recruited for this study via email, social media, and snowball sampling. The first author sent email invitations to complete the survey to service providers within their professional network who delivered NDIS funded behaviour support services. Emails contained a brief summary of the purpose and aims of the study, contact details of the authors, and a link to access the survey on Qualtrics®. In addition, a link to the survey was also shared by all authors on various social media platforms. Potential respondents were invited to click a link to access the electronic survey at a time and place of their choice. They were first asked to read a short explanatory statement describing the aims of the survey, the potential benefits and risks of participating, the voluntary nature of participation, and how to contact the research team with questions. Next, they were asked to review the eligibility criteria to determine if they were eligible to participate. Finally, they were asked to provide their consent to participate. Once consent was provided, respondents were able to view and answer the survey questions.

Measures

This research formed part of a larger mixed method survey study. The full survey consisted of five author-created scales, including the Beliefs about Challenging Behaviour scale (nine items using a seven-point Likert-type response anchor), Beliefs about Positive Behaviour Support scale (14-items using a seven-point Likert-type response anchor), Beliefs about Restrictive Practices scale (12-items using a seven-point Likert-type response anchor), Personal Readiness to Reduce Restrictive Practices scale (12-items using a four-point Likert-type response anchor), and Organisational Readiness to Reduce Restrictive Practices scale (10-items using a four-point Likert-type response anchor). The survey also included three open-ended questions. The purpose of the current study was to conduct a qualitative thematic analysis of the factors that help or hinder behaviour support practitioners in their efforts to reduce and eliminate the use of RPs; therefore, data are only reported for the following two open-ended survey questions:

1. What barriers have you encountered when attempting to reduce and/or eliminate the use of restrictive practices with clients that you support?

2. What would help you reduce and eliminate the use of restrictive practices with clients that you support?

Data extraction and analysis

Data were analysed using thematic analysis (Braun and Clarke 2022). To extract the key themes from responses, a process of inductive thematic coding was undertaken. This methodology was selected for this study as no suitable pre-existing codes were identified, and it allowed for categorisation and exploration of all emergent themes expressed by respondents. Inductive thematic coding occurred across five steps: (1) become familiar with the data, (2) generate initial codes, (3) search for themes, (4) review themes, and (5) define themes.

Inductive coding began with the first and second author reading and re-reading all participants’ responses and identifying potential themes to be coded based on the presence of key words (i.e. semantic themes), as well as the underlying functional meaning (i.e. latent themes) evident in each response (Step 1; Braun and Clarke 2022). The first author then developed an initial coding frame with working definitions of all individual thematic codes created as a result of the first reading (Step 2). Once the initial codes were developed, the second author independently re-read each open-ended response and assessed the validity of the initial coding frame within a custom designed data extraction table in Microsoft Excel (Step 3). On the excel spreadsheet, open-ended responses were copied into the left-hand column and thematic codes were placed along the top row, forming a grid. Responses were then sorted into thematic codes. It was possible for one open ended response to be sorted into multiple thematic codes. For example, in a response to open-ended question #1, the response ‘provider willingness and consistency in using alternative strategies’ was thematically coded as both Attitudes and Implementation by placing a 1 on the spreadsheet in each column.

Following this process, the results were compiled, compared, and tabulated. At this stage, some thematic codes with few responses were consolidated into other themes based on semantic or latent similarities (Step 4). The themes and definitions were then refined and clarified (See Tables 2 and 3 for themes and definitions). The frequency with which participants provided a response related to a specific thematic code for each open-ended question was calculated by adding the number of 1’s in each column on the data extraction spreadsheet. The percent of responses related to a specific thematic category was calculated by dividing the frequency of responses for each theme by the total number of open-ended responses and multiplying by 100. These consolidated broader themes were independently reviewed by the second author and, following a consensus meeting, agreement was established (Step 5).

Table 2.

Thematic categories and definitions of responses to the question, ‘What barriers have you encountered when attempting to reduce and/or eliminate the use of restrictive practices with clients that you support?’ and the number and percent of statements related to each thematic category (N = 108).

Level	Theme	Definition	n (%)
Practitioner level barriers	Reluctance to reduce restrictive practices	Constraints or barriers related to dependency on restrictive practices or fear about reducing restrictive practices. A lack of desire or willingness from family members, service providers, or other professionals to reduce restrictive practices. Beliefs that the PWD needs to continue experiencing the restrictive practice due to concerns about safety of the PWD or others, or that the PWD needs to experience the restrictive practice due to a mental health or other co-occurring condition.	43 (39.8%)
	Apprehensive attitudes toward PBS or alternative strategies	Beliefs that positive behaviour support is too difficult or takes too long to implement successfully, and that restrictive practices are a quicker and easier way to reduce challenging behaviour. A lack of desire or willingness from family members, service providers, or other professionals to learn or try new ways to support the PWD or how to implement alternatives to restrictive practices.	29 (26.9%)
Organisational level barriers	Implementation barriers	Constraints or barriers related to staff turnover or a lack of staff to implement behaviour support plans or alternatives to the use of restrictive practices. Constraints or barriers related to lack of implementation, poor implementation fidelity, or lack of consistency of implementation of positive behaviour support strategies or alternatives to restrictive practices.	27 (25%)
	Lack of or inaccurate data	Constraints or barriers related to the collection of data on the use of restrictive practices to assist with the identification of the prevalence of use or changes in use over time, or to allow for monitoring of the effectiveness of positive behaviour support strategies or alternatives to the use of restrictive practices. May include lack of or inaccurate data, or lack of or inaccurate reporting on the use of restrictive practices.	19 (17.6%)
	Difficulties collaborating	Constraints or barriers related to collaboration and or communication with the PWD, family members, service providers, or other professionals, such as difficulty scheduling or holding team meetings or difficulty sharing information. Disagreements amongst team members about the 'right' or ‘best’ supports for the PWD.	17 (15.7%)
	Lack of training and supervision	Constraints or barriers related to opportunities to provide staff training in behaviour support plans and/or alternatives to the use of restrictive practices. Lack of time or opportunities for ongoing supervision of people responsible for implementing the behaviour support plan.	13 (12%)
	Difficulty accessing needed services	Constraints or barriers related to accessing appropriate services to assist with assessment, the development of behaviour support strategies, or to support the PWD (e.g. mental health supports), such as lack of service providers or long wait times to access services.	4 (3.7%)
Government and regulatory level barriers	Lack of agency	Constraints or barriers related to reducing restrictive practices because the practice (e.g. medication) is prescribed by another professional (e.g. doctor or psychiatrist) and the prescribing professional does not want to reduce the practice or does not have time, willingness, or data to evaluate the effectiveness of the restrictive practice or alternative strategies.	16 (14.8%)
	Confusion about restrictive practices	Confusion or disagreement about what constitutes a restrictive practice or difficulty identifying the use of a restrictive practice.	10 (9.3%)
	Insufficient funding	Lack of funding to support activities related to reducing restrictive practices, such as training in positive behaviour support or providing coaching in the implementation positive behaviour support or alternatives to restrictive practices.	9 (8.3%)

Table 3.

Thematic categories and definitions of responses to the question, ‘What else would help you reduce and eliminate the use of restrictive practice with clients that you support?’ and the number and percent of statements related to each thematic category (n = 99).

Level	Theme	Definition	n (%)
Practitioner level enablers	Greater awareness about restrictive practices and the rights of PWD	Greater community awareness of and understanding about the rights of PWD, and how the use of restrictive practices can violate the human rights of PWD. Greater community awareness of and understanding about alternatives to the use of restrictive practices, such as proactive (antecedent) behaviour support strategies and environmental modifications/changes.	18 (18.2%)
	Willingness from stakeholders	Support and ‘buy in’ from families, service providers, and other professionals for activities related to positive behaviour support. Willingness of key stakeholders to implement positive behaviour support strategies and alternatives to restrictive practices.	6 (6.1%)
Organisational level enablers	More time for training and supervision activities	More time to deliver training to families, service providers, and other professionals in positive behaviour support, use and reduction of restrictive practices, and alternatives to restrictive practices. More time to assess the effectiveness of positive behaviour support through team meetings and supervision activities.	30 (30.3%)
	Improved implementation	Access to a greater number of staff who can implement positive behaviour support strategies. More optimal staffing ratios, such as 1:1 staffing when needed. Improved adherence, quality, and consistency of implementation of positive behaviour support strategies and alternatives to restrictive practices.	18 (18.2%)
	More opportunities for collaboration	More opportunities to collaborate, communicate, and share information with the PWD, family, staff/service providers, and other professionals. More opportunities to include the PWD in the planning their own behaviour supports.	13 (13.1%)
	More data	Improvements in quantity and quality of data on the use of restrictive practices and on the effectiveness of positive behaviour support strategies and alternatives to restrictive practices. Easier ways to record, store, access, share, and analyse data.	12 (12.1%)
	Easier access to services	More timely and easier access to other allied health and medical professionals who can assist with diagnosis and assessment, and to provide recommendations for allied health and medical interventions and supports. Freedom for the PWD to pursue therapies and supports outside the positive behaviour support framework.	7 (7.1%)
Level	Theme	Definition	n (%)
Government and regulatory level enablers	More funding to support implementation activities	More funding to support the cost of implementation of positive behaviour support such as progress monitoring, data-based problem solving, facilitating team meetings, and supervision activities.	18 (18.2%)
	Better regulation and oversight of the use of restrictive practices and alternative strategies	Transparent regulatory systems to ensure providers are meeting their regulatory requirements around the use and reporting of restrictive practices, to ensure consistency across the sector. More oversight from regulators to ensure restrictive practices are being used only when needed and are being recorded and reported. Stronger regulation to ensure implementing providers use proactive behaviour support strategies in conjunction with (or in place of) restrictive practices.	12 (12.1%)
	More guidance and support from government and regulatory bodies	Timely and clear responses to questions about implementation of positive behaviour support strategies and use of restrictive practices from the NDIS Quality and Safeguards Commission. Clearer and easier to understand policies and protocols. Easier to use systems for reporting on the use of restrictive practices and easier and more streamlined systems for lodging behaviour support plans.	11 (11.1%)
	More practical resources	Resources for allied health and medical professionals about what restrictive practices are and how their use may violate the human rights of PWD. Easy to understand resources for non-practitioners on positive behaviour support and alternatives to restrictive practices.	7 (7.1%)
	Clearer definitions of restrictive practices	Clearer and easier to understand definitions about what does and does not constitute a restrictive practice.	7 (7.1%)
	Enhanced role clarity	Greater clarity how behaviour support practitioners interact with other professionals, such as medical professionals and supported independent living providers. Clarity around the role of the behaviour support practitioner when restrictive practices are prescribed by another professional (such as medication prescribed by a psychiatrist) or used by the family outside of the behaviour support plan. Clarity around the oversight for restrictive practices that are in use but not recommended or prescribed by the behaviour support practitioner.	5 (5.1%)

Following inductive thematic coding, themes were classified as practitioner level, organisational level, and regulatory (or government) level barriers and enablers. Practitioner-level variables were defined as specific barriers or enablers that might be best addressed by individual behaviour support practitioners in the context of their work (e.g. through the direct provision of positive behaviour support services to consumers and care teams). Organisational-level variables were defined as specific barriers or enablers related to factors beyond the provision of individual behaviour support plans that might be best addressed via a systemic approach within a service provider organisation (e.g. through the provision of time, resources, training, etc.). Government- and regulatory-level variables were defined as specific barriers or enablers that were likely outside of the control of individual practitioners and services provider organisations and would be best addressed by bodies such as the NDIS Quality and Safeguards Commission or State/Territory government departments (e.g. through the provision of funding for behaviour support services, resources for the disability sector workforce, policy and practice briefs, etc.).

Interrater reliability

Interrater reliability of thematic coding was calculated for 25% of responses to each open-ended question. Initially, the first author read all participant responses to each open-ended question and developed a coding frame with definitions. The second author then read all participant responses and assessed the validity of the definitions and codes. No changes were suggested. Following this, responses for each open-ended question were read and coded by the first author, with the second author independently coding 25% of responses for each question. Interrater reliability was then calculated by dividing the number of agreements by the number of agreements plus disagreements. This was undertaken for each of the two open-ended questions. Mean point-to-point agreement for Question 1 was 95.9% and Question 2 was 95.3%. After independent coding was completed, a consensus meeting was held and disagreements were resolved, with full agreement established.

Results

In total 109 participants responded to one or more of the open-ended survey questions. A summary of the demographic characteristics of respondents is presented in Table 1. The following results present an analysis of participant responses in relation to each research question.

Table 1.

Participant demographics (n = 109).

Level of registration with the NDIS Quality and Safeguards Commission	Provisional behaviour support practitioner	18 (17%)
	Core Behaviour Support Practitioner	23 (21%)
	Proficient Behaviour Support Practitioner	21 (19%)
	Advanced Behaviour Support Practitioner	25 (23%)
	Specialist Behaviour Support Practitioner	22 (20%)
Professional qualification(s)*	Board Certified Behaviour Analyst	23 (21%)
	Counsellor	4 (4%)
	Clinical Psychologist	1 (1%)
	Developmental Educator	7 (6%)
	Educational and Developmental Psychologist	3 (3%)
	Generally Registered Psychologist	11 (10%)
	Occupational Therapist	5 (5%)
	Registered Teacher	9 (8%)
	Social Worker	12 (11%)
	Speech Pathologist	1 (1%)
	Other	30 (28%)
	None	11 (10%)
Highest education	High school diploma	2 (2%)
	Bachelor’s degree	36 (33%)
	Graduate certificate	15 (14%)
	Master’s degree	54 (50%)
	Doctoral degree	2 (2%)
State or Territory*	Australian Capital Territory	7 (6%)
	New South Wales	42 (39%)
	Northern Territory	0 (0%)
	Queensland	18 (17%)
	South Australia	12 (11%)
	Victoria	47 (43%)
	Western Australia	3 (3%)
	Tasmania	1 (1%)
Employment status	Full time sole trader or contractor	9 (8%)
	Part time sole trader or contractor	4 (4%)
	Permanent full time employee	72 (66%)
	Permanent part time employee	18 (17%)
	Other	6 (6%)

^*Participants could select more than one response option for these questions.

Research Question #1: What barriers do Australian behaviour support practitioners encounter when attempting to reduce and/or eliminate the use of restrictive practices with clients that they support?

Table 2 depicts the number and percent of statements related to each thematic category from open-ended survey responses to Question 1.

Practitioner-level barriers

Practitioner-level barriers included reluctance to reduce RPs on part of stakeholders (n = 43) and apprehensive attitudes toward PBS or alternatives to RPs (n = 29).

The most common barrier was reluctance on part of family members, care team members, or other professionals to reduce the RP. Although the definition of this theme included reluctance on part of the PWD, no open-ended responses indicated that the PWD was specifically advocating against the reduction of RPs within their own behaviour support plan. Rather, participants noted that other stakeholders were often anxious or fearful about reducing RPs, citing safety concerns or fear of no longer being able to effectively manage challenging behaviour. For example, one participant noted that ‘Stakeholders are almost always resistant to reductions in RP even when it is no longer needed because of the “just in case” argument’ and another said, ‘Teams around an individual…are either scared of trying to support the person with less restrictive means, or do not believe that the person [can] ever be supported without restrictions’. Some participants reported that stakeholders felt the RP was necessary to manage other co-occurring conditions, such as psychosocial disability or mental health conditions, with one participant noting that it can be hard to reduce a RP ‘when the behaviour is linked to a mental health diagnosis’. In some cases, there was a perception on part of the stakeholders that the use of the RP would be necessary in the long term.

The second most commonly identified barrier was related to the attitudes of stakeholders including family members, care team members, or other professionals about the use of positive behaviour support and alternatives to RPs (n = 29). Specifically, participants indicated that some stakeholders felt that using positive behaviour support strategies would take too long or be too difficult, and that using RPs was a quicker and easier way to manage challenging behaviour. Some stakeholders expressed unwillingness to try alternative strategies, with one participant noting that ‘People who support the client often cling to what they know rather than trying a different way’. Participants also noted that family members and staff who supported the PWD daily were often burnt-out, exhausted, and stressed, and did not appear to have the ability to try new support strategies and alternatives to the use of RPs. One participant noted that there was a need to ‘address the crisis that families [are in] and trauma they experience’.

Organisational-level barriers

Organisational-level barriers included lack of staff, high staff turnover, or lack of consistent implementation of alternative behaviour support strategies (n = 27), challenges related to collection and analysis of data (n = 19), difficulties collaborating with families, staff, and other professionals (n = 17), few opportunities for staff training (n = 13), and difficulties accessing needed complementary services (e.g. mental health support services; n = 4).

Participants frequently reported facing difficulty coaching families and staff in the implementation of behaviour support strategies, with one participant noting that the ‘NDIS sometimes does not allow for the ongoing needs [of] staff teams to engage in implementation of a behaviour support plan, especially for a person with complex needs’ and another stating that ‘No training [may lead to] significantly impaired quality and consistency of implementation [leading to] poorer outcomes [for clients] and challenges assessing the efficacy of plan itself’.

Participants also reported difficulty gathering data on the occurrence of challenging behaviour or the frequency of use of the RP, which made it challenging to evaluate the effectiveness of positive behaviour support. One participant shared that they had difficulty ‘gaining behaviour data from support staff even after explaining importance of this for monitoring’ while others expressed concerns about difficulty gaining information about the client’s history, accessing previous data or data from other providers, and the underreporting of RPs.

Difficulties collecting and using data was often related to difficulties around collaboration with other stakeholders, such as support workers and other professionals. Several participants noted that the clients they supported did not have adequate funding to support collaborative activities such as team meetings. Others noted that stakeholders were sometimes unwilling to collaborate, with one participant noting that this can be particularly challenging when ‘the support team are not willing to collaborate and implement your RP fade-out strategies [or] take data on RPs’.

Participants also reported that it was difficult to collaborate with medical professionals or allied health professionals who also worked with the client. One participant noted that medical professionals who were responsible for prescribing chemical restraint lacked trust in behaviour support practitioners and ‘view[ed] behaviour support practitioners to be outside their lane when seeking information or seeking to consult’ and another stating that there needed to be ‘collaborative opportunities with relevant stakeholders (e.g. prescribing physicians) to gain the necessary evidence and to assist in building multidisciplinary team protocols and fade out procedures’.

Government- and regulatory-level barriers

Regulatory-level barriers included a lack of agency on part of the practitioner to recommend, monitor, and reduce a RP (n = 16), confusion about whether a practice met the definition of a RP (n = 10), and insufficient funding to support activities related to the reduction of RPs, such as implementation coaching and team meetings (n = 9).

Participants reported that they faced challenges when monitoring and advocating for the reduction of chemical restraint because medications were recommended and prescribed by another professional. Some participants felt that monitoring and reducing chemical restraint fell outside of their scope of practice, whereas others felt that collaborating with prescribing professionals was challenging. For example, one participant noted that ‘medications are prescribed and monitored by medicos so [behaviour support practitioners] can’t reduce dosage’ and another highlighted that ‘paediatricians [will] prescribe chemical resistant without consulting with the positive behaviour support practitioner, [and it is] difficult to consult with the paediatrician to eliminate the use of chemical restraint’. Several participants also reported that it was difficult to get medical professionals to fill out required paperwork to authorise the use of chemical restraint, with one noting that ‘it has been difficult on a number of occasions to have a GP fill out a Medication Purpose form and responses are often too vague’. This resulted in practitioners experiencing a lack of agency related to the reduction of RPs.

Relatedly, participants felt that other stakeholders were often unaware that what they were implementing constituted a RP (n = 10), with one participant noting that it was difficult to talk about reducing a RP when the use of such practices were ‘unauthorised’ and ‘implementing providers [do] not believe that a restrictive practice is a restrictive practice’. In addition, in some cases the use of a RP was normalised, as highlighted by a participant who said that ‘reducing RPs is generally a foreign concept; e.g. doors are locked because that's how it's always been’, another who said that RPs are ‘not clearly defined or even reported; in place with no one knowing when, why or how they were put in place’, and another who stated that ‘service providers disagree that [they are implementing] restrictive practices for a participant, saying that they are not restrictive practices – it’s just how it is and how it has always been’. Finally, some participants were confused about what constituted a RP, with one noting that for the ‘age of the children we work with [3-5-year old’s] some degree of environmental restraint is needed for safety’.

Research Question #2: What helps Australian behaviour support practitioners reduce and eliminate the use of restrictive practices with clients that they support?

Table 3 depicts the number and percent of statements for Question 2.

Practitioner-level enablers

Practitioner-level enablers included greater community awareness about and understanding of the use of RPs and alternatives to RPs (n = 18) and willingness from stakeholders to implement alternatives to RPs (n = 6).

Several participants highlighted the importance of working collaboratively with families and care teams to ‘place more emphasis on the importance of proactive strategies’ to prevent the occurrence of challenging behaviour, help families and care teams understand how a RP might infringe on the rights of PWD, and to support ‘implementing providers to have a greater understanding of PBS and their responsibilities and the role they play [in implementing PBS]. Participants noted that there was need to shift the current mindset of the disability support workforce from ‘caretaker’ for PWD to ‘educator’ working within an active support framework. Participants highlighted that raising awareness about alternatives to RPs, such as PBS, could improve willingness from families, service providers, and other professionals to implement alternative strategies.

Organisational-level enablers

Organisational-level enablers included time for training and supervision activities (n = 30), improved implementation of alternatives to RPs (n = 18), opportunities for care team collaboration (n = 13), access to data to facilitate data-based decision-making (n = 12) and easier access to complementary services (n = 7).

The most commonly reported activity that participants identified as enabling them to reduce the use of RPs was availability of time for training, supervision, and other implementation support activities. In particular, participants expressed a need and desire for more time (and funding) to allow them to undertake training and supervision activities and coach others in the implementation of positive behaviour support strategies and alternatives to RPs, with participants highlighting the need for ‘more funding in plans to accurately train and oversee the high volume of stakeholders’, ‘adequate funding to teach replacement skills’, ‘more in-depth training and in vivo modelling’, and ‘more hours to work with providers on why skill building is important’.

Participants also noted that team collaboration was important in their efforts to reduce and eliminate the use of RPs. In particular, participants noted that they desired better communication and collaboration with health professionals who prescribe chemical restraint since decisions about changing or eliminating medication fall outside the scope of practice of a behaviour support practitioner and should be made by the doctor or psychiatrist who prescribed the medication.

Participants noted that the collection of accurate data was integral to their work, as it allowed them to determine the effects of the implementation of positive behaviour support strategies on challenging behaviour, use of RPs, skill development, and quality of life for the client. Activities such as training, supervision, implementation coaching, and collaboration with other professionals provided fora to analyse data, discuss client-centred outcomes associated with the implementation of behaviour support strategies, make behaviour support plan changes if needed, debrief following instances of challenging behaviour which necessitated the use of a RP, and discuss ways to support the client with an aim to further reduce the use of RP in the future (i.e. engage in reflective practice). Participants noted that ‘The ongoing review and monitoring of data and progress is vital to reduce RPs, but it so often can't be provided at the required intensity’ and that more ‘support staff-friendly data collections methods that don't make it too much additional work to collect data’ are needed.

Government- and regulatory-level enablers

Government and regulatory level enablers included appropriate level of funding to support implementation activities (n = 18), transparent regulatory systems to ensure oversight of the use of RPs (n = 12), more guidance from government and regulatory bodies (n = 11), practical resources about RPs and alternatives (n = 7), clearer definitions about what constitutes a RP (n = 7), and greater clarity about the scope of practice of behaviour support practitioners (n = 5).

Participants stated that appropriate level of funding is necessary and when it is available it assists with implementing participants’ plans and reduced the need to use of RPs because it allowed more time for training (as noted above). In addition, it allowed for more time to explore organisational systems that either supported or hindered the delivery of high-quality positive behaviour support, with one participant noting that ‘significant funding [is needed] to bring about organisational change and to upskill the work force, [including] the development of practice leadership [initiatives] such as the coaches program’. Another participant argued that ‘restrictive practices are often band aid solutions [and] the amount of work that has to go into the process is not reflected in the amount of funding most customers receive. This greatly affects the ability to reduce restrictive practices’.

Participants advocated for transparent regulation of the use of RPs to ensure consistency across the sector in how RPs are used, monitored, and reduced. Participants stated that the sector could benefit from stronger oversight related to the provision of alternatives to RPs, with one participant calling for ‘stronger regulation [with respect to] how alternatives to restrictive practices are implemented’ and another participant desiring ‘greater [regulation] around the implementation of behaviour support plans’. One participant sought a ‘less punitive model for authorising and monitoring restrictive practices’. Another participant advocated for an independent workforce to review the use of RPs and ‘work in collaboration with behaviour support practitioners’ to determine if a practice is being misused or overused and to make recommendations for the reduction of RPs.

Participants indicated that more guidance from the NDIS Quality and Safeguards Commission about what constitutes a RP (particularly related to chemical and environmental restraint), how to resolve disagreements between professionals about using and reducing RPs, and a description of the procedures for reporting and monitoring the use of RPs (particularly on part of medical professionals) would be helpful. Relatedly, some participants said that clearer definitions when and how the use of specific practices constitutes a RP would assist them because it would allow for easier identification of the use of a RP and aid in resolving disagreements between stakeholders about whether or not the way a practice is used meets the definition of a RP. Of note, several participants called for greater understanding within the medical community about how certain types of medication function as chemical restraint, with one participant calling for ‘an appropriate national strategy aimed at [assisting medical professionals to] identify restrictive practices, first and foremost’.

Discussion

The first objective of the current study was to identify the barriers encountered by behaviour support practitioners when they seek to reduce or eliminate the use of RPs with clients they support. We identified ten unique themes related to these barriers, with the most common barrier being fear and reluctance on part of stakeholders. This finding is consistent with previous research (e.g. Webber et al. 2019) showing that family members, care team members, and other stakeholders may be reluctant to reduce RPs, due to anxiety or fear that it may compromise safety or may render the challenging behaviour as unmanageable. Other common barriers include apprehensive attitudes toward the use of positive behaviour supports or other alternatives to RPs on part of the stakeholders, difficulties implementing positive behaviour support strategies, a lack of (or inaccurate data) on the use of RPs, as well as difficulties collaborating or communicating with other team members. Of note, respondents reported a major barrier in collaborating with medical professionals who are responsible for prescribing chemical restraint. This was because often the medical professionals did not recognise that the use of the medication constituted a RP, and they were unwilling to reduce the use of the medication. Collectively, the findings of the current study adds to previous research suggesting that RPs (particularly chemical restraint) are often used routinely and as the primary means for reducing challenging behaviour, rather than as a temporary solution and in concert with alternative strategies (Tournier et al. 2020, Webber et al. 2011a). This is particularly concerning given the lack of evidence for the effectiveness of medication in the management of challenging behaviour displayed by PWD (Deutsch and Burket 2021, O’Dwyer et al. 2018, Tyrer et al. 2008).

The second objective of the current study was to explore elements that enable Australian behaviour support practitioners to reduce the use of these RPs. We identified 13 unique themes related to factors that enable behaviour support practitioners to reduce the use of RPs when supporting PWD. The most commonly identified enablers were adequate time and funding to support the delivery of training to families, service providers, and other professionals. This finding echoes previous research that reported availability of enough time and funding for direct training for staff and other key stakeholders in the use of positive behaviour support to be a critical component of effective service delivery for PWD who display challenging behaviour (Walsh et al. 2019, Wilson et al. 2020). Training may have several positive impacts on practice. First, it may improve the degree to which positive behaviour support strategies can be implemented as planned (Branch et al. 2018), which may increase the effectiveness of strategies for reducing challenging behaviour (MacDonald and McGill 2013). Secondly, training might improve the quality of positive behaviour support plans (O’Dwyer et al. 2017, Webber et al. 2011b) and improve staff confidence to implement components of PBS (Davies et al. 2015, Lowe et al. 2007). This may have the cumulative effect of decreasing stakeholder fear and anxiety about reducing RPs and generate more positive attitudes toward the use of positive behaviour support as an alternative to the use of RPs for preventing and managing challenging behaviour.

In what follows, we synthesise the results of the current study with other research findings and our own clinical experiences to provide a set of preliminary, evidence-informed recommendations for individual practitioners, service provider organisations, and government and regulatory agencies that may facilitate reductions in the use of RPs within the Australian disability sector. Such recommendations may compliment and extend the strategies described in the National Framework for Reducing and Eliminating the Use of Restrictive Practices in the Disability Service Sector (Australian Government Department of Social Services 2014) and the NDIS Quality and Safeguards Framework (Australian Government Department of Social Services 2016). We encourage practitioners, service provider organisations, and regulatory agencies to consider the findings and recommendations provided in the current study as a starting point for further conversations about ways to overcome barriers to reducing restrictive practices and, in turn, to ensure that the rights of PWD are protected and upheld in all aspects of service provision.

Recommendations for behaviour support practitioners

The results of the current study suggest that behaviour support practitioners perceive stakeholders to be resistant to reducing the use of RPs. This finding may be viewed as illustrative of the fundamental attribution error, or the tendency to favour dispositional (or attitudinal) explanations for behaviour over situational explanations (Jones and Harris 1967). We encourage behaviour support practitioners to carefully consider the reasons why family members, care team members, or other professionals may be resistant to reducing the use of RPs or trying alternative behaviour support strategies. This is especially important given the impact that challenging behaviour can have on the lives of families (Doubet and Ostrosky 2015). For example, it may be the case that family or care team members have tried alternative strategies in the past and have not been successful. Alternatively, families or care team members may not have viewed alternative strategies as practical or acceptable in their context. For this reason, we recommend that behaviour support practitioners work with families and care team members as partners in the behaviour support planning process. The collaborative model of behaviour support suggests that interventions for challenging behaviour may be more effective if they are co-designed by people who regularly interact with the PWD and who are most invested in the change process (Dunlap and Fox 2007). This may be because the people who have the most important relationships with the PWD have unique knowledge about the person (such as their preferences, strengths, goals, and needs) and the context in which interventions are to be implemented that may be beneficial to the design of interventions. A collaborative model may also be well-positioned to address many of the barriers identified by behaviour support practitioners in the current study, such as reluctance and fear. Marshall and Mirenda (2002) and Dunlap and Fox (2007) describe components of a collaborative model of behaviour support designed to address challenging behaviour, including trusting relationships, family involvement and support, and family-centred planning. In what follows, we provide several practical recommendations for behaviour support practitioners based on this model.

First, we recommend practitioners build a strong therapeutic alliance with the PWD, family, and members of the care team. A therapeutic alliance is a relationship between a practitioner and client in which the practitioner views that client (or team) as an active partner and equal in the treatment process (Stubbe 2018). Research has shown that the therapeutic alliance is an important part of person or family-centred care and can improve outcomes for clients (Baier et al. 2020, Bose 2022). In the provision of PBS, a strong therapeutic alliance might be developed by spending time with the PWD, family, and care team and listening to their concerns, prior to the development of a behaviour support plan. During this time, the practitioner can gather information about the types of practices used by the team to respond to challenging behaviour and whether such practices constitute RPs. The practitioner can also seek to understand why such practices are used and how the use of practices might in fact fulfil an immediate need and promote a sense of physical and psychological safety for the PWD and others. Finally, during this time, the practitioner can learn more about previously used behaviour support strategies, the degree to which previous strategies were successful, and why previous strategies may have been ineffective or abandoned.

Secondly, we recommend that the practitioner determine if the PWD and family is facing hardships in areas of safety, housing, relationships, or other lifestyle areas, and, if so, take steps to connect the family with social support services or other community-based supports. If families are facing significant hardships in other important aspects of life, it may be difficult for them to fully engage with behaviour support services. By contrast, healthy and resilient families and care teams may be better positioned to fully participate in the behaviour support process. It is important for practitioners to recognise the scope of their own practice and competence when supporting PWD and families, and make referrals to more suitably qualified professionals when appropriate (Brodhead et al. 2018).

Third, we recommend that practitioners engage in person-centred planning with the PWD, the family, and care team. Some research suggests that person-centred planning may be associated with improvements in outcomes for PWD (Claes et al. 2010, Ratti et al. 2016). Person-centred planning is an individualised, active, and collaborative approach used to identify valued outcomes associated with the provision of behaviour support, and to identify how specific strategies might be used to achieve these outcomes (Mansell and Beadle-Brown 2004). Person-centred planning might be used during or after the functional behaviour assessment to co-design the behaviour support plan with care team members. Person-centred planning meetings might provide a safe and transparent forum for practitioners and team to identify the use of RPs and the reasons why RPs are used. During person-centred planning, practitioners and care team members might write down specific perceived barriers to reducing the use of RPs and then generate a list of potential solutions to each barrier. By engaging in this collaborative problem-solving process, care team members may be better positioned to offer solutions and play an active role in generating new strategies for reducing the use of RPs.

Finally, we recommend that practitioners advocate for time and funding to ensure that coaching and ongoing monitoring of the behaviour support plan (including ongoing monitoring of RPs) is an integral component of the services they provide. To re-iterate Hayward et al. (2019), PBS is not simply developing a ‘plan;’ rather, PBS is a framework that includes implementation support, monitoring of valued client outcomes over time, and data-based problem solving. Providing implementation support has been identified to be a critical component of PBS (Gore et al. 2022), but requires ongoing contact between the practitioner and care team following the development of the behaviour support plan. However, participants in the current study indicated that implementation coaching could be challenging, particularly when there was a perceived lack of willingness on part of families or care team members to engage with PBS. To ensure plan implementers are successful in their implementation efforts, we recommend that practitioners focus on the implementation of one strategy or component of the behaviour support plan at a time, while building implementer confidence and fluency. This may increase the likelihood that team members will be successful and experience meaningful behaviour change as a result of their implementation efforts.

Recommendations for service provider organisations

The results of the current study suggest that more systemic strategies beyond the provision of individualised positive behaviour support plans may be needed to reduce the use of RPs (Hayward et al. 2019, 2022). Indeed, previous research has shown that multi-component organisational reform packages (or systemic approaches) may contribute to reductions in the use of RPs (Craig and Sanders 2018, Leoni et al. 2018, Sanders 2009). Such organisational systems approaches should support individual practitioners to undertake the activities described above, through the provision of time, training, or resources. Huckshorn (2006a) outlined several core strategies used within organisational interventions for reducing RPs, including leadership, data collection and analysis, staff training, use of specific tools to reduce RPs (risk assessments and safety plans), involvement of families and care teams, and high levels of coaching and feedback to teams responsible for implementing behaviour support strategies. Given the variability of skills of the behaviour support practitioner workforce, such strategies might best be delivered within a tiered model that embeds opportunities for practitioner supervision and professional development (Hartley et al. 2016).

One starting point may be for service provider organisations to work collaboratively with government and regulatory agencies to develop guidelines or checklists for assessing the degree to which specific organisational systems are in place to support reductions in the use of RPs. Examples of similar documents are provided by Huckshorn (2006b) and Stirling et al. (2011). Such guidelines might include an overview of strategies for developing an organisational plan that includes measurable goals related to reductions in the use of RPs, strategies for establishing leadership teams who can guide processes related to reducing RPs within the organisation, methods for building workforce capability in evidence-based alternatives to the use of RPs, structuring supervision experiences for all staff, creating systems to promote ethical and data-driven decision-making, and incorporating input and feedback from service users (including families and PWD).

The establishment of organisational processes to facilitate data-based problem solving and decision-making are central to organisational interventions (Newton et al. 2011). Within organisations, processes for facilitating data-based problem solving might include (a) the development of standardised methods across the organisation for collecting, analysing, and reporting data on the use of RPs for individual clients, (b) the establishment of organisational peer review committees that meet regularly to review data and generate ideas for reducing the use of RPs across the organisation, and (c) the establishment of partnerships with external practitioners, researchers, and people with lived experience of disability to discuss barriers related to the reduction of RPs, share ideas about best practices for reducing the use of RPs, and develop case studies describing effective strategies used by organisations to reduce the use of RPs over time.

Recommendations for government and regulatory agencies

The findings of the current study suggest clearer definitions of how and when the use of specific practices constituting a RP would be of great value to the sector. It is important to note that a RP is not defined by what it looks like (its form), but rather by the way the practice is used (for example, the use of psychotropic medication may constitute a RP in one context but not in another). Of note, there remains confusion about whether the use of certain medications under certain conditions constitutes chemical restraint. Better understanding of the contexts in which a practice meets the definition of an RP is likely to have a positive effect as it may improve reporting of the use of RPs and potentially reduce their use. Clearer examples (and non-examples) of the ways in which specific procedures meet the definition of a RP may reduce the variability of interpretation by practitioners and other professionals, potentially leading to improved reporting of their use across the sector (Clark et al. 2018). As part of the Regulated Restrictive Practices Guide (NDIS Quality and Safeguards Commission 2020), decision trees have been created to aid practitioners in the identification of RPs. To facilitate their use by practitioners, these decision trees could be made available as single page PDFs and supplemented with multiple video examples of practitioners demonstrating how they work through each decision tree to determine if a practice meets the criteria for a RP.

One challenge identified in the current study was a lack of data on the use of RPs. To measure reductions in the use of RPs over time, it is important to collect accurate data on their use. For this reason, we recommend that government and regulatory bodies encourage and reinforce the accurate reporting of the use of RPs, and aid practitioners and service provider organisations to identify and use practical data collection systems in their work. The encouragement of accurate reporting will likely be associated with an increase in reporting and, thus, a perceived increase in the use of RPs. We assert that this is in fact a desirable outcome because it will allow for the accurate identification of when, where, why, and how often RPs are used, data that has previously been lacking in the disability sector in Australia. To facilitate accurate reporting of the use of RPs, members of government and regulatory bodies could meet with behaviour support practitioners to identify the barriers and enablers to timely and accurate reporting and take steps to reduce any barriers to reporting, such as cumbersome processes or difficult to use reporting systems. Such conversations may also allow for the identification of other barriers to accurate reporting, such as fear of negative repercussions from regulators as a result of reporting, lack of clarity amongst practitioners about what constitutes a RP (a challenge identified in the current study), or practical challenges related to the collection of data on the use of RPs on part of support workers, family members, or others who support PWD. We also recommend that the NDIS Quality and Safeguards Commission publish data on the use of authorised RPs to allow the public to monitor the frequency of their use and the potential effectiveness of larger scale initiatives designed to reduce their use.

Finally, clarity is needed regarding the role of behaviour support practitioners in the recommendation, monitoring, and reduction of chemical restraint. Prescribing medication for any purpose is beyond the scope of practice of a behaviour support practitioner, but the responsibility for authorising and monitoring its use, and advocating for its reduction, now seemingly sits with the practitioner. Behaviour support practitioners may have limited influence over the decisions of medical professionals, who are the appropriately qualified professionals to authorise the use of chemical restraint. Not only is the use of chemical restraint pervasive with people with intellectual disabilities who display behaviours of concern (Richardson et al. 2020), it is also widely used in the aged care sector with people with dementia (Lee et al. 2021) and in emergency rooms as a first response to people suffering from acute mental health crises (Muir-Cochrane et al. 2020). Indeed, the Royal Australian College of General Practitioners (RACGP) has recognised the problem of over prescription of medication in response to challenging behaviour and recommends that medication be used only as a last resort (RACGP 2020). However, a national strategy aimed at improving the identification, monitoring, and reduction of chemical restraint on part of medical professionals has not yet been issued. We recommend that such a strategy be developed as a shared activity between State and Territory government agencies, the NDIS Quality and Safeguards Commission, and peak medical professional bodies such as the RACGP as a matter of priority.

Limitations and future directions

The current study provided a snapshot of the perspectives of 109 Australian behaviour support practitioners, which is a relatively small sample size. Demographic data collected as part of this study revealed that respondents were evenly distributed across registration groups (core, proficient, advanced, and specialist), most held additional professional qualifications in allied health disciplines, and many completed post-graduate university coursework. It is unknown whether the respondents who completed this survey were representative of the wider behaviour support practitioner workforce, or if a larger sample size of respondents would have reduced possible sampling bias and provided somewhat different results. The results of this study should be considered preliminary in nature and care should be taken when interpreting data and applying it to the wider population. Future research is needed to identify the educational and training experiences of behaviour support practitioners, and to explore whether there are differences or similarities in perspectives about the barriers practitioners face when reducing RPs as a function of their background variables such as the registration group, professional qualification, education level, or years of practice.

Although participants provided their perspectives on the types of factors that currently or in the future would help them to reduce the use of RPs, the degree to which these enablers are currently being used in practice is unknown. For example, there is a paucity of Australian research describing successful strategies for building the capability of families, support workers, and service providers to adopt, implement, and evaluate to implement components of the positive behaviour support framework. In addition, there are no longitudinal Australian studies showing how the provision of positive behaviour support decreases the use of RPs over time – either for individuals, or across multiple individuals receiving services within an organisation. Researchers might consider conducting case studies within individual organisations that deliver positive behaviour support to PWD who experience RPs, to describe how time, funding, and resources are allocated to activities such as staff training and supervision, care team and progress review meetings, data collection and analysis, and other organisational change approaches to reducing RPs that have been described in the literature (e.g. Leoni et al. 2018). Such case studies could highlight examples of effective practices to be adapted and implemented by service providers and recommended within policy and practice briefs.

Only behaviour support practitioners were sampled as part of this research. Future research is needed to explore the perspectives of PWD, families, care team members, and organisational leaders about those aspects that help and hinder efforts to reduce the use of RPs. In addition, future research is needed to explore the acceptability and usefulness of positive behaviour support strategies and other alternatives to RPs from the point of view of PWD and their families, since alternatives that are not viewed as safe and acceptable by the direct recipients of behaviour support are unlikely to be adopted and implemented. Such research findings will enhance our current understanding of the contextual fit (or the alignment between (a) the strategies used to deliver positive behaviour support and reduce RPs, (b) the goals, values, strengths, and needs of PWD, and (c) the skills and resources of those tasked with implementing) of current approaches to delivering behaviour support in Australia.

Finally, it has been recognised that the use of RPs, if overused, misused, or used as the first and only option for managing challenging behaviour may restrict a person’s autonomy and freedom and may conflict with the human rights of PWD (Chan 2016). However, simply reducing RPs is unlikely to ensure the rights of PWD who display challenging behaviour are protected and upheld. As outlined in the NDIS Quality and Safeguards Commission’s PBS Capability Framework (2019), behaviour support practitioners have an obligation to take further steps to uphold the rights of the people they support. Future research is needed to explore how behaviour support practitioners uphold the rights of PWD, what help them uphold the rights of the individuals they serve, and the barriers they encounter when attempting to protect and uphold the rights of their clients. The findings of such research can be used to inform policy and practice guidelines that describe ways for practitioners to further protect and uphold the rights of PWD who display challenging behaviour while providing services that maximise client safety and minimise harms to the PWD and others.

Conflicts of interest

The authors do not have any conflicts of interest to declare.