The behavioural advisory sessions (BAS) were developed to reduce the community nursing waiting list and gatekeep referrals for behavioural support. The BAS provides structured monthly sessions for supported living staff to receive advice and support from nurses and analysts regarding residents' low-level behavioural issues. An evaluation found the BAS reduced the waiting list to zero and mostly had positive impacts, though some providers were unprepared and failed to fully engage. The BAS process could be improved with better preparation of providers and more protected nursing time.

1. Behavioural Advisory Session Evaluation
Introduction
The behavioural advisory sessions (BAS) were devised in November and
December 2010 by the community nurses with consultation with the link
behavioural analyst. BAS was developed following analysis of the
community nurses waiting list finding a high proportion of service users
referred for active work from a CLDN for minor behavioural issues.
Historical experience has also shown that there are consistently
inappropriate nursing referrals for full behavioural assessments and
interventions. The BAS therefore had two main objectives firstly to reduce
the amount of service users waiting allocation for a community nurse for
behavioural assessment and work without requiring them being placed on
the team case list for set piece of work. Secondly to effectively gate keep
the allocation of community nurses for active behavioural work.
Prior to the introduction of the BAS the community nursing waiting list
was reviewed. 10 service users were identified as awaiting allocation for
community nursing meeting the criteria for accessing the BAS process,
which are as follows:
o Low impact challenging behaviour
o Living in a supported living or residential
placement
o Motivated home leader and staff team
o Previously know to team
o Previous professional behavioural work
preferable
In cases where service users present as a significant or high risk to
themselves, staff and / or the public will continue to be allocated to a
community nurse on receipt of referral. Where cases were found to meet
the BAS criteria it was agreed that one member of direct support staff and
the senior support work (formally home leaders) would attend. The senior
support worker was to be invited via a letter with important information
and examination of the BAS process (see appendix 1). It was agreed that
these sessions would be no longer than 1 hour, with 30 minutes for
information gathering and 30 minutes consultation. These sessions would
be held at the CLDT HQ once a month over a maximum of 6 meetings. To
start with it was decided that these sessions would be run by two
community nurses and a behavioural analyst to increase nurse experience,
knowledge and skills, whilst ensuring appropriate implementation of
assessment tools and interventions. It was decided that initially the BAS
would be run once a month as a pilot and if successful another BAS team
would be implemented.

2. The BAS process is based on the basic principles affecting behavioural
function looking at antecedents, reinforcers and environment modification.
The nurses and behavioural analyst involved were not to carry out any
active work and only provide advice and support to the participants within
the session. The participants were then expected to complete a number of
aims and objectives identified in the sessions, such as the completion of
assessment tools, up-dating or creating of behavioural protocols and
making environmental changes. The advice given by the nurses and
behavioural analyst must be evidenced based and objectives achievable
and given time scales. It was hoped that the process will build and develop
the participant’s skills, which should be transferable to the rest of the
support team.
It was found through the nursing modernisation meetings that a large
proportion of these service users had already had some degree of
behaviour assessment and intervention by community nurse and / or the
critical needs service. Therefore in most of these cases there should be
existing assessments and interventions. It was agreed that many of these
individuals’ behavioural needs could be met through reviewing and
updating existing behavioural information. The BAS attempts to provide a
structured approach for this process with community nurses providing
advice and support for project managers and project workers to
appropriately up-date behavioural information. Small proportion of the
referrals suitable for BAS did not have historical behavioural assessments
and in these cases it is important to introduce appropriate assessment
tools to ensure that advice and support given is evidence based.
Through discussions in the nurses modernisation meetings it was agreed
that service users should not attend as discussion regarding there
challenging behaviour can be very anxiety provoking and distressing for
them. Also this would enable the community nurses to discuss behaviour
proactive and reactive management strategies and how these should be
implemented in a much more efficient manner.
The BAS aims is to provide a safeguard to inappropriate referrals for
medium to low level behaviour intervention ensuring that cases are only
allocated where needed, enabling nurses to have more time to work with
complex cases. This gate keeping is completed in the initial behavioural
advisory session through an interview and review of existing behavioural
information. The first session follows a set format (see appendix 2) with a
number of questions regarding behaviour, health, social and lifestyle
changes. This information should provide the community nurses enough
information to decide if the case is appropriate to continue through the
BAS process or if a community nurse should be allocated.

3. Evaluation
It has now been a year since the BAS has been implemented and an
evaluation of the service has been completed. The following document will
analysis the evaluation records from the service managers, community
nurses and behavioural analyst involved in the process.
The evaluation found the 10 about of cases had been to the initial
behaviour advisory session. From these cases 8 went through the full 6
sessions or less. The remaining 2 were allocated for community nursing
for team case load. Data from the nurse’s waiting list for behavioural
support have shown that there has been reduce from 10 to 0. The sessions
are continuing to run on a monthly basis with two BAS teams, however
these are not running to capacity and one BAS group a month could meet
the current demand.
Service Provider Evaluation
The evaluation sheets were only completed by service managers who had
concluded the BAS process. No data has been collected from individuals
involved in only the initial behavioural advisory session. The evaluations
sheets found that 2 of senior support workers found the BAS had a
positive impact on the service user’s behaviour and 2 feeling that it was
mostly positive. The remaining two were unable to say due to being moved
to the project late in the BAS process.
One senior support worker stated that the BAS should gather much more
detailed information in the first meeting and provide more individualised
recording tools. She also felt that visual data analysis would be more
beneficial for the service user’s staff team. 2 senior support worker stated
that the process could be improved the whole staff team having a better
understanding of the process. 2 senior support worker became involved in
the BAS process near the end and they felt that they were not given
enough information on the sessions. They recommended that more
information is given to senior support workers that join the BAS mid way
through.
Community Nurses Evaluation
Four community nurses were involved with the BAS process working in
two teams each reviewing and advising 3 cases once a month on a
designated day. The community nurses have reported a number of positive
aspects that the implementation of BAS had brought. All the nurses
involved felt that the BAS process encourages and promotes staff teams
and management to develop there own protocols leading to a sense of
ownership and therefore increasing the likelihood of implementation and
consistent approach. The nurses involved also felt that it effectively
prevented the inappropriate allocation of community nurses as well as

4. being a very effective use of nursing resources. Another area that the
nurse agreed the BAS produced was the development of skills and
knowledge of staff and management, which should be transferable to
similar projects. Other positive aspects indentified by the nurses were:
• Identifying good practice
• Staff encouragement and building confidence
• Revisits and developing existing work, interventions and protocols
• Clear process
• Very positive when working with a motivated staff team
• Encourages team work and increases job satisfaction when done
correctly
The nurse evaluation sheets found that there were a number of areas in
which the BAS process could be improved. The major problem that all
community nurse found was that the service provider had not fully read or
understood the information sent regarding the BAS process and want was
expected from the and there staff team. Consequently bringing the service
user to the sessions or not bring specified documentation so data analysis
could not be completed and therefore interventions and advise could not be
given. There was once team that brought the service user to 3 sessions
another team did not know that there was a behavioural support plan in
place until session 3.
Although the nurses found that BAS is an appropriate use of there clinical
time the majority of them found that it was resource intensive with four
nurses having to dedicate half a day over the two teams. The nurses also
reported that the lack of protected time became a hindrance as important
meetings taking presentence over BAS and days subsequently being
changes. Once this change had occurred it was difficult to find a day in
which all parties could attend.
The nursing team found that commitment and motivation of the staff
teams and their senior support worker is essential to the BAS process. The
provider must be committed to the process and implement the aims and
objectives set in the BAS and bring any data or new documentation to the
next session, as without this the BAS ineffective. Unfortunately the
nurses did experience poorly motivated staff teams with workers with
limited understanding and experience of learning disabilities. Often these
teams have limited communication with there management and
consequently work is not completed and / or support staff will want to
discuss all of the issues they are experiencing. Poor staffing levels and
non-attendance was a major negative aspect of the process often with very
minimal warning of cancelation or none at all. Due to the restructuring in
Community Living Service the community nurses found that there were
regular changes in service user’s support team and management, which
very disruptive for the service user and makes it difficult for aims and
objectives to be completed.

5. Some of the nurses felt that the BAS process needed to be more holistic
with quality of life being more evident. The current process concentrates
on topography of behaviours, triggers and reinforcers without enough
emphases level and variety of activities, choice and independence.
Out of the 6 cases that went through the BAS process 5 had already had
involvement from a community nurse, with 2 of these having involvement
from BST. In these cases it is essential that previous behavioural
interventions, protocols and behavioural support plans are brought to the
initial session. These will then be reviewed by the community nurses and
advice given to the senior support worker and / or key worker to up-date,
make changes to behaviour documentation or ensure that current
protocols are being implemented appropriately.
Conclusion
Following evaluation by the community nurses there were a number of
areas that were found needed improvement. Firstly the BAS pathway was
streamlined to be clearer and more coherent. The letter format and
information was also simplified in order for team managers to have a
better understanding of the process, stressing the vital importance of not
being the service user and the need for assessments and data required for
each session.
The format of the initial behaviour advisory session has also been changed
to incorporate more of a positive behavioural support element. This should
make this process more holistic and focus more on quality of life issues
and proactive management strategies.
The behavioural analyst attended around 50% of the behaviour advisory
sessions due to heavy work load and breakdown in communication;
however these sessions still ran very effectively and the community nurses
were able to advise appropriately with positive results. Therefore the level
of behavioural analyst resource for the BAS process needs to be reviewed.
One suggestion is that the behavioural analyst be accessible during these
sessions.
Currently both BAS teams are not running at capacity and if this were to
continue one team might be more appropriate. Many of the community
nurses felt although BAS was an appropriate and good use of there time,
it was very resource intensive. Therefore further discussion needs to be
had regarding if these sessions could be run by one community nurse with
support from the behavioural analyst if required.
Protected time to complete BAS sessions each month is extremely
important. This should also incorporate time to write up the minutes for

6. each session. Clinicians need to ensure timely delivery of these minutes as
they have clear aims and objectives to be completed.
An important part of the BAS process is the completion of behavioural
assessment tools by the individual’s staff team. The nurses involved
agreed that it would be beneficial to have access to a number of
behavioural assessments tools immediately due to the limited time
available. Therefore it is suggested that a file of relevant assessment tools
should be compiled and taken to each BAS. A lap top could also be
valuable to quickly and effectively write up data provided by support staff
and where possible analysis data.
Development of a letter to providers to be sent when BAS instructions
have not been followed i.e. service user being brought, no data, DNA. At
the beginning BAS process the community nurse must discuss with the
provider the importance of completion of work, motivation and ensure that
they have fully understood there role within the sessions.
Lastly as breakdown in communication has been an issue for nurses,
project workers and senior support worker, it is essential for an
information leaflet to be created. This should be aimed at staff teams to
help raise understanding of the BAS process and what is expected from all
involved.

7. each session. Clinicians need to ensure timely delivery of these minutes as
they have clear aims and objectives to be completed.
An important part of the BAS process is the completion of behavioural
assessment tools by the individual’s staff team. The nurses involved
agreed that it would be beneficial to have access to a number of
behavioural assessments tools immediately due to the limited time
available. Therefore it is suggested that a file of relevant assessment tools
should be compiled and taken to each BAS. A lap top could also be
valuable to quickly and effectively write up data provided by support staff
and where possible analysis data.
Development of a letter to providers to be sent when BAS instructions
have not been followed i.e. service user being brought, no data, DNA. At
the beginning BAS process the community nurse must discuss with the
provider the importance of completion of work, motivation and ensure that
they have fully understood there role within the sessions.
Lastly as breakdown in communication has been an issue for nurses,
project workers and senior support worker, it is essential for an
information leaflet to be created. This should be aimed at staff teams to
help raise understanding of the BAS process and what is expected from all
involved.