Organisational environment and challenging behaviour in services for people with intellectual disabilities

1About 5-15% of people with intellectual disabilities (ID) display challenging behaviour (Emerson, 2001; Hamlin & Oakes, 2008; Hensel, Lunsky & Dewa, 2014). Challenging behaviour includes physical and verbal aggression, problematic sexual behaviour, self-injury, destructiveness, and stereotypical behaviour. These behaviours are often of such intensity, frequency, and duration that they pose a safety risk and threaten the quality of life of the person, other service users with ID, as well as people in their support systems (Allen et al., 2005; Allen et al., 2007; Emerson, 2001; Dilworth, Philips & Rose, 2011). Furthermore, most support services for people with ID and challenging behaviour are associated with high rates of restraint, seclusion and medication, and physical abuse of and by people with ID and challenging behaviour (Allen et al., 2005; Allen et al., 2007; Emerson, 2001).

2It may not be excluded that the organisational environment of support services influences challenging behaviour in people with ID, and conversely, that challenging behaviour affects the organisational environment (Dilworth, Philips & Rose, 2011). The organisational environment of support services for people with ID and challenging behaviour needs clear operational policies and working methods, a concentration of relevant expertise, and a collective identity to help staff to be more tolerant and better equipped to cope with these challenges (Felce et al., 1998). Challenging behaviour, causing damage and injury, are reported in these support services, leading to special building requirements, i.e. protected equipment and restrictions of access to parts of the buildings (Allen et al., 2007). It is also reported that these people often reside in impoverished settings (Allen et al., 2005; Emerson, 2001).

3It is now widely accepted that “intellectual disabilities” and “challenging behaviour” are interactional, ecological constructs, rather than strictly internal deficits or traits of the person. They should be understood as resulting from complex interactions between individuals and their environments (American Psychiatric Association [APA], 2013; Hamlin & Oakes, 2008; Dilworth, Philips & Rose, 2011; Schalock et al., 2010; Tossebro et al., 2012; Wehmeyer et al., 2008). Since environments, including organisational environments of services for people with ID, are complex in itself, it might be helpful to use a theoretical framework which takes this complexity into consideration. Knowledge about the relationships between the organisational environment and challenging behaviour may be useful to promote effective support services as well for research purposes. In the present study, the authors report on a search of the literature to identify and clarify these relationships. The ecological theory of human development and functioning proposed by Uri Bronfenbrenner, was used as a framework to analyse and discuss findings. In the literature, Bronfenbrenner’s theory is referred to as “bioecological theory,” “socio-ecological theory” and more recently as “Process-Person-Context-Time model” (Bronfenbrenner & Morris, 2006; Griffore & Phenice, 2016). In this article, we use the term “ecological theory,” and it will be briefly presented.

4Bronfenbrenner (1979, 1994, 1999; Absil, Vandoorne & Demarteau, 2012; Bronfenbrenner & Morris, 2006) states that individual human functioning and development are the results of complex reciprocal interactions between an active, bio-psychologically developing person (the ontosystem) and the environment, which is conceived as four nested “layers”: micro-, meso-, exo-, and macrosystem. Each of these four systems consists of persons, objects, and symbols. These systems are interrelated, and dynamic. First, the person and their environment are seen as mutually interacting and influencing each other through proximal processes. These are characterised by person-person interactions (dyads) the individual is engaged in. Second, person, environments and interactions change over time. This temporal aspect of these systems constitute an extra ecological element: the chronosystem. (Bronfenbrenner, 1979, 1994, 1999; Bronfenbrenner & Morris, 2006; Tudge et al., 2009). The ecological model can be represented as a nested set of four ecological systems surrounding the person with its biopsychological constitution, as is shown in Figure 1, in which the temporal dimension of these systems is visualised as an arrow (INSERM, 2016: 982).

5The ontosystem consists of personal biological (genetic and physical) dispositions and psychological characteristics (skills, character, experiences) (Bronfenbrenner & Morris, 2006; Tudge et al., 2009). The microsystem consists of activities, social roles, and interpersonal relations in face-to-face settings (i.e. family, school), including interactions of residents with ID and challenging behaviour with staff or family members. Note that a person is engaged in more microsystems. The mesosystem refers to the interactive connections among different microsystems; for example, between family members and group home staff, or between staff members mutually, or between staff member and the person’s teacher. The exosystem encompasses relationships between a residents’ microsystem and proximate elements, so a resident does not interact directly with the exosystem but what happens or is decided here affects the microsystem and subsequently the resident. For example, managers who do not have direct contact with residents but interact directly with staff, such as, higher management of the service organisation, human resources management and facilitating services. The macrosystem consists of the all-encompassing patterns of rules, funding systems, and attitudes that are shared in the micro-, meso-, and exosystems, and are characteristics of a culture. It contains, for example, belief systems, customs, financial resources, governmental structures, and budget allocation systems. The chronosystem can, for example, relate to the changing of the person, and changes in the interaction between staff member and resident (microsystem) as a result of staff turnover, or developments in the organisational vision or structure (exosystem) (Bronfenbrenner & Morris, 2006; Tudge et al., 2009).

6In most cases, support services for a person with ID and challenging behaviour (ontosystem) depend on collective funding and national disability policies (macrosystem), which are essential for facilitating the service organisations (exosystem) in order to organise sufficient and qualified staff who directly interact with residents on day-to-day and face-to-face bases (microsystem) (Allen et al., 2005; Guerrero et al., 2014; Svab & Tomori, 2002). Other organisational environment aspects, such as physical design and organisational structures, may also exert influences, but they have received less research attention (Hulgin, 2004). Residents participate in more microsystems such as their family or work settings, and the interactions between these microsystems constitute the mesosystem. Changes and development in time in these systems constitute the chronosystem.

7The aims of the present study were to explore the literature on the relationship between disability service organisations and challenging behaviour in residents with ID, and to identify aspects and interactions between these aspects that may be important in the understanding of this relationship. According to Bronfenbrenner’s ecological theory, the organisational environment (exosystem) strongly affects the microsystem and the person within. Thus, this literature review sought to determine the influences or roles of different aspects of the organisational environment on challenging behaviour in residents with ID.

8To explore the relationship between the organisational environment and challenging behaviour in residents with ID, we used a scoping study, which is a type of literature review. A scoping study is a method for mapping key concepts within a research area, sources for literature and the different evidence, and is often used when prior studies have not reviewed a certain area (Arksey & O’Malley, 2005).

9This scoping study was conducted using three search strategies. First, we used a combination of the three search terms (e.g. intellectual disability, challenging behaviour, organisation), which generated too little studies to conduct an analysis. So, we used two combinations of search terms “intellectual disability” with “challenging behaviour,” and the combination “intellectual disability” with “organisation” and their synonyms and MeSH terms, using search engines Medline, PiCarta Online Contents, ScienceDirect, ERIC, and SpringerLink. The second strategy was an additional search of the contents of the Journal of Applied Research in Intellectual Disabilities, the Journal of Intellectual Disability Research, the Journal of Policy and Practice in Intellectual Disabilities, and journals of the American Association of Intellectual and Developmental Disabilities ([AAIDD]; American Journal of Intellectual and Developmental Disabilities, Intellectual and Developmental Disabilities, and Inclusion), using the search terms “challenging behaviour” and “organisation.” The third strategy was the “snowball method,” exploring references cited in included articles of the first two search strategies.

10Articles included in this study were original research reports, literature reviews, and case studies, and published in English from 2000 to 2016. Search criteria included participants who received support services including living arrangements in a group or residential setting for children or adults with ID and challenging behaviour. Articles were excluded if they were studies into prevalence, comorbidity, medication, clinical therapy, diagnostics, or medically and neurologically oriented. The next step was the examination of the abstracts of the included articles to determine eligibility for inclusion in the analysis, based on whether the articles addressed organisational aspects with respect to challenging behaviour in residents with ID, sometimes mediated by staff, or the relationship between the macrosystem and disability service organisations. The final step was conducting an in-depth analysis of each article by two researchers, and charting of the data of all articles included in this scoping study by summarising the information on the relationship between challenging behaviour and organisational aspects, and analysing results using the ecological framework.

11The first search strategy of this scoping study, using the combination “intellectual disability” with “challenging behaviour,” resulted in 1850 hits and 39 potentially eligible articles, and the combination “intellectual disability” with “organisation” resulted in 112 hits and 19 potentially eligible articles. After an examination of the 39 and 19 titles, we found 7 articles which were part of both search combinations, resulting in 51 included articles based on title. Subsequently, the abstracts of these 51 articles were examined, resulting in 7 articles, which were included in the in-depth analysis. The second search strategy yielded the following:

• Journal of Applied Research in Intellectual Disabilities, 404 hits and 8 included articles;

• Journal of Intellectual Disability Research, 551 hits and 4 included articles;

• Journal of Policy and Practice in Intellectual Disabilities, 197 hits and 1 included article; and AAIDD journals, 391 hits and 4 included articles.

12This second search strategy led to the inclusion based on abstract of an additional 17 articles. Thirdly, the application of the “snowball method” led to the inclusion of 4 additional articles. Thus, the scoping study included a total of 28 articles, which were examined in the in-depth analysis (see Table 1, published as online appendix, for an overview of the results).

13To chart the 28 articles, we used a descriptive-analytical method (Arksey & O’Malley, 2005). We collected standard information about the articles, such as aim, key words, design and methods, and conclusions, and used Bronfenbrenner’s ecological theory as an analytic framework to critically organise the diverse studied factors of the 28 articles in accordance with their association with the systems of the theoretical framework, and in order to analyse the factors and the interrelations between these factors (Arksey & O’Malley, 2005) (see Table 1, published as online appendix, for an overview of the results).

14The results of this scoping study are charted according to the ecological theory of Bronfenbrenner in Figure 2, and discussed accordingly below.

15The level of adaptive behaviour of residents seems to be associated with the quality and outcome of received support, and is not linked to the quantity of the provided support (Beadle-Brown, Bigby & Bould, 2015; Felce, Lowe & Jones, 2002; Felce & Perry, 2004). For example, more-able residents in combination with staff who had worked in hospitals and had knowledge of challenging behaviour and Active Support as a working method, results in higher quality supports (Beadle-Brown et al., 2014; Mansell et al., 2008).

16Challenging behaviour in residents with ID is associated with lesser quality and quantity of support services. Many children with ID and challenging behaviour are labelled with a mental disorder, resulting in lower support quality since regular services for residents with ID are not well equipped for residents with mental disorders, and vice versa (Surjus & Campos, 2014). In addition, community placement in a small group home is often unsuccessful for residents with ID and sexually inappropriate behaviour, because of their specific and complex behaviours plus the lack of adequate professional support for staff, and insufficient resources and qualified staff (Broadhurst & Mansell, 2007; Mansell et al., 2002).

17In summary, at the level of the ontosystem negative associations are seen between the availability and the quality of support services and residents characteristics, such as lower levels of adaptive behaviour and presence of challenging behaviour. Furthermore, lack of qualified staff and weak support of direct support staff by the organisation of staff present risks for the quality of support for residents with ID and challenging behaviour.

18Staff members’ perceptions of residents influence staff performance (White et al., 2003). For example, low-performing group homes with less community activities for residents tend to have staff who regard residents as different and prioritise staff’s interests over residents’ interests. These staff members also feel isolated from the rest of the organisation (Bigby et al., 2012; Bigby et al., 2015; Gillett & Stenfert-Kroese, 2003). In contrast, in higher-performing group homes with respect to quality of life outcomes for residents, staff members have emotional bonds with their residents, who are regarded as being “like us” (i.e. they have ordinary lives, need human company), which is promoted by, for example, an experienced staff member who is always present to teach and monitor staff members (Bigby et al., 2015).

19Repetitive threat and exposure to aggression affects staff members’ perceptions of challenging behaviour. Threat and exposure can have negative psychological consequences for staff, resulting in less intense or less appropriate support. Consequences for support quality were less when staff had little fear of violence, were exposed to less-severe aggression on a daily basis, recovered rapidly, and viewed exposure to such situations as part of the job. Nonetheless, managers need to pay attention to the subjective experience of direct support staff and provide substantial support to staff (Dilworth, Philips & Rose, 2011; Hensel, Lunsky & Dewa, 2014). Secondly, Dilworth, Philips & Rose (2011) concluded that staff members rated residents’ control of their challenging behaviour as less problematic in settings in which staff displayed positive attitudes toward residents, exosystem aspects such as the physical and social environments were appropriate, and the support service seemed to be properly structured (Dilworth, Philips & Rose, 2011).

20Positive interaction between staff and residents with challenging behaviour leading to decreasing challenging behaviour incidents is enhanced through feedback from a coach, and by the presence of an organisational philosophy, which states to whom staff are managerially accountable and defines the roles of different involved professionals (Courtemanche et al., 2014; Sutton et al., 2016). The amount of contact between residents and staff members is furthermore associated with good allocation of staff, coaching by managers, and more experienced staff, and was not linked to more staff, a greater presence of key workers, and residence size (Beadle-Brown, Bigby & Bould, 2015; Felce, Lowe & Jones, 2002).

21The diversity of residents’ needs is greater in more heterogeneous groups, and therefore they need staff with more specialised skills. However, residents receive less support and staff performance is inefficient because of more time spent on planning and management of residents’ activities (Mansell et al., 2002). More homogeneous groups with many residents with challenging behaviour are associated with reduced staff diversity and educational level. Also, residents are at greater risk of abuse by staff members (Felce, Lowe & Jones, 2002; White et al., 2003).

22At the level of the microsystem, it may be concluded that staff’s perceptions of residents’ abilities and behaviour influences the quality of interactions between staff and residents, and therefore the quality of support services. These perceptions of staff are facilitated by staff’s sense of being embedded in the organisation and being supported by a suitable and structured organisational environment (for example support from coaches and managers). Literature is inconclusive about heterogeneous and homogeneous grouping of residents, both can be associated with negative residents outcomes. In the present review, no studies were found which examined the relationships between specific disorders, such as autism or attention deficit hyperactivity disorder, and the organisation of support services.

23The least researched topic appears to be the mesosystem. The network of staff members and differences in power and perceptions between staff members mutually are the only aspects of the mesosystem in the literature. So, interactions of different microsystems of the resident with ID and challenging behaviour are indistinct. However, from an ecological perspective and from the perspective of the availability of support resources, interactions between staff members and other microsystems of residents with ID such as family, school, work and leisure environments are highly relevant.

24The literature shows that, power dynamics influence the relationships among staff members. For example, cliques of staff members can have their own ways of working and exclude external involvement from others outside the clique with respect to improving the quality of life of their residents (Beadle-Brown, Bigby & Bould, 2015; Gillett & Stenfert-Kroese, 2003). To avoid problematic relationships between staff and residents, which might result in challenging behaviour, staff members must set boundaries between personal and professional relationships within their networks (White et al., 2003). The quality of the supports is also associated with differences between staff members in whether they are positive about choice and inclusion of residents with severe ID. Thus, coaching and modelling of the different attitudes between staff members for example by a manager, is necessary (Beadle-Brown, Bigby & Bould, 2015; Bigby et al., 2009; White et al., 2003).

25The exosystem refers to aspects, such as leadership, mission statement, power, culture, personnel policy, performance monitoring, and implementation of working methods (such as Active Support). At the exosystem level, staff practices and organisational issues are distinguished to help chart evidence from the literature.

3.4.1. Exosystem – staff practice

26The implementation of national policies in support organisations for residents with ID appears not to be easy, as can be seen in the United Kingdom, where specific guidelines were formulated to systematically express the meanings and applications of national policies for daily work practices (Bigby et al., 2009). The assessment of staffs’ values, attitudes, and skills with respect to policy goals and values during, for example, recruitment and training is necessary, as well as creating safe spaces within organisations for staff members to discuss attitudes and examples of good support practices in line with policy values (Bigby et al., 2009; Beadle-Brown, Bigby & Bould, 2015; Walker, 2012; White et al., 2003).

27The implementation of a working support or treatment method for challenging behaviour is hindered by lack of resources and passive leadership of managers. Implementation is associated with staff’s attitudes, type of working method, feedback, and practice leadership (Beadle-Brown et al., 2014; Beadle-Brown, Bigby & Bould, 2015; Courtemanche et al., 2014; Guerrero et al., 2014). Effective and efficient implementation of working methods is linked to aspects, such as experiential learning, and the presence of more qualified staff, who evaluate and discuss their tasks, which results in better interaction between staff and residents as well as with managers (Deveau & McGill, 2016; Mansell et al., 2008). Hulgin (2004) states that different organisational types are associated with different obstacles and strengths with respect to the implementation of a new working method.

28Performance is frequently monitored in order to develop new support practices by staff, this is done by managers and in accordance with organisational values and goals. (Deveau & McGill, 2016). Performance monitoring in successful support services for residents with ID and challenging behaviour is associated with written intervention strategies, regular reviews of daily practice, and involvement of other professionals (Broadhurst & Mansell, 2007). Successful services also seem to have clear roles and responsibilities, managerial support, good team structure and cohesion, and integrated care (Broadhurst & Mansell, 2007; Hensel, Lunsky & Dewa, 2014; Sutton et al., 2016). When support practices are not monitored and become isolated, the risk of low-quality care increases, because staff members become inaccessible and resistant to advice from others in the organisation or external involvement (Sutton et al., 2016; White et al., 2003).

29In summary, at the level of staff practice in the exosystem, the organisation needs to implement policies and working methods in the hectic daily practices of supporting residents with ID and challenging behaviour. Staff performances are monitored by the organisation during different organisational activities, and is enhanced by coaching staff and stimulating reflective discussions. So the supportive and facilitating role of the manager is vital in coaching staff.

3.4.2. Exosystem – organisational aspects

3.4.2.1. Practice leadership

30Frontline managers have a high impact on daily support practices for residents with ID and challenging behaviour, and are mediators of organisational conditions, which are set outside the microsystem of reciprocal interactions between staff and residents. The frontline manager shows practice leadership by setting appropriate standards, offering feedback on “bad practices” and attitudes with respect to incidents related to challenging behaviour, and by providing teams with coaching and structure. For staff, these managers define jobs, mediate stresses, create values, and establish well-functioning working environments (Deveau & McGill, 2016; Beadle-Brown, Bigby & Bould, 2015; White et al., 2003; Wooderson, Cuskelly & Meyer, 2016). Therefore, managers must have sufficient time to monitor and offer guidance in daily practice (White et al., 2003). Frontline managers furthermore must combine the informal, interactional aspects of their leadership role with the more formal and bureaucratic aspects of an organisational context (Bigby et al., 2015; Deveau & McGill, 2016). In summary, frontline managers should act as buffers and facilitators between support and treatment requirements, managerial demands from the organisation, and the vicissitudes of daily practice.

3.4.2.2. Authentic leadership

31Authentic leadership of higher management and the board is characterised by a passion for providing high-quality services to residents with ID, awareness of values in the field of ID, and transparent and authentic behaviour in accordance with the mission statement (Thompson Brady et al., 2009). Thompson Brady et al. (2009) conceptualise it as a dynamic process between leaders and followers, i.e. leaders inspire others to identify with them and the organisation, link their emotions to those of their followers, support self-determination, and activate positive social exchanges (ibid.).

3.4.2.3. Mission statements

32A strong, authentic organisational mission statement stimulates, shapes and reinforces staff’s behaviour and attitudes, as is the development and consistent implementation of organisational procedures to monitor and direct staff behaviour (Bigby et al., 2012; Bigby et al., 2015; Walker, 2012). Bigby et al. (2015) demonstrated the tension between an orientation programme for new staff focused on values as stated in a mission statement, i.e. positive attitude towards residents with ID, and an introductory programme focused on procedures, i.e. focused on risk management. This orientation programme and risk management are difficult for staff to combine when supporting residents with challenging behaviour and helping them to achieve goals, which sometimes involves risk taking to let residents experiment with new behaviours. A more effective orientation of the organisation (i.e. to achieve increased family involvement) is developed by regular reflection on processes and outcomes in practice within the organisation and with national best practice support services (Walker, 2012).

3.4.2.4. Personnel policy

33Personnel policy consists of clearly formulated requirements and demands with respect to staff’s knowledge and skills, and clear descriptions for staff of the supported population and the resident characteristics of people with ID and challenging behaviour. A clear policy, which is incorporated in structures and processes of group homes, stimulates a positive culture (Bigby et al., 2015; Li, Xueya & Cram, 2011). Staff should be informed about “what to expect” and “what is expected from them” in order to enhance realistic expectations about their job. Personnel policy (i.e. adequate staff support structures, compensation, autonomy) is associated with job satisfaction, which can be predicted by the organisational model and staff members’ characteristics, such as age and educational level (Chou, Kröger & Lee, 2010). A lack of job satisfaction is furthermore linked to the organisational climate, and can complicate team functioning, and prevent staff from identifying residents’ needs while displaying challenging behaviour (Sutton et al., 2016). In contrast, properly functioning teams are associated with greater senses of teamwork, leadership, and personal involvement with residents and the given support (Walker, 2012; White et al., 2003).

3.4.2.5. Power

34White et al. (2003) conceptualise power as a construct that can be out of balance within the hierarchy of a service organisation. This imbalance is reflected in the use of force to control others or to actively promote oneself as an authority figure, even in the absence of the required experience. For example, staff members who feel powerless or less fit for their tasks may resort to the exertion of power over residents with challenging behaviour, who in turn may seek to regain control by abusing fellow residents. Another example is imbalance in the relationship between staff and management, consisting of misunderstanding and inconsistent decision making (Sutton et al., 2016; White et al., 2003).

3.4.2.6. Culture

35Culture is a key factor affecting staff members’ behaviour and residents’ quality of life (Bigby et al., 2012; Felce, Lowe & Jones, 2002; White et al., 2003). Bigby et al. (2012; Bigby et al., 2015) identified five dimensions of group home cultures for residents with ID: (1) alignment of power-holders’ values, (2) regard for residents, (3) perceived purpose, (4) working practices, and (5) orientation to change and innovative ideas. Longevity of sstaff helps to perpetuate the culture, which can lead to the sustainment of a negative culture, but it can also positively buffer the effects of a stressful work environment, as is the case with incidents of challenging behaviour. A more negative organisational culture with oppositional, competitive, and perfectionistic elements is associated negatively with job satisfaction and employee well-being (Bigby et al., 2015; Gillett & Stenfert-Kroese, 2003; White et al., 2003). Poor service conditions and organisational design, and poor placement procedures for residents with challenging behaviour are associated with a declining organisational culture. Such a culture tends to be linked to an authoritarian management style, less focus on residents and more social pressure on staff members to control the behaviours of residents (White et al., 2003).

3.4.2.7. Size and organisational model

36Research shows that the number of years a particular service setting exists, is linked to a larger size of the setting and fewer staff hours per resident. An increased orientation towards residents is, however, related to the greater presence of key workers and better organised working methods (Felce & Perry, 2004). The size of the residential model (e.g. group home with less then 6 residents, small residential home with less then 50 residents, or institution with more then 50 residents) and the organisational status (e.g. statutory, voluntary, or private sector) are linked to job satisfaction (Chou, Kröger & Lee, 2010). In the United Kingdom though, the organisational status showed marginal variation in staffing, internal organisation, and milieu when residents’ abilities were taken into account (Felce, Lowe & Jones, 2002).

37In summary, at the level of organisational aspects, personnel policy and mission statements give direction to staff’s activities and attitudes, while supporting residents with ID and challenging behaviour. Guidance for staff should not only be written down, but also visible in the leadership styles of frontline and higher managers and the CEO. Within the organisational hierarchy, balanced power relations also result in a more appropriate organisational environment. Organisational culture, if positive and not authoritarian, helps staff to support residents according to their needs and to prioritise their work activities. The organisational model seems less of influence on the support of challenging behaviour in residents with ID.

38Macrosystem consists of the all-encompassing patterns of rules, belief systems and attitudes that are shared in the micro-, meso-, and exosystems, and are characteristics of a culture. Most western countries have successfully reduced the number of persons with ID in institutions if not closed residential institutions and state-run long-stay psychiatric hospitals with generally positive outcomes (Bigby, 2006; Surjus & Campos, 2014; Svab & Tomori, 2002). Nonetheless, de-institutionalisation has also led to the fragmentation of service provision to residents with ID, and reduction of the impact of specialised training in ID in some of the countries. This situation complicates access to as well as the quality of support services for residents with challenging behaviour (Felce, Lowe & Jones, 2002; Mansell et al., 2002; Surjus & Campos, 2014).

39The strengthening of individual consumer rights is supported by the United Nations Convention on the Rights of People with Disabilities as well as by certain national disability policies, such as the Americans with Disabilities Act, which is promoting goals such as economic self-sufficiency, equal opportunity, full participation, and independent living (Thompson Brady et al., 2009; Tossebro et al., 2012). Residents with challenging behaviours, however, are significantly more challenged to participate in society and need more intense and facilitation of these supports, which is not an easy task for any national policy. However, if these special needs are not met adequately, it may even increase challenging behaviours in people with ID.

40Different welfare states are restructuring their systems in order to reduce collective commitments to vulnerable populations. They shift from standard to flexible and diverse services, foster a more explicit role of informal care systems, and integrate economic and social criteria for services (Surjus & Campos, 2014; Svab & Tomori, 2002). In the 1990s, most Scandinavian countries made local governments fully responsible for support services for residents with ID, resulting in the development of more generic services under the responsibility of local authorities (Tossebro et al., 2012). Changes in the way disability service organisations are funded, have consequences for organisational resources and the quality of care (Broadhurst & Mansell, 2007; Guerrero et al., 2014; Sutton et al., 2016). The heterogeneity of organisations within countries is reduced by standardisation of organisational solutions by benchmarking, which tends to focus on less expensive services through cost-reduction (Tossebro et al., 2012).

41Drivers of change in policies and disability service organisations consists of media attention (for example, scandals involving extreme challenging behaviours and restrictive or failing supports), specific government actions, the demonstration of local best practices, and the strengthening of the ideology of normalisation (Tossebro et al., 2012). For example, a strategy was formed after public pressure in England, resulting in the development of a National Service Framework with national standards for delivery and monitoring of mental health services for residents with challenging behaviour, in combination with a large investment by the government (Surjus & Campos, 2014; Svab & Tomori, 2002).

42In summary, the macrosystem (i.e. policies, budgeting and belief systems regarding people with ID) exert considerable influences on support service organisations predominately without specific guidelines with respect to residents with challenging behaviour. There is no specific attention found in the literature at the level of the macrosystem regarding people with ID and challenging behaviour.

43The chronosystem reflects the temporality of the ecological systems, such as changes in the manner support services are provided and how residents with ID and challenging behaviour are grouped, based on changing national policies and belief systems. Tossebro et al. (2012) and Svab & Tomori (2002) observed different trends over time in support services for people with ID occurring at different paces in different countries, including inequality across municipalities and resident populations, marketization, new public management, and the (re)emergence of larger group homes. For example, de-institutionalisation in Norway began with the establishment of small group homes (n = 4 by 1990), which evolved into larger groups (n = 7 by 2010) and grew gradually towards clustered settings of approximately 25 residents with ID or challenging behaviour or elderly residents (Tossebro et al., 2012). The rationales behind this development were the cost-saving potential of larger settings, provision of more professional care, staff stability, and reduction of residents’ loneliness. However, research has not confirmed the effectiveness of the rationales of staff stability and reduction of loneliness (ibid.).

44According to ecological theory, the onto-, micro-, meso-, exo- and macrosystems are interrelated. It is concluded that only 7 of the 28 studies included in the review studied more than two ecological systems, focusing mainly on various combinations of the onto-, micro-, and exosystem (Beadle-Brown et al., 2014; Beadle-Brown, Bigby & Bould, 2015; Felce, Lowe & Jones, 2002; Dilworth, Philips & Rose, 2011). Two studies focused primarily on the macrosystem (Mansell et al., 2002; Surjus & Campos, 2014), and one explored the micro-, meso-, and exosystems (White et al., 2003). Organisational environment aspects, such as physical design and organisational structure of settings and services influence different system levels of the ecological model, but they have received less research attention (Hulgin, 2004). From the studies collected in our search, some patterns do emerge. First, positive interactions between staff members and residents are linked to a clear organisational philosophy, the use of a working method that is congruent with staff attitudes and skills, coaching, availability of resources, and managerial leadership. Second, unfavourable factors for staff-residents’ interactions are associated with teams being isolated from the organisation and imbalanced power structures, resulting in diminishing involvement and support from others outside the team, which is essential in support services for people with challenging behaviour. Third, values and attitudes of staff are formed by organisational and national policies and belief systems. Fourth, staff values and attitudes are affected by a proper physical and social environment and by the service structure, which in turn is linked to a positive organisational culture if sufficient staffing is available. It can be concluded that a number of aspects are interrelated, however the relative impact of the different aspects on each other and the directions of the influences are not always clear.

45The present literature review, using a scoping study, identified various forms of relationships between organisational aspects and residents with ID and challenging behaviour. These relationships were analysed using the ecological systems and their interrelatedness of Bronfenbrenner’s theory.

46This literature review demonstrates that ecological theory can be used for analysing relevant information with respect to the role of organisational environments of support services for residents with ID and challenging behaviour. Ecological research on the interaction between challenging behaviour in residents with ID and the organisational environment is scarce. This may be related to the fact that support for people with ID and challenging behaviour is more focused on specific treatment or issues which require specialised clinical knowledge instead of a focus on the organisational setting.

47At the ontosystem level of the ecological model, the level of adaptive behaviour and the presence of challenging behaviour are associated with access to and the quality of support services. For example, sexually inappropriate behaviour may come with challenges for staff and organisational resources, so it is perceived as difficult to manage and puts pressure on the quality of support and hence may lead to denial of access to a particular support service (Broadhurst & Mansell, 2007; Dilworth, Philips & Rose, 2011). At the level of the microsystem, adequate daily interactions between residents and staff members are affected by a complex combination of staff perceptions and beliefs, the philosophy of the service, experience and qualifications of staff, and leadership qualities of the management. For example, if staff is not appropriately coached, they may be insecure of how to cope with residents, resulting in more incidents related to challenging behaviour (Walker, 2012; White et al., 2003). The least researched topic is the mesosystem: the significance of interactions among different microsystems therefore remains unclear. Nonetheless, Bronfenbrenner’s model suggests that positive relationships between the resident’s family (and other persons involved in direct contact with the resident in e.g. a school or work setting) and staff members play a favourable role in creating positive conditions for supporting the resident. Results at the exosystem level of the present review (Section 3.4) show that there are many factors with respect to the understanding of the organisational environment of support services for people with ID and challenging behaviour. This system is highly relevant but also complex for several reasons. First, the organisational environment consists of a wide variety of aspects, and relationships between these aspects are not often studied. Second, the structure and policies of an organisation, such as the power structure and leadership, as well as cultural issues seem important factors to facilitate support for residents with ID and challenging behaviour. However, these aspects are difficult to manage, because they often are formulated in general terms and are difficult to operationalise. At the macrosystem level in which support service organisations are embedded, overarching socio-political values and budget systems can pose efficacy risks for organisations. With regard to the chronosystem, alterations in support services should be evident at all levels. Ontosystem factors such as aging of the person, changes in (mental) health conditions, and treatment effects can be examples of time related factors, which influence the relationship of people with ID and challenging behaviour and their support system. At the microsystem level, staff turnover and team changes are known to be potential risk factors for the quality of support and for staff’s work satisfaction (Buntinx, 2008). At the exo- and macrosystem level, changes in socio-political principles underlying the structure and budget system are temporal factors, which should be considered in the understanding of support effectiveness. However, not all of these factors were recognised in the results of the present literature study or the temporality is indistinct.

48The following organisational aspects, as seen in this study, seem to be of importance in support services for residents with ID and challenging behaviour: committed leadership and management, balance of power in the organisational hierarchy, and a clear, authentic mission statement. For example, staff needs clear directions from the organisation’s mission statement and congruent coaching from managers in order to know how to respond to challenging behaviour. Well-structured teams with clear roles and responsibilities for staff, good communication and coaching from frontline managers and relevant experts are also essential in these support services. This relates to a transparent working environment in which the hectic daily work situation is manageable. Regular team reflection on staffs’ practices, values and attitudes, evaluation and feedback from experts outside the team and organisation, and managerial sensitivity to staff members’ subjective experience of aggression are of importance for maintaining and enhancing the quality of support for residents with ID and challenging behaviour. In addition, successful services are characterised by written personalised intervention programmes and overt coaching and training. Sufficient availability of resources, a positive attitude towards interventions, and commitment of the organisation as a whole to handle problems and strains that are associated with the support or treatment of challenging behaviour are necessary.

49Studies using different methods and populations make comparison and compilation of results difficult. This leads to several inconveniences for drawing conclusions. First, finding a common denominator in varied research results belonging to the same ecological system(s) leads to a more abstract level of conclusions. Second, generalisation of the results and conclusions on the basis of various studies involving residents with ID and challenging behaviour is difficult, because reports in our literature review did not always define the nature of the conditions and behaviours of the subjects, and in any case, characteristics of people with ID and challenging behaviour are highly idiosyncratic. Third, challenging behaviours and their intensity as reported in the studies we found, have not been assessed in comprehensive functional analysis, but rather on the basis of behavioural scales administered by staff.

50The use of a scoping study has also limitations, such as the difficulty to evaluate the quality of the evidence of the primary study in a formal sense, and to weigh the specific aspects of the phenomena under study in the different studies (Arksey & O’Malley, 2005). Furthermore, we did not conduct an exhaustive search in all the journals in the field of ID, only the most recognized journals were used.

51The use of the theory by Bronfenbrenner may also have limited our analyses, and other ecological models may also have been useful with respect to analysing information from studies about people with ID and challenging behaviour. For example, the International Classification of Functioning, Disability and Health (WHO, 2001) or the Disability Creation Process (Fougeyrollas et al., 1998). However, the Bronfenbrenner model is more apt to classify different levels of environmental factors. Furthermore, we used a simplified graphic representation of Bronfenbrenner’s theory as used by INSERM (2016). There are though more graphic representations such as by Absil, Vandoorne & Demarteau (2012) or Neal & Neal (2013) which may also be useful to understand the complexity of the ecological system and in future research.

52Use of an ecological approach helps to shift focus of attention in challenging behaviour from the person as the locus of the problem to the lack of fit between the person and their (organisational) environment. Understanding the complex and reciprocal interactions that occur in and between elements of the different ecological layers may contribute to identify and solve problems, which are rather of an organisational nature than a clinical or health related nature in order to achieve positive outcomes for residents with ID and challenging behaviour. The influences of the organisation on the quality of care and on challenging behaviour in residents with ID are evident though complex and not easily unravelled. Shogren (2013) concluded that studies into contextual factors related to (the support of people with) ID are important, but the generalisation of evidence is difficult, because contextual factors are independent and intervening aspects, and contexts differ from one another and over time. Even though studies with an ecological perspective are complex, the prevalence of challenging behaviour in residents with ID and the quality and effectiveness of the services provided for this population deserve systematic study from the ecological perspective.