Positive Approaches Journal, Volume 14, Issue 1

Volume 14 ► Issue 1 ► June 2025

Positive Interactions Checklist to Evaluate Staff and Client Interactions

Alanna Morrissey, MA, BCBA, LBA, Kasey E. Bedard, Ph.D., BCBA-D, Mary Strittman, Ph.D., BCBA-D, and Tyler Re, Ph.D., BCBA-D

Applied Behavior Analysis Department, The Chicago School of Professional Psychology

Human connection is often acknowledged as an important part of maintaining a high quality of life.¹ Part of this human connection is fostered through caring, and positive interactions with family members, peers, and colleagues; however, people with developmental disabilities may have less access to meaningful relationships due to a variety of factors and barriers.² These barriers do not make relationships any less important and may mean that the importance of interactions with therapists and professional caregivers becomes a potential source to fill some of these relationship gaps.³

The relationship between a professional caregiver or therapist and the person receiving care may therefore have an important impact on the quality of support and life of people with intellectual and developmental disabilities.⁴ It is important for health care professionals to foster positive human connections, because they may often represent a large degree of the social support that their patients receive.¹ People with disabilities often rely on help from their professional caregivers to assist them with their everyday tasks, including self-care skills, coping with challenging situations, communicating, and social interactions.⁴ The degree of support that a person requires, as well as additional challenges such as behaviors of concern, may impact the frequency and quality of interaction with those providing support and care for a person. Therefore, putting a focus on positive interactions is warranted.⁴

The medical and nursing fields were some of the earliest to put an emphasis on the interactions and quality of care provided by nurses to their patients.⁵ Efforts are ongoing within the health care system to enhance care quality and bring a more humanized approach to medical care; however, these efforts may inadvertently impact patient autonomy.⁵ While research indicates that a strong nurse-patient relationship can shorten hospital stays and increase satisfaction with care, nurses report preferring passive or submissive patients, which may be indicative of a reduction in autonomy.⁵ Despite this concern, inadequate nurse-patient relationships tend to compromise both the quality of care and autonomy, meaning that further investigation is needed to identify the best way to support both quality interactions and autonomy.⁵

Considerations of autonomy and quality of interactions are equally important within the community of therapists and professional care staff working with clients who have intellectual or developmental disabilities. Meaningful interactions have been defined as any type of interaction that is viewed as important or pleasing to clients or includes some type of functional or supportive action.⁶ Positive staff to client interactions are imperative because not only do they reduce the likelihood that behaviors of concern will occur,⁷ but they also allow staff valuable opportunities to get to know the specific needs of each client and enable them to respond in a person-centered and individualized way to those needs.⁸ Social support has also been proposed to influence a person’s degree of functioning, health perceptions, and overall quality of life.⁹ Clients with disabilities who are treated with dignity and respect show improvements in well-being, making social interactions an imperative component of care.¹⁰

Simons et al. conducted a study to evaluate existing research on factors influencing the development of meaningful staff-client relationships. Findings indicated that negative attitudes or interactions from staff resulted in an increase in challenging behavior from clients.⁴ In a separate study, Vanono et al. examined the outcomes of staff participation in a workshop that focused on positive interactions. The researchers looked at the changes in the frequency of positive interactions between the staff and clients from baseline to after they completed the workshop. They used both the scores from the positive interaction checklist and the positive interaction checklist interview.¹¹ The results showed a small improvement in the positive interactions between staff and clients post-intervention.¹¹ The study also showed that the staff members all increased their knowledge and awareness of positive interactions and that their skills were maintained at a two month follow up.¹¹ Although this study did include a few questions to solicit the client perspective, the researchers noted a limitation, due to only providing clients with yes or no questions, thereby limiting the amount of information collected in this domain.¹¹ Screening measures that provided a broader opportunity for individuals receiving care to express their perspectives are needed.

Positive Interactions Rating Scale Development

The Positive Interaction Rating Scale (PIRS) was initially developed based on aspects of staff social interactions identified as important in existing literature, followed by expert and practitioner review in a series of nominal focus groups.^{4 11} The domains selected as relevant based on the literature are as follows: support, verbal communication, and behavior. Each of those domains includes subdomains that break down both supportive and unsupportive staff qualities further. Additionally, PIRS includes interviews across all domains from both the supervisor and client perspectives. While a further examination of reliability and validity is needed, the PIRS presents a preliminary means of evaluating positive interactions to identify where further staff training may be needed.

Initial Evaluation and Validation of Content

Several peer-review measures were used to solicit expert opinions on the PIRS, including a series of focus groups and a final review to reach consensus on revisions using the Delphi Method. A nominal group technique is a structured small group discussion with experts on a specific topic used to reach a consensus on an idea.¹² During the group, the participants respond to questions provided by the moderator and give feedback on what has been presented to them during the meeting. Participants were asked to prioritize checklist components in order of most to least important. Additionally, they were asked to note any components they felt were redundant or unnecessary and to make recommendations on any components or domains they felt had been overlooked. Following ranking and discussion, participants voted to allow for a quantitative representation of proposed priorities and changes.

The experts included in the nominal group technique for the PIRS were experts in Applied Behavior Analysis (ABA), Organizational Behavior Management (OBM), supervision, and training. Before the meeting, the moderator emailed the participants the PIRS checklist to allow time to review the domains, subdomains, and questions. The focus groups began with a PowerPoint presentation providing an overview of the nominal group technique process and the PIRS. Participants were then provided with four questions: What domains are most important?;, aAre any domains missed; sShould any domains or subdomains be excluded?; and Is there anything else you would recommend adding or removing from the checklist? Once all four questions were answered, participants were allowed to discuss the responses and then asked to rank the responses in order of importance. The moderator collected the ranked responses and revised the checklist accordingly.

Following development and initial review during the focus group process, the Delphi Method was used to conduct a series of program reviews by a group of experts that included Board Certified Behavior Analysts (BCBA), who were also experts in OBM, ABA, supervision, and staff training. Revisions from these experts were included in the final draft of the program. Three rounds of revisions were made based on expert feedback until all three experts were satisfied with the checklist.

Domains of the PIRS

As mentioned, the domains included in the PIRS are support, verbal communication, and behavior. Questions are included across domains to evaluate supportive and unsupportive qualities of care exhibited by staff members. The initial rating scale is meant to observe staff members interacting with clients; however, this rating scale is followed by a second scale evaluating client perceptions across the same domains.

Supportive Qualities

Support

Meaningful interactions reflect a balance between client’s needs and caregiver’s support.¹³ Clients with developmental disabilities require support to complete everyday tasks, to help with communication, challenging behavior, and coping.¹⁰ Supportive qualities included in the PIRS were as follows: Presentness/proximity, training/assistance, choice/self-advocacy.

Presentness/Proximity. This domain aims to capture the extent to which a staff member remains present and maintains proximity to a person when appropriate, while respecting personal space. This is important as it ensures that clients feel they have access to a person if they need assistance.¹⁴ Staff engagement can also support the development of meaningful relationships for people who may have fewer than average opportunities to form these relationships.

Training/Assistance. Staff members also demonstrate support by using teaching methods appropriate for the learner’s support needs with encouragement, while a person develops the skills to complete tasks confidently and independently.¹⁵ Professional caregivers and therapists often take a significant role in supporting the development of new skills for those they care for.¹⁶ Providing too much or too little prompting during a teaching procedure can cause frustration, prompt dependence, or failure to acquire the skill.¹⁷ Providing an appropriate level of prompting is important to support independence, and both prompting and encouragement play a role in ensuring the teaching process is not stressful or aversive.¹⁷

Choice /Self-advocacy. Empowering clients through choice and advocating for self-determination are pivotal in fostering independence while maintaining health and safety.¹⁸ When clients are involved in the decision-making process, it not only promotes autonomy, but also contributes to a sense of agency and self-esteem. Providing opportunities for choices can be integrated into daily routines, including a variety of decisions, such as selecting outings and leisure activities, providing input on meal planning, identifying preferred forms of positive reinforcement, and setting personal goals. By creating a supportive environment where clients are encouraged to express their preferences and feel respected in doing so, staff can enhance the overall quality of life of those they support.

 

 

Verbal Communication

Communication is a dynamic process that includes interacting and engaging with others.¹⁹ Verbal communication includes vocally expressed words, the accompanying sounds, and the tone of voice used to convey meaning. Communication skills are critical in many aspects of life, influencing interpersonal relationships and giving context to the intent of spoken words. Supportive communication is often characterized by attributes such as enthusiasm, verbal warmth, and humor. ^{22 28 20 3 22}

Verbal Warmth. Verbal warmth is demonstrated when a staff member uses kind, positive, or encouraging words to address their clients.²⁰ Studies indicate that positive verbal interactions are correlated with enhanced well-being and life satisfaction among clients. ²¹

Humor. Humor can be understood as communicative behavior that results in laughter. ²² Humor in interactions between health care providers and clients is a valuable and often underutilized resource.²³ Humorous interaction has been shown to have a positive impact on both health care providers and their clients and can help reduce anxiety, depression, and embarrassment.²³

Behavior

Interpersonal staff behavior is one of the most influential factors associated with challenging behaviors in clients with disabilities. ²⁴ Key behaviors from staff that can shape client development include non-verbal warmth, cultural sensitivity, patience, flexibility, trust-building, respecting client privacy, and positive behavior management. Conversely, staff behaviors can be counterproductive and sometimes evoke or encourage challenging behaviors. ²⁴ Improving the quality of the social interactions between staff and clients can substantially improve clients’ life experiences. ¹¹

Non-verbal Warmth. Expressions of non-verbal warmth such as appropriate physical touch, smiles, and positive body language are a useful means of demonstrating support and care, especially for clients with communication difficulties. Gestures such as high-fives and touches on the shoulder, silly facial expressions, and smiles, contribute to a positive atmosphere.²⁰ Body-language cues that indicate attentiveness to a client include facing the client, making eye contact, and active listening. ²⁵

Cultural Sensitivity. When a staff member is sensitive to cultural differences, it demonstrates respect for different backgrounds, traditions, norms, beliefs, and values that may be important to the people they support. When staff demonstrate understanding and acceptance of various perspectives, it fosters stronger, more equitable relationships.²⁶ Observing cultural sensitivity ensures that all clients are treated equitably, regardless of their background or diagnosis.

Patience and Flexibility. People with intellectual and developmental disabilities may exhibit a variety of communication, learning, behavioral, and physical challenges²⁷ that necessitate tailored support, and result in the need for assistance completing tasks of daily living. It is often helpful for professional caretakers to embody patience, as demonstrated by providing extra time and accommodations in response to client challenges without displaying frustration.²⁸ Additionally, flexibility in caregiver approaches allows for adjustments tailored to an individual client's needs. Caregivers open to trying new approaches if current procedures are not working or are causing distress, can help reduce the likelihood that daily tasks become stressful or aversive.²⁹

Trust and Providing Privacy. Trust is an important aspect of any interpersonal relationship, and the staff to client relationship is no different. Reliability and consistency across interactions can help build a trusting relationship between professional caregivers and their clients.³⁰ Trust extends to ensuring privacy, with Health Insurance Portability and Accountability Act (HIPAA) laws guiding the protection of personal information. ³¹ In addition to the privacy of personal information, people receiving care also benefit from personal privacy. This can include providing a person with personal space when safety is not at risk, especially when a person is using the bathroom, bathing, changing, or when a client requests to be alone.³²

Positive Behavior Management. Positive behavior management involves using reinforcement strategies to support clients in developing adaptive and functional skills.³³ Core principles of this approach include upholding client respect, providing social validation, maintaining dignity, embracing person-centered planning, and fostering self-determination.³³ These principles align with the Behavioral Analysis Certification Board (BACB) ethical code, which emphasizes reinforcement, and encourages consistency in maintaining the least restrictive environment possible. Using positive behavior management strategies can reduce the likelihood of aversive control, improving quality of life.³³

Unsupportive Qualities

Support

The current body of literature indicates that not all staff qualities and behaviors support positive outcomes. Detrimental staff behaviors can include impeding independence by providing unnecessary or unwelcome support or being neglectful or non-responsive to clients.^{34 35 36 37 38}

Preventing Independence. Genuine support involves enabling clients to do as much as they can independently, thus promoting autonomy and reducing overbearing supervision.³⁴ Professional care providers should support the development of adaptive skills that promote self-sufficiency, rather than completing tasks on behalf of clients without providing guidance or training.³⁵ Additionally, ignoring a person’s attempts to self-advocate denies them their right to autonomy. It is widely accepted that every person has the right to make informed decisions about their health care, and health care professionals should not impose their own beliefs or decisions upon their patients.³⁶ Although some issues may arise based on the client’s capacity to make decisions on serious matters, efforts should be made to provide opportunities for informed choices whenever safe and healthy.

Neglect. Neglectful behavior includes failing to engage with clients either verbally or non-verbally, particularly when doing so includes failing to address immediate needs.^{39 37} Neglect can involve being non-responsive to a person’s requests or questions and ignoring the person.³⁹ Trained professional care providers should be able to recognize the difference between neglectful behavior and recognizing a client’s need for solitude or privacy, and to find the balance between respecting personal time and meeting care needs.

Verbal Communication

Effective and respectful communication by staff is central to maintaining a positive and supportive environment. The use of disrespectful language undermines client dignity and should be avoided.^{40 29}

Disrespectful Language. Using disrespectful language can include behaviors like being rude or discourteous by using offensive or dismissive language to address a person. It can also include using language that trivializes a person’s concerns or reduces their identity to their diagnosis. These types of interactions often belittle and “bother” clients, rather than bolstering their self-worth. Well-intended discussions, such as discussing a client’s behavior with a supervisor, may also be perceived as disrespectful by the person being discussed, so it is imperative to maintain privacy and respect in such conversations.⁴¹

Behavior

Unsupportive behavioral qualities in staff members can negatively impact client well-being. Such behaviors include using coercive control, being non-inclusive, and acting disrespectfully towards clients and their privacy.^{42 43 44}

Coercive Control. Coercive control includes any verbal or non-verbal behavior that uses punishment, threats of punishment, humiliation, intimidation, or other forms of verbal or physical abuse, used to control a person’s behavior.⁴³ Given the degree of harm that can occur because of coercive control, this type of behavior should be avoided at all costs.

Non-inclusive. Being non-inclusive may involve unnecessarily denying clients access to events or activities. This excludes instances where the activity may endanger the client’s health and safety, and there is no reasonable accommodation.⁴⁴ Staff should actively work to include clients and provide them with a choice of reasonable and appropriate activities, and make accommodations as needed to facilitate client involvement.

Disrespectful. Disrespectful behavior may include avoiding eye contact during interactions and conversations or making negative facial expressions, such as eye-rolling or frowning at a client.⁴² When a staff member disrespects their client’s privacy, they are crossing a person’s boundaries and violating their trust. Disrespectful comments can also negatively affect a client’s mental health and model negative behaviors that clients may imitate.

 

Clients’ Behavior

There are often many challenging aspects to working with clients within the intellectual and/or developmental disability (IDD) population. One such challenge includes behaviors of concern exhibited by the client.⁴ Clients’ challenging behaviors can impact staff morale, leading to decreased social interaction and quality of care.⁴ Client behavior may also contribute to high rates of staff turnover and burnout. An increase in staff turnover rates may have a negative effect on clients with Autism Spectrum Disorder .⁴⁵ Research has linked staff turnover rates to job satisfaction and training adequacy, suggesting that improved training may help improve staff retention. Additionally, research indicates that staff burnout is often correlated with attitudes toward clients with disabilities, pointing to a need for better training on potential challenges.⁴⁶

For clients with IDD experiencing developmental delays, communication barriers can hinder social engagement and negatively affect quality of life.⁴⁷ Diverse communication methods such as sign language, picture exchange cards, and augmentative and alternative communication devices, in addition to limited language, can make it difficult to have meaningful conversations. Studies have shown that better training and improved environmental support are needed to continue to enhance relationships for people with IDD.⁴⁸

Discussion

The domains support, communication, and behavior were chosen as the basis of the PIRS because of the important role they play in social interactions.^{25 11}  Providing positive support can lead to healthier relationships between staff and clients. Whether staff members engage in supportive or unsupportive communication also impacts the responses and mood of their clients.³⁶ Staff behavior has been shown to be one of the most influential factors resulting in success or failure when working with clients with IDD.⁴⁹ The PIRS subdomains and questions are designed to help capture and measure the quality of care provided by staff members and indicate areas where a staff member may need more training. Since the PIRS provides both the supervisor's and clients' perspectives on staff members’ supportive and unsupportive qualities, the checklist offers a diverse perspective and ensures that all relevant stakeholders can provide input to the greatest degree possible.

Previous research has shown the importance of having positive staff and client interactions for both the quality of life for clients and the job satisfaction for staff members.^{9 13 50} The relationship between a professional caregiver or therapist and the person receiving care may, therefore, have an important impact on the quality of support and life of people with intellectual and developmental disabilities.⁵¹ Positive staff engagement, providing choices, positive verbal interactions, patience, and flexibility are just some of the supportive qualities found in other studies that, when used in interactions with clients with IDD, have shown improvements. ^{28 51 14 18} Staff members play a role in providing those they support with a more meaningful life, and daily interactions can have a significant impact on health and well-being. The PIRS, while preliminary, presents a means of assessing professional caregiver to client behavior and relationships, and is unique in that it includes client perspectives and input.

Future Research

While this checklist has undergone extensive evaluation by experts in the field, much additional work is needed to evaluate the reliability and validity of the checklist. An evaluation of the PIRS during real-world applications would contribute to evaluating the feasibility and perceptions of professional caregivers, clients with IDD, and supervisors. The checklist would also benefit from ensuring that checklist responses remain consistent over time, and that independent raters demonstrate consistency when evaluating instances of staff behavior. Assessing the validity and reliability of the tool will help ensure the integrity, quality, and overall usefulness of the tool as an assessment measure capable of informing potential interventions.³

Author Note

We have no known conflicts of interest to disclose.

Correspondence regarding this article should be sent to Alanna Morrissey, The Chicago School, 325 N Wells St, Chicago, IL, 60456.

Email: alanna@asfnj.com

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Biographies

Alanna Morrissey is Clinical Director and Partner of an ABA company in New Jersey; A Smiley Face NJ. She is a Board-Certified Behavior Analyst and received her PhD in ABA at The Chicago School in 2024. When she isn’t working in the field you can find her working out or spending time with her dogs.

 

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