Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: a realist review.

Background: There is some evidence to support approaches to reduce restrictive practices in settings for people with a learning disability who may also have a diagnosis of autism or mental health problems. However, there is a significant knowledge gap in how and why such approaches work and in what contexts.

Aim: This study aimed to understand how, why, for whom, and under what circumstances approaches used by healthcare staff to prevent and reduce the use of restrictive practices on adults with learning disability or autism work (or do not work).

Design: The review followed a realist approach. This approach was chosen to understand the mechanisms by which approaches to prevent and reduce the use of restrictive practices work. The review adhered to current Realist and Meta Narrative Evidence Syntheses: Evolving Standards quality and publication standards.

Data sources: Applied Social Sciences Index and Abstracts (ProQuest), Cumulative Index to Nursing and Allied Health Literature (EBSCO), MEDLINE (Ovid), PsycInfo (Ovid), EMBASE (Ovid) and Web of Science Core Collection and stakeholder consultations.

Review methods: Four main steps were followed: (1) locating existing theories, (2) searching for evidence, (3) extracting and organising data and (4) synthesising the evidence and drawing conclusions. In Steps 1 and 4, the views of stakeholders (academics, key experts, practitioners, people with lived experiences, carers) supplemented systematic searches in electronic databases, supporting the interpretation of results and making recommendations.

Results: A total of 53 articles were included, after screening 14,383 articles. In line with realist methods, eight context– mechanism–outcome configurations and an overarching programme theory were used to explain the why and how of preventing and reducing the use of restrictive practices for people with a learning disability. Restrictive practices commonly occur when people with a learning disability, who display behaviour that can harm or who experience communication difficulties, are detained in environments that are unsuitable for their needs, including mental health hospitals. Furthermore, they happen when staff are inadequately trained, lack person-centred values, struggle to regulate their emotions and display limited communication skills. Restrictive practices happen where there is a lack of adequate staffing, a negative organisational culture, and where they are accepted as the ‘norm’. Drawing on these findings, we set out recommendations to include positive risk-taking, greater involvement for families and carers, and targeted training for staff. Organisations need to recognise overuse of restrictive practices and using coproduction and leadership within the organisation to implement change.

Limitations: Many of the papers reviewed were not directly related to people with learning disability, therefore there is a clear need for greater research in this area. Primary research from focus groups has been used to highlight issues and compliment the limited evidence base. While it is recognised that commissioning individualised community approaches is a possible way to reduce the use of restrictive practices, this was beyond the scope of this review.

Conclusions: This review shows that solutions for reducing restrictive practices exist, but that targeted frameworks are lacking and resources to support the implementation of evidence-based strategies in this population and related settings are compromised. More research is needed on how approaches shown to be effective in other settings such as mental health could be tailored for people with learning disability. Furthermore, more research regarding carers’ roles is warranted.

Study registration: This study is registered as PROSPERO CRD42019158432.

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129524) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 14. See the NIHR Funding and Awards website for further award information.