Findings - Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: a realist review - NCBI Bookshelf An official website of the United States government Here's how you know The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Log in Show account info Close Account Logged in as: username Dashboard Publications Account settings Log out Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation Bookshelf Search database Books All Databases Assembly Biocollections BioProject BioSample Books ClinVar Conserved Domains dbVar Gene Genome GEO DataSets GEO Profiles GTR Identical Protein Groups MedGen MeSH NLM Catalog Nucleotide OMIM PMC Protein Protein Clusters Protein Family Models PubChem BioAssay PubChem Compound PubChem Substance PubMed SNP SRA Structure Taxonomy ToolKit ToolKitAll ToolKitBookgh Search term Search Browse Titles Advanced Help Disclaimer NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. Duxbury J, Haines-Delmont A, Baker J, et al. Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: a realist review. Southampton (UK): National Institute for Health and Care Research; 2025 May. (Health and Social Care Delivery Research, No. 13.14.) Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: a realist review. Show details Health and Social Care Delivery Research, No. 13.14. Duxbury J, Haines-Delmont A, Baker J, et al. Southampton (UK): National Institute for Health and Care Research ; 2025 May. Contents Search term < Prev Next > Chapter 5 Findings This realist review incorporates both primary and secondary data, moving beyond peer-reviewed literature to include views and experiences of key players in this field of work, to unpick the why and how of preventing and reducing the use of RP for people with a LD who may also have a diagnosis of autism or mental health problems. It is recognised across the board that restrictive interventions are no longer acceptable ‘de facto’ practices. This is closely linked to our own positioning and implicitly the context for this review which is threefold. Firstly, RP happen in the context of people with LDs who may display behaviour that can harm or communication difficulties who are often detained in settings/environments which are unsuitable for their needs, especially mental health hospitals. Secondly, they happen in the context where staff are inadequately trained, or do not have the right values/emotional regulation/communication skills or are stressed/burnout. Thirdly, RP happen in the context of a lack of positive organisational culture, where they are used and accepted as the ‘norm’. The context for this review (and our key emerging theories) is, after all, the reality for the people involved, that is people with a LD or autism, or staff. It is the environment/backdrop of the interventions/programmes being used. In this chapter, we present the findings from the analysis and synthesis of the literature reviewed. The chapter is structured around findings regarding the three key levels/stakeholder groups/actors which were identified in Step 1. Here we provide a narrative of findings, followed by a realist analysis containing one or more CMOCs. Illustrative data (i.e. extracts from manuscripts) to support our interpretations in each of the CMOCs. Some of these data derive from quotations presented in relevant articles, other data come from focus groups. The main searches resulted in identifying a range of theories and models to give a rationale explaining why CMOCs work (substantive theories). These substantive theories have been used to support configurations, to substantiate inferences about mechanisms, to validate interpretations of the literature and/or to contribute to the development of programme theory. Our review has highlighted how complex factors at human and organisational level influence the use and perpetuation of damaging RP. This relates to a number of theoretical frameworks, a selection of which are outlined including the SDT and the patient-centred care models (the person): the ECOM: self-efficacy theory, the cognitive appraisal model (staff): and the Six Core Strategies, the positive and proactive care framework, the HIC model and self-leadership (organisation; see Figure 3 ). FIGURE 3 Key targeted theories and models underpinning the three theory areas/stakeholder groups. As noted by others, the use of RP does not occur in isolation but conveys attention to group membership, decision-making and accountability and organisational structures. This realist review moves beyond identifying barriers of and facilitators to minimising RP to reach an explanation of how and why staff engage with such practices differently under different circumstances. There are three parts of this chapter Findings : the first ( Stakeholder Group 1: people with lived experience ) focuses primarily on family members, carers and persons with LD and autism themselves; the second ( Stakeholder Group 2: staff ) presents data from the literature relating to staff with a focus on workforce development and debriefing; while the third ( Stakeholder Group 3: the organisation ) covers organisational influences. In each of these parts, the following sequence is used: First, we provide a narrative of findings based on our analysis of the data found within the literature. This is then followed by a detailed realist analysis that contains one or more CMOCs. Illustrative data (i.e. extracts from manuscripts) that we have used to make our interpretations and inferences for each of the CMOCs are also provided in each of the subsections. For some CMOCs there is a larger number of supporting quotations from the literature included in the review, while other CMOCs are supported by a smaller set of data. This would provide some indication of the strength with which arguments can be made out of the data included here, but quantity would not be the only consideration. The level of detail and depth within each of the quotations and the confidence with which we can draw inferences from the data also plays a role. Some articles presented a wealth of data (possibly because of reporting flexibility in some journals), whereas others were constrained in the data they could present, therefore limiting the number of data we had available to us. However, this does not mean that arguments cannot be made with adequate strength for CMOCs supported by a smaller set of data, especially when substantiated by relevant theory. Relevant substantive theories have therefore been integrated throughout. Refined CMOCs after synthesising data are presented in this section. Each area of interest/stakeholder group section begins with a description of the rationale behind CMOCs (substantive theories). After theories, CMOCs are presented followed by relevant extracts from papers included in the review and primary data quotes. CMOCs are then grouped at the end of each section into partial programme theories. The first set of CMOCs fall within the remit of those with lived experience. Stakeholder group 1: people with lived experience (people with learning disabilities and families/carers) People with lived experience are central to the explanation of theories and findings within this review and crucially the importance of personalised care and communication (CMOCs 1 and 2). When exploring this first CMOC, the use and value of care plans are highlighted. SDT 87 is one of the key theories supporting an explanation of why it is important to give more autonomy to people with LD over their own care and to be encouraged and allowed to regulate their own behaviour. Relatedness to staff is also an important element here that could lead to positive outcomes, as people will get motivated to change their behaviour in a positive relationship with staff. The importance of SDT in the lives of people with LD is specifically explored by Di Maggio et al . 88 Context–mechanism–outcome configuration 1: individualised care plans The first CMOC highlights the importance of person-centred planning. If individualised care needs are identified within co-created PBS plans (C) that match a person’s care and communication needs (identified by a functional assessment) (M), then this can result in the use of person-centred interventions (M). To achieve this people with LD and their families/carers need to be accepted and valued as part of the care team (M). This results in the facilitation of positive lifestyle adaptations, better functionality and a reduction in perceived behaviour that can challenge (O) which in turn could lead to a reduction in RP (O). This CMOC concentrates on the significance of individualised care. The importance of plans is highlighted in many papers included in this review, for example: Alongside planned Active Support strategies, Positive Behaviour Support includes proactive strategies intended to ensure that the person is consistently having their needs understood and met, so that there is less of a need for them to behave in ways that might be seen as challenging. 78 This allows for … lifestyle change and improved quality of life through multi-component treatment plans while decreasing the frequency of challenging behaviour. 74 An integral mechanism to achieve positive outcomes is seen as the inclusion of appropriate personalised care interventions: Treatment interventions lead to lasting change in a patient: a new understanding, increased coping skills or enhanced ability to manage the illness. 89 Examples are: teaching and reinforcing coping skills, identifying warning signs and symptoms and problem solving around relapse prevention. 89 , 61 One example of how this impacted positively on a person is reported here. His behaviour support plan included activity sampling, picture sequencing to improve the predictability of daily events, reduction of unnecessary speech, and offering him requests using a visual two-way choice format. 74 Through the reduction of behaviour that can challenge, it is also possible to reduce RP: Positive behavioural support plans that take a biopsychopharmacosocial approach have been shown to reduce incidents of challenging behaviour. 70 Families being accepted and valued as part of the care team, however, rarely occurs, as emphasised in our focus groups with family members: There’s this perception that the professionals are the experts and we somehow don’t know what we’re talking about and the person even less so. Actually, that couldn’t be further from the truth. It can only ever be therapeutic if it’s a partnership and if that power balance is stabilised and equalised a little bit. Obviously carers, loved ones, family, can help tremendously. We’re there not for money Stakeholder focus group 1, participant 6, mother Context–mechanism–outcome configuration 2: communication In this second CMOC, we can see how authentic communication both underpins and builds upon person-centred planning. When staff communicate with persons with LD in a way that fosters a sense of autonomy to manage their own emotional state (C), by taking account of communication challenges, and with less authoritarian or confrontative interactions (M), then staff will have greater tolerance for behaviours that can harm (or be perceived as ‘challenging’) (M). This helps to create a trusting relationship (M), where restrictive interventions would not be used in the interest of the organisation, or perceived as punishment (O), conflict would decrease (O), and there would be less incidents requiring the use of approaches such as restraint and seclusion (O). This second CMOC focuses on how staff in care settings communicate with people with LD communication problems, together with unmet needs, have been seen as a major reason behind conflict and resulting behaviour that challenges: Challenging behaviour is often the result of unmet needs or a communication problem, and not necessarily a direct result of a patient’s clinical condition. 70 It is key to recognise a challenging behaviour as a form of communication. Service users will feel anger and distress in certain situations, as a natural response. Therefore, it is important to understand the activating event and whether physical intervention is the best method of de-escalation in any given situation. 79 An unmet need compounded with communication limitations expressed as challenging behaviour has also been highlighted in our focus group with family members: She was definitely fight and flight. She wasn’t able to verbalise. She became so traumatised that she was shouting, flapping her hands everywhere, stimming, throwing things. They deemed it as aggressive behaviour. All it was, was communication. They had taken away her scaffolding which she uses to survive really and blaming her for them removing her scaffolding. Stakeholder focus group 2, participant 2, mother Enhancing communication with a person with LD has been a successful strategy to deal with and decrease the use of restrictions in care, as described by support staff in one study: Start a dialogue with the client … Not confront the client … Knowledge of client is helpful in the process of caring. 80 Participants identified a lack of communication between both parties as the cause of incidents requiring restraint. They suggested that increased communication with staff would improve this situation. 90 A literature review about factors that influence nurses’ decisions about secluding people with LDs found that persons that were ‘hardly approachable’ were secluded more frequently and highlighted: This variable clearly suggests an emphasis on the importance of communication in preventing seclusion… 72 The interface between contexts, mechanisms and outcomes involving people with lived experience is illustrated in Figure 4 . This is our first partial programme theory that combines CMOC1 and CMOC2. FIGURE 4 The interface between contexts, mechanisms and outcomes involving people with lived experience that contribute to our first partial programme theory (CMOCs 1–2). Our second group of CMOCs relates to matters influencing staff behaviour including staff stress, training and reflection. Stakeholder Group 2: staff The role of staff in the minimisation of and indeed the reliance upon the use of RP cannot be underestimated. A number of factors are influential including stress, workforce development and reflective practice. The importance of workforce development and practices such as debriefing to reduce RP can be in part explained by self-efficacy theory. 91 Self-efficacy is about one’s beliefs over their own capacity. It is a foundation for one’s motivation, well-being and personal accomplishment. Donat 67 explained the connection between occupational stress, knowledge and competence using self-efficacy theory suggesting that individuals who believe that they can achieve desired outcomes when faced with challenges experience lower levels of fear, frustration, and discouragement when attempting to address those challenges. Individuals with higher levels of behavioural knowledge and competence will be more effective in their attempts to modify behaviour. They will also be more accurate in judging their capability. Furthermore, they can more effectively recognise when assistance is needed or when expectations need to be modified, a key feature of de-escalation. Thus, they can successfully do more and are more aware of their limitations. This promotes a more effective work environment and lower occupation-related stress. We can then assume that by improving knowledge and skills and increasing a sense of self-efficacy staff will believe in their own capabilities. This will also give them opportunities for reflexive activities such as debriefing, and a positive impact on reducing the use of restrictions will be accomplished. Self-determination theory may also have a key role in staff performance. Self-efficacy is a result of good education and training, while SDT could explain how it works. It is not just that they are competent, but that they have the autonomy to do things differently in their work. This happens in interaction with peers and persons with lived experience. Context–mechanism–outcome configuration 3: stress-reduction efforts to mitigate staff burnout This third CMOC has to do with staff stress and how this needs to be addressed to reduce the use of RP. If staff work in environments where stress and burnout are highly prevalent, due to factors such as staff shortages, exposure to trauma, and the need to restrain people with LD (C), adopting well-being interventions such as mindfulness (M) can facilitate lower levels of stress and burnout (O). Staff are then more likely to display factors associated with therapeutic communication such as kindness, empathy, and positive interaction with people with LD (O), and so feel more motivated to work (O). Proactive supportive practices have been shown to reduce patient–staff conflict (O), minimise RP (O) and improve standards of care and personal levels of satisfaction (O). The Emotional Cognitive Overload Model is used to help us understand how individuals become overloaded when they are not able to cognitively process the inputs that they receive. ECOM is defined as the negative emotional and cognitive manifestations resulting from the inability to adequately process pertinent input and handle the associated mental load. This can then result in further stress, impact upon behaviour and burnout. It has been reported in the literature that staff may have stress and burnout in care environments. Goulding and Riordan 69 reported that nurses who worked in a secure setting for women with LD as an example experience frustration, because they lack formalised support and appreciation: The theme of risk of stress and burnout was also attributed to responses stating that staff did not always feel adequately acknowledged or appreciated for their contribution within the service and that working with the women was very challenging and that working within a female service could be quite isolating. 69 The importance of staff well-being and the repercussions it can have for the care they provide was also reflected in our focus groups with carers: The management don’t talk to the staff and they don’t treat the staff pretty good. So if they’re not going to treat the staff very good, how is it going to make the staff feel towards the clients? Stakeholder focus group 4, participant 1, mother Supporting staff well-being is important for many reasons but may be directly related to the reduction of RP in care: Staff burnout, low morale and stress may lead to an increase in patient-staff violence and restrictive practices. 72 Negative evaluations of staff mood included references to staff being bad-tempered and short-tempered. Two participants made reference to staff being ‘ratty’: ‘If you ask them, can you do this, like a trip out, they can be ratty. Say oh you’ll have to wait, I’ll sort it out the next day’ P2. 64 A number of interventions are proposed in the literature to address stress and burnout. It is suggested that they could have other positive outcomes too, contributing to a better quality of care: …interventions are based on mindfulness practice, which is linked to increased levels of self-awareness and compassion. 58 Mindfulness-Based Positive Behavior Support (MBPBS) was more effective than treatment as usual in enabling caregivers to manage their stress, and reduce the use of physical restraint and medications for aggressive individuals in their care. There were reductions in aggression, the need for 1:1 staffing, and staff turnover. 28 Singh et al . 2016 Context–mechanism–outcome configuration 4: staff training Our fourth CMOC is related to the importance of workforce development in the reduction of RP. If all staff teams are trained using methods that have been shown to reduce RP including those that prioritise therapeutic communication skills and the needs of people with LD (C) involving those with lived experience to share their stories and highlight the impact of trauma (M), then staff are more likely to provide person-centred, non-coercive and trauma-informed care (M). They are then more likely to use their learning (M), to adopt alternatives to RP (M), which would decrease the use of such practices (O). There is a lack of education around dealing with violence and aggression: when asked whether respondents had the opportunity to access further educational courses for support to deal with violence and aggression at work, only four out of 23 respondents ticked this box. 69 Goulding and Riordan 2016 We found that several of the hospitals we visited did not employ staff with the necessary skills to work with people with autism who also have complex needs and challenging behaviour. Many, including those working directly with people in segregation, were unqualified healthcare or nursing assistants. 71 The importance of staff training was also raised in our stakeholder focus groups with one participant stating: I’ve seen the most terrible behaviour in the psychiatric hospitals for people that are Autistic because they don’t have the training in Autism. The way that they treat someone maybe having a manic episode, interferes with how they are as an Autistic person. Stakeholder focus group 3, participant 1, mother In a study conducted in Australia about seclusion and restraint use with people with LD , training and support were highlighted as key areas: Comprehensive training in intellectual disability … about the needs of people who have a disability who are subjected to restraint and seclusion. This type of support to disability workers may help to reduce behaviours of concern and the resulting use of restrictive practices. 84 There are some important elements in training that could be interpreted as mechanisms to decrease the use of RP: If direct care staff are intrinsically motivated to provide care that is of the utmost quality and have an understanding that the use of seclusion and restraints is not patient-centered, they will be more likely to benefit from the educational training on alternative strategies to decrease their use. 61 Involving people with lived experience in teaching is seen as an important strategy: One way to address this can be by appealing to the human side of employees. One possible teaching strategy may be to use consumer’s to help teach the alternative strategies. By using people with mental illness to help educate direct care staff on avoiding the use of seclusion and restraints the organization may interest employees more. The former patients can even share personal stories of their experiences with seclusion and restraint in the hopes of influencing staff to better avoid their use. 61 In contrast, it has been argued that training and education do not always reduce the use of RP. There may be multiple complex reasons for this, one being that the context and mechanism were not sufficient to produce the right outcomes. Other studies have shown no change in the use of restraints despite staff education on how to reduce their use. 61 Embedding training within broader organisational value-based frameworks and environments is therefore key. Context–mechanism–outcome configuration 5: reflection and reconnection This fifth CMOC focuses on recommended reflective practices such as debriefing and learning from events where RP have been used. If following the use of RP (C) reflective practices such as debriefing are employed (M), then this allows those involved to understand and reflect upon conflict and events (M), share feelings, concerns, learn lessons (M) and revisit BPSs (O). Future conflict could then be prevented, and the use of restrictive interventions minimised (O). A debriefing session should follow as soon as possible after the procedure. This involves gathering of all staff involved in the seclusion/or restraint for the purpose of discussing the events. 60 One study suggests that post-incident debriefing is a new practice and may not be sufficiently rooted in services yet in a positive way. It is therefore important that debriefing is introduced with appropriate workforce development: We are just in the process of strengthening our DB [debriefing] process which is weak … at the moment further training in debriefing is needed. 66 In the literature, there are examples of staff debriefing, but also an impetus to provide debriefing to persons with LD as part of a behavioural support plan, as opposed to just tick box exercises: Debriefing procedure of individual and witnesses to physical restraint and seclusion/confinement time-out described. 24 … Giving service users and staff the opportunity to reflect on adverse events and identify areas for improvement and learning together … is essential. 77 The inadequacy of debriefing procedures was echoed in our stakeholder focus groups with participants agreeing that debriefing was rare. One participant said ‘Never. Never in eleven years. We would be informed of incidents but never a debrief, never’ (Stakeholder focus group 1, participant 1, father) . This was a strong consensus, and the missed opportunities were highlighted, as exemplified by one carer participating in one of our focus groups: I told them and told them that the medication they put her on would make her violent because she’s been on it before and nobody listened to me. So all these restraints and her violence were because they put her on a medication. Had there been a debriefing, I could have informed them. Stakeholder focus group 2, participant 2, mother There are different ways and components of successful debriefing and mechanisms of how it works, described for example by Black et al . 60 They propose that desirable outcomes should include: The prevention of the future misuse of imposed restrictions (this includes either implementing seclusion and restraint when not appropriate or avoiding these modalities when they are indicated). 60 In summary, in combining CMOCs 3–5 to formulate our second partial programme theory ( Figure 5 ), one can see the development of the importance of creating positive environments where staff are supported, sufficiently resourced and able to be reflective and learn from previous events and shared information. FIGURE 5 The interface between contexts, mechanisms and outcomes staff that contribute to our second partial programme theory (CMOCs 3–5). Our third focus arising from this review and preliminary work is that of the organisation. Stakeholder Group 3: the organisation Organisational-level issues and how care is structured are identified as of significant importance in this review and can impact upon the quality of care and its outcomes. Leadership is key to this process. There are a number of frameworks explaining factors that can affect the quality of care including the Donabedian structure–process–outcome framework. 92 It is evident that reorganising the delivery of care and staffing levels are key structural components in this chain, and that leadership is an integral part of the process, leading to positive care outcomes. 93 The importance of strong leadership is emphasised in, for example, organizational and management theories and will increase motivation and commitment for staff to provide high-quality care. The Six Core Strategy approach is a classic example of this and has an increasing evidence base. With regards to staff mix, the Framework for Inclusive and Collective Leadership 94 underpins some of the ideology behind CMOC 6. This framework outlines how the notion of collective leadership involves shifting from traditional command-and-control structures and ‘heroic’ individual leadership towards a model that shares and distributes leadership to wherever expertise, capability and motivation sit within organisations. West et al . 95 later argued it gives a rationale for why it is crucial that leaders in health organisations show by example that a culture shift is needed from blame to positive practices and being creative with finding and trying new solutions to address conflict situations: Attending: being present with and listening with fascination to those we lead. This involves noticing and inquiring about suffering and distress, and challenging approaches oriented to blame and punishment. Context–mechanism–outcome configuration 6: reorganising care delivery The sixth CMOC focuses on rethinking care delivery and reviewing existing practices and care services with a more preventative organisational as opposed to individual lens. If organisations that use RP routinely (C), review their use in services (M), together with staff and people with lived experience and families/carers (M), and reorganise care using evidence-based approaches, such as the HIC model, Safewards and the Six Core Strategies to reduce coercion (M), then the use of RP could be reduced in the long term (O). Organisational factors … Many of these strategies centre on the structure of the organisation itself: the need for strong leadership, successful reporting, recording and reviewing practices in regard to the collection of data, and the development of those people working within the organisation. 86 … an institutional philosophy advocating reduced SR use. 73 Thus, the reconstruction of beliefs, attitudes, and behaviors of professionals can be promoted by sharing perspectives among staff and patients, as well as critical-reflective educational interventions and changes in organizational policies and culture. 82 In our focus groups with carers, they repeatedly reported organisations unwillingness to review practice alongside carers, despite their advocacy for working together: If organisations genuinely wanted to have all of that understanding of the individual to help them get better then they could very easily find ways to build up communication links with carers and loved ones and to have that joint way of working. But actually, my experience is that that’s not the case. Particularly in inpatient services, it’s out of sight, out of mind. They don’t really fully understand what the goals of care even are. They’re just ticking boxes and going through the motions. Stakeholder focus group 1, participant 6, mother Examples of organisational-level programs include the HIC model: The HIC-model integrates the medical model and the recovery model and focuses on contact and crisis prevention and continuity of care between outpatient treatment and acute admission wards. 81 The Six Core Strategies take a more overarching organisational approach highlighting multiple factors including data-informed practice and leadership: Clinical teams agree how they will use data. The value and richness of such data is apparent to clinical teams as requests for different data sets were used to monitor, plan and review the impact of PBS plans. 29 Many of these approaches reflect the impetus arising from the DH Positive and Proactive framework. 96 The purpose of this guidance was to support the development of service cultures and ways of delivering care and support which better meet people’s needs and which enhance their quality of life (QoL). It provides guidance on the delivery of services together with key actions that will ensure that peoples’ needs are better met, which will reduce the need for restrictive interventions and promote recovery. It aims to radically transform culture, leadership and professional practice to deliver care and support which keeps people safe. Context–mechanism–outcome configuration 7: ensuring appropriate staffing levels and balanced staff mix The seventh CMOC focuses on the importance of appropriate and sufficient staffing. If there are sufficient and permanent staff (C), taking account of a balance of staff gender, skill mix and experience (M), then there are greater opportunities for staff to be available to address the individual needs of people with LD (M), and to facilitate preventative actions (M). Experienced and educated staff may promote more evidence-based methods (M) meaning that RP could be minimised (O). There are also reasons for restraining that are not client-related, but are related to organisational boundaries. Support staff have reduced possibilities to give good care due to limited working time and staff shortage. 80 Nursing assistants had a greater perception about the importance and necessity of restraint. This perception was related to the reduced knowledge of alternatives for the management of aggressive behavior and greater sense of vulnerability to suffer aggression. 82 It has been suggested that a mix of both junior and senior staff is necessary for the reduction of RP: Greater variability supports the development of competency outlined by Benner; 97 less experienced staff learn from and challenge more experienced staff and therefore promote best practice. 98 Greater experience is inversely associated with seclusion use ( p ≤ 0.001), supporting the idea that the greater the experience of the main carer, the less seclusion is used. 72 In one study participants perceived young staff as lacking experience and knowledge to support them effectively. Often this resulted in a lack of mutual respect: Conversely, some participants felt that older members of staff lacked motivation: They’ve been here so long that they’ve had enough of the job. P8 64 Context–mechanism–outcome configuration 8: strong, committed and compassionate leadership Our eighth and last CMOC is related to leadership in care settings. It has been rated as one of the most important, single strategies in reducing RP in services for people with LDs. If compassionate and thoughtful leadership is strong, both operationally and strategically (C), then there will be less conflict on the wards (O). This is because when leaders engage in positive role modelling (M), work within open and transparent environments (M), and communicate clear expectations, staff are more able to prioritise direct care demands (O) and promote high-quality and person-centred interactions with people with LD (O). This will reduce the need to reactively rely upon the use of RP (O). One of the four most important factors for reducing RP has been suggested to be frontline practice leadership… 66 The main leadership characteristic that participants identified as having contributed to the reduction in SR was the ability to unify staff efforts. 73 Of critical importance are leadership behaviours demonstrated at a senior level. In the first instance, a clear organisational statement identifying restraint reduction as a key priority is paramount. Then, backing up ambitions with capacity and resources, captured and job planning facilitates the intentions into good practice. 29 Suggestions as to how leadership should be embedded into practice have been made: For example, leadership requires: a designated senior board-level manager to collect and collate data regarding RP and ensure and agree RP training and standards are discussed and agreed at the most senior management level. 66 Violence is less frequent and less severe when a unit has strong leadership, clearly defined rules, clear expectations, and a predictable schedule of groups and activities. 61 Core competencies and expertise in engagement and collaboration can serve effective leadership. Working ethically in a caring role and can take its toll on the workforce. Clinical psychologists are well placed to work at an organisational level to provide training and supervision for front-line staff and carers. 58 Further it is argued that there should be a clear organisational-level statements about and a vision for reducing RP: Also of critical importance are the leadership behaviours demonstrated at the most senior level. In the first instance, a clear organisational statement identifying restraint reduction as a key priority is paramount. Then, backing up such a statement with appropriate capacity and resources, captured within job planning processes, facilitates the translation of good intention to good practice. 29 The interface between contexts, mechanisms and outcomes that contribute to our third partial programme theory with regards to organisation is illustrated in Figure 6 . Our final partial programme theory highlights the significance of reflexive and appropriately resourced organisations where leaders are committed to ‘connection before correction’ as an underlying trauma-informed and human rights-orientated philosophy. Compassionate and visible leadership is paramount in this instance as outlined in models such as the Six Core Strategies. FIGURE 6 The interface between contexts, mechanisms and outcomes that contribute to our third partial programme theory regarding the organisation (CMOCs 6–8). Overarching programme theory Having outlined our eight emerging CMOCs and three partial programme theories, we now synthesise our work to present an overarching programme theory. To summarise, our programme theory of reducing the use of RP in NHS and independent sector settings that consolidates the relationship between the eight CMOCs emerging from the data is illustrated in Figure 7 . Three broad interconnecting key theory areas (stakeholder groups) were identified early on to support the need for investment and change for people with lived experience (individuals with LDs and their family members/carers), staff and at organisational level in order to minimise RP for people with a LD who may also have a diagnosis of autism or mental health problems. FIGURE 7 Summary of our programme theory of reducing the use of RP in LD care settings that consolidates the relationship between the eight CMOCs. In the development of our overarching programme theory, analysis and synthesis of the literature was guided by a number of perspectives including substantive theories as outlined, where deemed relevant. This was used to support configurations and consolidate inferences about mechanisms and to validate interpretations of the data and contribute to programme theory development and refinement. Specifically, three interrelated key components were seen to be central to our programme theory comprising aspects related to the person with lived experience (and their families), staff and the organisation and how they influence and impact upon the use of restrictive interventions in LD settings and how they might be minimised by adopting inter-related person-centred practices within organisational change underpinned by compassionate leadership practices and with people at the heart of practices. Our programme theory also explains what drives challenges to embedding such practices within organisations such as staff burnout, a lack of engagement with carers and persons with lived experience and the over-reliance of non-person-centred approaches. Bringing the literature and theories together in addition to findings from focus groups, it was clear that with regards to people with lived experience, strategies including effective communication, autonomy and care planning underpinned by theories of SDT and person-centred care models are central to effective relational working. Secondly, the importance of addressing staff needs, both professionally and personally, given the intensity of the environments they work in, warrants structured reflexive approaches such as debriefing and related workforce development. In addition, self-determination should not be looked at solely as a matter of individual attitude, but the management and culture of the organisation need to give permission to frontline staff to do the right thing. The importance of this is further highlighted by underpinning theories such as the ECOM, the cognitive appraisal model and self-efficacy theory. Each emphasises the impact of stress and need for learning and support. This is then further illustrated by the final piece of the jigsaw, the organisation which needs to address person-centred care delivery initiatives, ensure sufficient and supported staffing models and above all subscribe to and invest in strong and authentic thought leadership. Theoretical and complex organisational models include the Six Core Strategies, positive and proactive care, the HIC model and concepts related to self-leadership and moderation. These interconnected components are multidirectional in that they are both interdependent and reliant upon each other and representative of the need for an overarching reflexive systems approach. As discussed in the literature reviewed, outcomes result from the inter-relationships between the important contexts in which care takes place in within LD settings. For example, our programme theory indicates that while there are interventions that have been shown to work in mental health settings in reducing RP ( what works? ), for example, the six Six Core Strategies, and Safewards, the ‘who’ in these settings is significant, in this case, people with LDs, because of the contexts and mechanisms at play. For example, interventions might not work in reducing the use of RP because of staff stress and burnout that can be associated with working in complex environments without the necessary workforce development and skill mix. Fundamentally, there appears to be a lack of understanding about peoples’ needs – commonly referred to as ‘challenging behaviour’ and the imminent need for specialist targeted training for staff about those with LDs and autistic people. This in turn can translate as organisational failure to recognise these key differences, and in particular the need to understand expressions of unmet need. The importance of highlighting and recognising the role of family members/carers and to include them as advocates in their loved one’s care and in workforce development is a key way forward. Our review indicates that where staff work in and do not have adequate training and support in challenging environments, they are more likely to experience high levels of stress and have extended absences. Positive practice therefore needs to be relational involving family members to advocate for their loved ones and help bridge gaps (at ward/staff and organisational levels) for a better understanding of communication needs and the reduction of triggers that could escalate the use and over-reliance of RP on adults with LDs in NHS and independent sector settings. Copyright © 2025 Duxbury et al . This work was produced by Duxbury et al . under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/ . For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited. Bookshelf ID: NBK614113 Contents < Prev Next > Share Views PubReader Print View Cite this Page Duxbury J, Haines-Delmont A, Baker J, et al. Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: a realist review. Southampton (UK): National Institute for Health and Care Research; 2025 May. (Health and Social Care Delivery Research, No. 13.14.) Chapter 5, Findings. PDF version of this title (1.7M) In this Page Stakeholder group 1: people with lived experience (people with learning disabilities and families/carers) Stakeholder Group 2: staff Stakeholder Group 3: the organisation Overarching programme theory Other titles in this collection Health and Social Care Delivery Research Recent Activity Clear Turn Off Turn On Findings - Approaches used to prevent and reduce the use of restrictive practice... Findings - Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: a realist review Your browsing activity is empty. Activity recording is turned off. Turn recording back on See more... Follow NCBI Twitter Facebook LinkedIn GitHub NCBI Insights Blog Connect with NLM Twitter Facebook Youtube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov