Title: A realist review of approaches used to prevent and reduce the use of restrictive interventions on adults with learning disabilities in NHS and independent sector settings
Funder: Department of Health and Social Care

Abstract: Background_x000D_ There are guidelines and public pressure to reduce and prevent the use of interventions that are used to restrict vulnerable people with mental health, learning disabilities and/or autistic spectrum disorders. However, these are not used in many services and are only guidelines. We are using the term restrictive interventions to include a range of practices. For example, observation, seclusion, physical and mechanical restraint, and the use of medication. All forms of restrictive interventions are damaging physically and emotionally to service users and put strain on staff who, on the whole, are trying to do their best._x000D_ _x000D_ Although we know that there are a number of approaches that are being used in healthcare services such as Positive Behaviour Support (PBS), which try to prevent conflict by understanding the needs of the person and so reduce the need for restrictive interventions, we still don’t know what really works in reducing restrictive interventions. There is limited research in this area._x000D_ _x000D_ This review (looking at the information and literature to see what works) will fill a gap especially in looking at how specific places and their environments and what seems to guide their approaches work in trying to make change. _x000D_ _x000D_ Question_x000D_ What works to reduce the use of restrictive interventions on adults with learning disabilities in NHS and independent sector settings? This includes adults with learning disabilities who may also have autism or mental health co-morbidities_x000D_ _x000D_ Aim_x000D_ The overall aim of this review is to gain a deeper understanding of how, why, for whom, and in what circumstances approaches used to prevent and reduce the use of restrictive interventions on adults with learning disabilities (who may also have autism or mental health co-morbidities) are most successful._x000D_ _x000D_ The work _x000D_ We are using a realist review. In lay terms, this is a way of looking at the research information, which tries to explain why approaches to prevent and/or reduce restrictive interventions work and why they do not work in different settings for different people. We estimate the project will take just under 2 years to complete._x000D_ _x000D_ Impact of our work and ways of spreading our findings _x000D_ Involvement of experts by experience and advocacy groups will be important to achieve our aims in a way that is meaningful. We have 2 experts by experience co-applicants leading on and engaging in dissemination of findings amongst and on behalf of carers and service users via their connections with Positive and Active Behaviour Support Scotland (PABSS), Dimensions UK, Learning Disability England, Learning Disability Partnership Board, Restraint Reduction Network (RRN), The National Sevice User Network (NSUN), BILD, and the Tizard Centre. Once completed, we will share the findings of our project in a number of ways through social media such as Twitter, TV and radio broadcasting, in journals, presenting at conferences and writing reports. Given that this is a high-profile issue, there will be a need and thirst for further research in this area, policy development, media coverage and further public lobbying based upon our findings.

Lay abstract: Research question _x000D_ _x000D_ What are the mechanisms that work to reduce the use of restrictive interventions on adults with learning disabilities in NHS and independent sector settings? This includes adults with learning disabilities who also have autism or mental health co-morbidities. _x000D_ _x000D_ Background _x000D_ _x000D_ Despite national and international guidelines and political and public pressure to reduce and prevent the use of restrictive interventions on vulnerable populations, these are still common. Restrictive interventions can include the use of observation, seclusion, physical restraint, mechanical restraint, rapid tranquilisation and/or other chemical restraint (RRN, 2019). Recent data point to a significant 50% increase in the use of restrictive interventions on adults with learning disabilities in English hospitals (NHS Digital, 2018). A number of approaches have been implemented in healthcare services over the last decade to address this issue - Positive Behaviour Support (PBS), Safewards, the Six Core Strategies, REsTRAIN Yourself. Despite their widespread use, there is no unifying theory that explains how or why these methods are supposed to ‘work’ in reducing the use of restrictive interventions. This review will fill a gap in the evidence base by developing programme theories of why current approaches work and do not work in preventing and/or reducing restrictive interventions with this vulnerable population. _x000D_ _x000D_ Aims and objectives _x000D_ _x000D_ The overall aim of this review is to gain a deeper understanding of how, why, for whom, and in what circumstances approaches used to prevent and reduce the use of restrictive interventions on adults with learning disabilities are most successful. _x000D_ _x000D_ Methods _x000D_ _x000D_ To address these objectives, a realist review will be conducted according to RAMESES guidelines (Wong et al., 2013). The realist review will focus on ‘how’ interventions work and under what circumstances approaches to prevent and/or reduce restrictive interventions work. We will use a realist logic of analysis to align data from 4 project phases with context mechanism outcome configurations (CMOs): _x000D_ _x000D_ (1) formulating mid-level theories in the form of CMO configurations; _x000D_ _x000D_ (2) conducting a systematic search of literature; _x000D_ _x000D_ (3) testing and refining programme theories; and _x000D_ _x000D_ (4) developing recommendations and disseminating findings. _x000D_ _x000D_ Timelines for delivery _x000D_ _x000D_ The project will be completed in 22 months. _x000D_ _x000D_ Anticipated impact and dissemination _x000D_ _x000D_ Involvement of experts by experience and other stakeholders in the review will allow for better knowledge transfer throughout. We have 2 experts by experience co-applicants leading on and engaging in dissemination of findings amongst and on behalf of carers and service users via their connections with Positive and Active Behaviour Support Scotland (PABSS), Dimensions UK, Learning Disability England, Learning Disability Partnership Board, Restraint Reduction Network (RRN), BILD, and the Tizard Centre. Once completed, we will share the findings of our project in a number of ways through social media such as Twitter, TV and radio broadcasting, in journals, presenting at conferences and writing reports. Given the high profile nature of this issue we anticipate that there will be a need and thirst for further research in this area, policy development, media coverage and further public lobbying based upon our findings. We are well placed nationally and internationally through our current networks and reach to have significant impact and to drive information exchange opportunities.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH