Electronic publication, Published on August 3rd, 2025.
		https://doi.org/10.33700/jhrs.4.1.143
		eISSN: 2820-5480

Residential Care Staff’s Knowledge of Reporting Restrictive Practices in Intellectual Disability and Older Persons Care Settings: A Scoping Review

Abstract

Introduction: Restrictive practice is an intentional restriction of an individual’s voluntary movement or behaviour. Given the impingement of human rights associated with restrictive practice, many jurisdictions all over the world have advocated for a reduction in their use, highlighting the importance of reporting restrictive practice. However, a paucity of literature exists examining the knowledge of residential care staff regarding reporting restrictive practice.

Aim: To examine the knowledge of residential care staff regarding the reporting of restrictive practices in intellectual disability and older persons care settings.

Methods: A scoping review referenced to JBI and PRISMA guidelines was used. The studies were retrieved from a library multi-search function of various databases. Sixteen studies were included in the final analysis.

Findings: Findings demonstrate that residential staff lack knowledge of what defines a restrictive practice and find the reporting system as unnecessary, time consuming and burdensome. The identified barriers to reporting restrictive practice included: fear, lack of clear guidelines and awareness of the reporting system, lack of time, and staff shortages. While the facilitators included awareness campaigns, availability of appropriate reporting structures, and managerial support.

Conclusion: This review suggests that improvements in terms of residential staff understanding of and reporting of restrictive practice is required. Moreover, this review has the potential to assist policymakers to understand the individual, organisational and regulatory barriers and facilitators to reporting restrictive practice within intellectual disability and older persons care settings.

Keywords: residential care staff, residential care, reporting, incidents, restrictive practices, knowledge, older persons, and intellectual disability

Citation: Mukwashi, V.R.L., Sharvin, B., Maher, R., Davitt, M., Benett, L. (2025). Residential Care Staff’s Knowledge of Reporting Restrictive Practices in Intellectual Disability and Older Persons Care Settings: A Scoping Review. Journal of Health and Rehabilitation Sciences, 2025 Aug 3; 4(1), 48–61. https://doi.org/
10.33700/jhrs.4.1.143

Copyright ©2025 Mukwashi, V.R.L., Sharvin, B., Maher, R., Davitt, M., Benett, L. This is an open-access article distributed under the terms of the Creative Commons 4.0 International License (CC BY 4.0)

Introduction

Restrictive practices are defined as intentionally restricting an individual’s voluntary movement or behaviour (Health Information and Quality Authority (HIQA), 2024) and can be applied using physical, chemical, environmental (Department of Health, 2011), or psychological constraints (HIQA, 2023).

Restrictive practices violates an individual’s autonomy and freedom (Hamers et al., 2016; Estevez-Guerra et al., 2017) and consequently can lead to decreased physiological well-being (Muluneh et al., 2024), reduced mobility and cognitive functioning, worsening of non-cognitive symptoms of dementia (Muluneh et al., 2024), injury and/or death from entrapment and asphyxiation (Bellenger et al., 2018).

Older adults and individuals living with intellectual disabilities (ID) are more likely to need support with daily living activities, as they may experience higher rates of life-limiting physical and mental co-morbidities compared to the general population (Cooper et al., 2018).

Many older adults and persons living with an ID rely on care from others, such as long-term care residential facilities (Khan et al., 2024).

The literature has reported that these vulnerable groups may have restrictive practices applied to them as a response to challenging behaviours and some co-existing cognitive conditions (Sheehan et al., 2015; Cooper et al., 2018).

However, the moral, ethical and legal necessities of restrictive practices within healthcare and disability support is much debated (Mcsherry & Freckelton, 2015).

The literature has reported safeguarding concerns in relation to residents’ ability to consent to restrictive practices (Dunbar et al., 2022a; Dunbar et al., 2022b).

Therefore, examining the knowledge of residential care staff regarding the reporting restrictive practices is paramount.

Given the negative outcomes associated with restrictive practice, many jurisdictions all over the world have advocated for a reduction in their use (Government of Australia, 2022; HIQA, 2023).

Reporting restrictive practices is valuable as a resource for planning, delivering, monitoring, managing and improving care in relation to restrictive practice use (HIQA, 2023).

However, the literature has identified varying degrees of knowledge of reporting restrictive practices amongst health care professionals (HCP’s) (O 'Regan et al., 2022) and has questioned whether HCP’s knowledge influences the use of restrictive practice in nursing homes (Kassew et al., 2020; Carrero-Planells et al., 2021). With this in mind, this scoping review examines the literature on residential care staff knowledge of reporting restrictive practices within ID and older persons care settings.

Material and methods

A comprehensive scoping review was conducted using the Joanna Briggs Institute (JBI) protocol, a nine-step approach and includes: (1) abstract; (2) introduction; (3) methods; (4) review question; (5) inclusion criteria; (6) search strategy; (7) study selection; (8) data extraction; and finally, (9) data analysis and presentation (Peters et al., 2022).

This review also used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart (Page et al., 2021) for reporting findings.

The PRISMA flowchart was chosen for its usefulness in showing the steps taken in selecting and excluding papers for inclusion in the scoping review.

There is clear evidence of how, why and what studies were selected or rejected.

Review question

The purpose of this scoping review is to examine residential care staff knowledge of reporting restrictive practices within ID and older persons care settings.

It is important to note that scoping reviews mostly use the JBI’s Population, Concept and Context (PCC) approach (Peters et al., 2022). With this in mind, this scoping review examines the following research question:

What is residential services staff (Population) knowledge of reporting restrictive practice (Concept) in older persons and ID care settings (Context)?

Inclusion criteria

The inclusion criteria included: primary research such as qualitative, quantitative, or mixed-methods studies that focused on and answered the research question; studies published in the English language between 2013 and 2025 (much change in legislation and practice in restrictive practices has occurred within this timeframe); with full text availability; and studies that focused on all forms of restrictive practices in older persons and ID healthcare settings.

Search strategy

A search of several databases including Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCO, Science Direct, Google Scholar and PubMed was undertaken using the multi search function.

In the selection of studies key search terms using the Boolean operators AND/OR were used to search the databases as identified in Table 1.

The decision to use a multi-search approach came from the realisation that some papers, especially those relating to ID services, used terminology from social care and some appeared in social care journals and not just health science sites.

The reference lists of appropriate studies were also hand-searched for additional articles.

Literature was found examining restrictive practices that are in use and discussions on the benefits and disadvantages of restrictive practice use.

Due to unavailability of papers written specifically about reporting restrictive practices, the search included papers on incident reporting systems and medical incident reporting, because some restrictive practices are reported as incidents or through the incident reporting systems (NDIS Quality and Safeguards Commision, 2020).

In Australia, inappropriate use of restrictive practices are reported under the Serious Incident Response System (SIRS) whilst physical and chemical restrictions are reported through the National Aged Care Mandatory Quality Indicator Programme (Government of Australia, 2022).

Reports on medical incidents included reports on chemical restrictive practice use.

Study selection

The initial search identified 3291 papers (see PRISMA, figure 1).

After excluding a further 1,070 of these papers that examined restrictions such as Covid restrictions and prisons, the final yield of papers was 2,221.

Eight hundred and eighty-nine (n=889) duplicateswere identified and removed, and 1,332 were screened of which 1,127 papers were excluded.

These were for example newspaper articles which had been included in the initial results because a library multi-search function was used.

The remaining 205 selected papers were identified for full reading in relation of terms of eligibility.

Some articles referred to restricted medical services like abortions, whilst other papers had no information relating to restrictive practices.

Many papers broadly discussed restrictive practices as a concept without exploring the knowledge or reporting of restrictive practice.

Fourteen primary studies met the criteria for inclusion in the scoping review.

Two reviewers screened the 191 papers rejected by the first researcher and identified four papers that were potentially relevant to the scoping review.

Of these four, two were deemed relevant, resulting in 16 papers finally selected for the scoping review.

Data extraction

The data extracted from the selected studies is presented in table 2 and presents the study title, authors, publication year, the population, concept and context of the study and the methods utilised within the included studies.

The key findings from each study are also specified.

Table 1: Key search terms

Fig. 1: PRISMA flow diagram

Data analysis & presentation

To better understand residential care staff knowledge of reporting restrictive practices within ID and older persons care settings, this paper focuses on the classification of four themes found from the review of studies reporting on restrictive practices, and other incident reports in nursing homes and acute hospitals.

The themes are: (1) residential staff knowledge of reporting restrictive practices; (2) residential staff perceptions of reporting restrictive practices; (3) residential staff attitudes to reporting restrictive practices; and finally (4) barriers and facilitators of reporting restrictive practices at the individual, organisational and regulatory levels.These themes will now be explored.

Residential staff knowledge of reporting restrictive practices

Residential services staff have varying degrees of knowledge of reporting restrictive practices.

A quantitative study undertaken by AbuAlRub et al., (2015) in seven Jordanian hospitals examined nurses (n=307) and physicians (n=144) awareness of incident reporting.

This study found that nurses had greater knowledge of the incident reporting system (80.8%) compared to physicians (53%).

In addition, nurses have reported more incidents than physicians, with 42.2% of nurses having completed an incident report, compared to 24.6% of physicians.

Participants cited forgetting and fear of disciplinary actions as reasons for not reporting.

While most physicians and nurses knew of the existence of the incident reporting system, only 69.6% of nurses and 48.5% of physicians knew what to do with the form once completed.

Oweidat et al. (2023) conducted a cross-sectional survey to assess nurses’ level of awareness and perceptions of the incident reporting system in 15 Jordanian hospitals.

This study found a high awareness of the incident reporting system by nurses (94.8%).

Findings also highlighted that nurses in accredited hospitals had higher awareness of incident reporting compared to nurses in non-accredited hospitals.

A study investigating injury incident reporting in ID services in Glasgow found that a majority of paid carers were aware of the incident reporting procedure, with only 2.2% unfamiliar with the procedure (Finlayson et al., 2015).

This study did not specify any of the carers’ qualifications. O' Regan et al. (2022) prepared a database of statutory notifications in Ireland between 2013 and 2019.

Their aim was to describe the development of an analysable database of statutory notifications from older persons and ID care facilities.

They encountered a high degree of missing data and information in earlier years and suggested that this missing data may have been due to inadequate knowledge by health care providers or lack of reporting guidelines.

Residential staff perceptions of restrictive practices

Findings from the included studies reported that residential services staff have varying perceptions of restrictive practices.

For example, in Sweden, Björne et al. (2022) found that staff had mixed perceptions about what they deemed a restrictive practice with some reporting that they did not know whether locking away medications; controlling diets; or blocking the service user’s path deemed as a restrictive practice (Björne et al., 2022).

In a cross-sectional analysis of restrictive practice notifications submitted to the regulator from disability and older person’s residential care facilities in Ireland, Dunbar et al. (2022a) found that staff did not record seclusion as a restrictive practice, despite this falling under environmental restrictions. Notifications also showed antibiotics and beta-blockers listed as a chemical restraint (Dunbar, et al., 2022a; Dunbar et al., 2022b).

In addition, there were examples of physical, environmental and chemical restraints reported as ‘other’, despite the categories being available to select from (Dunbar, et al., 2022a; Dunbar et al., 2022b).

Øye and Jacobsen (2020) conducted a mixed method study in four nursing homes in Norway, from 2012 to 2014, to investigate the types of informal restraints used in nursing homes.

Staff highlighted problems with defining restrictive practices. Staff also used the expression, ‘grey-zone restraint’ indicating a form of restraint not clearly regulated by legislation. In addition, informal restraints were not clearly defined and were dependent on staff’s interpretation.

In a mixed methods study to determine and compare the rates and use of coercive practices in mental health care across nine countries the durations and rates of coercive measures were highly variable with Wales reporting no mechanical restrictive practice use in the period under review and Japan had the highest rates and duration of coercive measures.

In addition, many countries were found to differ in their definitions of restrictive practices (Savage, et al., 2024).

Residential staff attitudes towards reporting restrictive practices

Chen et al. (2018) conducted a cross-sectional study of nurses in three Taiwanese hospitals and surveyed nurse’s attitudes towards reporting medical incidents and factors that affect reporting. Some health care workers found the reporting system burdensome.

Participants in management positions and with post-graduate qualifications reported a higher willingness to report medical incidents compared to those in non-

managerial positions and less qualifications. Björne et al. (2021) conducted a survey among healthcare staff in one Swedish municipality to ascertain if incident reports contribute to improving quality in ID services for those with challenging behaviours. Participants in this study reported completing the reports in a perfunctory manner, just to comply with regulations. Some reports did not include any mention of restrictive practices used in incidents in which altercations occurred between service users.

Barriers and facilitators to reporting restrictive practice at the individual, organisational and regulatory levels

Some studies highlighted barriers and facilitators to reporting restrictive practice at an individual level. For example, Bahadori et al. (2013) conducted quantitative studies on barriers to reporting medication errors in nursing and found that characteristics such as age and level of education had no bearing on a nurse’s knowledge of reporting medication errors. In contrast, Chen et al.’s (2018) study found that nurses who highly rated their professional development were less likely to report errors. Leif et al. (2023) conducted an online survey amongst behaviour support practitioners in Australia working in ID services. The aim was to understand their experiences in designing and delivering behaviour support plans that include restrictive practices. Unwillingness to change was also highlighted as a key finding, with staff expressing unwillingness to use alternatives to restrictive practices and often using what they know best rather than trying different ways of managing challenging behaviours.

At the organisational level, the organisational culture, governance and policies were found to affect staff knowledge of reporting restrictive practices. Numerous quantitative studies explored barriers to reporting medication errors by nurses in Saudi Arabia, Iran, Nigeria and Iran again, respectively and found the reporting system time consuming (Aboshaiqah 2013; Bahadori et al., 2013; Oshikoya et al., 2013; Tabatabaee et al., 2014). Leadership styles and organisational culture were cited as barriers, with nurses reporting that managers focused on individual nurses, blaming them rather than focusing on the reporting system (Aboshaiqah 2013; Bahadori et al., 2013; Oshikoya et al., 2013; Tabatabaee et al., 2014). Awareness campaigns held by Jordanian hospitals to increase their employees’ awareness of the incident reporting system is also mentioned as an organisational factor responsible for high awareness of the incident reporting system (Oweidat et al., 2023).

At a regulatory level, O’ Regan et al. (2022) recognised that the legal requirement to notify the healthcare regulator of medical incidents forces health care staff to report. In Jordan, a monetary penalty is given to health care staff who are found at fault in a reported incident. This acts as a barrier as it leads to less reporting, for fear of such penalties (AbuAlRub et al., 2015). In four different studies on understanding barriers to reporting medication errors, fear of legal consequences and job losses were cited as reasons for not reporting (Aboshaiqah 2013; Bahadori et al.,2013; Oshikoya et al., 2013; Tabatabaee et al., 2014). In addition, raising awareness of the reporting systems by accrediting bodies was found to be a facilitator of reporting restrictive practice by nurses (Oweidat et al., 2023).

Discussion

This section will discuss a summary of findings, and the strengths and limitations of both the primary research and the review itself. In addition, this section will outline what the review adds to existing knowledge and finally the implications for future practice, theory, education, research and policy.

Summary of findings

Whilst the definition of a restrictive practice is clearly outlined in the literature as intentionally restricting an individual’s voluntary movement or behaviour (HIQA, 2024), the findings of this review highlight an inconsistency amongst residential staff of what is deemed a restrictive practice (Øye & Jacobsen, 2020; Björne et al., 2021; Björne et al, 2022). In addition, a lack of awareness in relation to the classification of restrictive practice were identified (Dunbar et al., 2022a; Dunbar et al., 2022b) and this can consequently lead to both inaccurate reporting of restrictive practices and the efforts to reduce their use (Bowers 2000; Roper et al., 2015). Therefore, comparing find¬ings across studies within different health care settings, as well as assessing the effectiveness of interventions, and identifying ways to effectively minimize these practices will be challenging (Muluneh et al., 2024). It has been recommended that clearer examples of how certain procedures meet the definitions of restrictive practices may improve reporting by reducing variability of interpretation by practitioners (Clark et al., 2018).

Findings of this review also highlight that nurses have a greater awareness of incident reporting systems compared to physicians (AbuAlRub et al., 2015; Oweidat et al.. 2023). This suggests a large proportion of incident reporting is completed by nurses despite the fact that residential care facilities are staffed by a multi-disciplinary team which includes amongst others: health and social care assistants, catering staff, occupational therapists, physiotherapists and doctors. In 2023, Ireland’s National Safeguarding Office introduced roles for nurses as Clinical Nurse Manager 2, in the different regions (HSE National Safeguarding Office, 2023). However, Ireland’s social workers have argued that this can lead to safeguarding being viewed through a clinical lens instead of a rights-based model (McGarry et al., 2022).

Under/over-reporting of restrictive practices may be influenced not only from lack of knowledge, but by staff perceptions and attitudes of the reporting process as well. This review highlighted that reporting restrictive practices and other incidents such as medication errors, was perceived to be burdensome (Oshikoya et al., 2013; Tabatabaee et al., 2014; Chen et al., 2018) and studies highlighted that residential staff complete reports in a perfunctory manner, and only as a regulatory requirement (Björne et al., 2022).

Although environmental restrictions were the highest reported restrictive practice in Ireland in 2020, less than 50% of nursing homes reported on them, suggesting under-reporting (Dunbar et al., 2022b). Dunbar et al. (2022a) posit that the availability of the ‘other’ categorisation of restrictive practices within the HIQA database may have led to misreporting as there was an option to just identify any restrictive practice, if one was unsure. In Ireland, 18.3% of residential care facilities reported zero use of restrictive practices (Dunbar et al., 2022b). This may mean they adhered to the zero tolerance to restrictive practice use throughout the year, or they did not report, either intentionally, or because they did not know what to report.

The findings of this review have established that staff attributes appear to be directly related to a higher working knowledge of reporting restrictive practice such as self-confidence; higher levels of education; higher management positions; and more years of experience (Chen et al., 2018). Higher management positions enables managers to have access to feedback on reports submitted, arguably therefore encouraging more reporting, whilst higher levels of education and experience may mean one has received appropriate training on reporting restrictive practices. At the organisational level, hospital accreditation in Jordan was found to be a factor in facilitating reporting restrictive practice (Oweidat et al., 2024). The primary differences in accredited and non-accredited hospitals are adherence to quality, patient safety and staff competence standards, with accreditation serving as a marker for excellence (Shaw et al., 2014; Oweidat et al., 2024). The rigorous process that goes into accreditation may account for the higher knowledge of reporting systems by nurses working in accredited hospitals. In other jurisdictions like Ireland however, all hospitals and residential care facilities are regulated and do not operate without accreditation (HIQA, 2022; HIQA, 2023). Staff shortages in nursing homes can result in staff prioritising actual care to residents and neglect other duties such as reporting and documentation (Yang & Zhang 2023; Khan et al., 2024). Caregiving deficiencies lead to adverse outcomes, including caregiver stress and burnout (Khan et al., 2024). At the regulatory level, authorities such as HIQA in Ireland require mandatory periodic reporting of all types of restrictive practices (Government of Ireland, 2013a; Government of Ireland, 2013b), which encourages reporting. In other jurisdictions, legal consequences, such as docking of wages for those found at fault, and potential job losses, may discourage reporting (Aboshaiqah 2013; Bahadori et al., 2013; Oshikoya et al., 2013; Tabatabaee et al., 2014; AbuAlRub et al., 2015).

Strengths and limitations of this review

The systematic approach presented in this scoping review has provided the ability to explore and synthesize a range of evidence on a topic that has been under-examined. It has contributed to the current understanding of how to promote the wellbeing of older adults and individuals with ID in care settings. However, this scoping review is not without limitations. The paucity of literature on reporting restrictive practices led the author to resort to including papers that reported on medication errors and any incident reporting that involved staff in nursing homes and acute settings, to gain an understanding of the general knowledge of reporting by healthcare workers. While the aim of this scoping review was to examine the knowledge of residential care staff regarding the reporting of restrictive practices in intellectual disability and older persons care settings the majority of studies included in this scoping review only discuss nurses' knowledge, despite nursing homes staffed by a multi-disciplinary team.

Some of the primary research presented in this review acknowledged small and unrepresentative samples (Chen et al., 2018; Leif et al., 2022; Oweidat et al., 2023; Savage et al., 2024) and may have led to inaccurate generalizations and limit the applicability of the research findings. In addition, some studies relied on self-reporting data (Tabatabaee et al., 2014; Finlayson et al., 2015; Dunbar et al., 2022a; Dunbar et al., 2022b; O’Regan et al., 2022) which may result in reporter bias. Øye and Jacobsen (2020) carried out field observations in nursing homes in Norway and this may have led to researcher bias as personal views may influence interpretation of observations. Finally, the search included only studies published in the English language, which increases the risk of study selection bias.

What this review adds to existing knowledge

While this review has improved the understanding of residential staff knowledge of reporting restrictive practice, it highlights that restrictive practice is a complex concept and lacks clarity. Bearing this in mind, a clear definition of restrictive practice is required in order for all residential staff to understand and report restrictive practice within ID and older care settings. The importance of establishing universal definitions, classifications and reporting standards to enable consistent and meaningful global comparisons is required.

This review also highlighted the burdensome nature of reporting restrictive practices for residential staff. Macrae (2016) compared the health incident reporting system to the aviation industry and recognised that healthcare sectors encourage large quantity of incidents to be reported whilst the aviation industry only focuses on serious incidents. This poses a question of whether healthcare services should continue reporting all incidents or should they rather prioritise certain incidents?

The negative perceptions of reporting restrictive practice identified in this review can assist regulatory authorities that record restrictive practice notifications, such as Ireland’s HIQA to enhance understanding of the challenges associated with reporting. It also has the potential to develop interventions or enhance existing policies that can assist residential care staff to improve reporting restrictive practice.

The reporting of restrictive practices is a regulatory requirement in many but not all jurisdictions. Therefore, there is a need for the World Health Organisation, to encourage countries not currently reporting restrictive practices to do so. The review amplifies the need for further regulatory involvement in staff training on reporting restrictive practices.

Implications for future practice, theory, education, research and policy

This scoping review highlights that all members of the multi-disciplinary team should be encouraged to interact with the reporting systems as much as nurses do, so that there are no disparities in the working knowledge of reporting restrictive practices between nurses and other residential care staff (Oweidat et al., 2023). According to Liang & Huang, (2023) knowledge of restrictive practices can be improved through multicomponent interventions. Arguably, this has the potential to rectify the under, over and misreporting of restrictive practices.

This review also highlights the need for curriculum changes in future undergraduate and post-graduate healthcare education, to include training on restrictive practices and inclusion of reporting of these as part of routine healthcare duties, to improve practice. The review also has the potential to guide policy changes on how best to implement policies in the regulation of restrictive practices, whilst taking into consideration the perceptions and attitudes that residential staff currently have. This will ensure that policies are inclusive of all members of the multidisciplinary team in residential care, not just nurses, as currently reflected in the studies included in this scoping review.

Given the lack of clarification and understanding in relation to restrictive practice, arguably a concept analysis is warranted to improve our understanding of this complex concept. Future research is required to examine factors to reporting restrictive practice at the individual, organisational and regulatory level. In addition, future research could utilize different research methodologies such as Soft Systems Methodology (SSM) (Checkland 1981) in order to explore the problematic situation related to the use of restrictive practices that can violate an individual’s autonomy and freedom. It could also compare real world data and provide changes that can improve not only the use of restrictive practice but also the reporting of restrictive practice. SSM is a collaborative approach and provides dialogue between individuals and groups with contrasting views (Malekijahan et al, 2024). This may provide an opportunity to interrogate the negative perceptions staff currently seem to hold towards reporting restrictive practices.

Conclusion

This review is both timely and relevant in relation to examining residential care staff’s knowledge of reporting restrictive practices in ID and older persons care settings and how it relates to health policy, service design and delivery. Findings suggest that restrictive practice is a complex concept and improvements in terms of residential staff understanding of and reporting of restrictive practice is required.

This review has the potential to assist policymakers and healthcare leaders to improve residential staff’s knowledge of reporting restrictive practice and has identified implications for future practice, theory, education, research and policy.

Conflict of interests

The authors have no conflict of interest to declare.

Acknowledgement

This study is funded by Nursing and Midwifery Planning and Development Unit, South East, Ireland.

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