Impact statement
Restrictive care practices, including physical restraint, seclusion and chemical restraint, are among the most challenging interventions used in adult mental health inpatient care. Although they are intended to protect patients and others from immediate harm, their use can negatively affect patients, families and healthcare professionals, and may have lasting psychological, ethical and legal consequences. This review demonstrates that decisions to use restrictive practices are not based solely on a patient’s clinical condition. Instead, they are influenced by a complex combination of healthcare professionals’ experience and attitudes, patient characteristics, workplace culture, staffing levels, organizational policies, legal requirements and broader social and cultural factors.
By bringing together evidence from 21 qualitative reviews, this umbrella review provides a comprehensive understanding of why restrictive practices continue to vary across mental health services. The findings highlight that reducing unnecessary restrictive care requires more than individual clinical judgment. Healthcare organizations should strengthen staff training, improve organizational support, promote multidisciplinary collaboration and implement clear, evidence-based decision-making frameworks. Policymakers should also ensure that legislation, professional guidelines and service standards support the least restrictive and most person-centered approaches to care.
The findings have important implications for clinicians, healthcare leaders, educators and policymakers seeking to improve the safety, quality and consistency of mental health care. By addressing the multiple factors that influence decision-making, mental health services can reduce avoidable use of restrictive practices, better protect patients’ rights and dignity and promote safer, more ethical and recovery-oriented care. This review also identifies priorities for future research to develop and evaluate interventions that support consistent, transparent and evidence-informed decision-making across diverse mental health settings.
Introduction
Restrictive care practices (RCPs) refer to interventions used in healthcare settings, particularly in mental health care, to manage a person’s behavior when it poses a risk to themselves or others (Roper et al., Reference Roper, McSherry and Brophy2015). These practices include physical restraints, mechanical restraints, seclusion, chemical restraints, involuntary admission or treatment and other forms of formal and informal coercive measures (McSherry and Maker, Reference McSherry and Maker2020; Muluneh et al., Reference Muluneh, Chavulak, Lee, Petrakis and Haines2025; Belayneh et al., Reference Belayneh, Lee, Petrakis, Aluh, Onu and Newton-Howes2026). Such interventions typically limit a person’s freedom of movement or decision-making and can cause both immediate and long-term harm (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b). Potential consequences include psychological distress, worsening mental health symptoms, re-traumatization, erosion of trust in therapeutic relationships and physical complications such as injuries, falls or, in extreme cases, death (Chieze et al., Reference Chieze, Hurst, Kaiser and Sentissi2019; Yıldız and Özkaraman, Reference Yıldız and Özkaraman2024).
Restrictive care practices (RCPs) remain widely used in inpatient mental health settings. A recent systematic review reported that up to 66% of individuals receiving inpatient mental health care have been exposed to at least one form of RCP (Belayneh et al., Reference Belayneh, Chavulak, Lee, Petrakis and Haines2024). Substantial variability in the use of restrictive measures has been documented across diverse clinical settings and contexts, reflecting differences in institutional practices and care environments (Husum et al., Reference Husum, Bjørngaard, Finset and Ruud2010; Belayneh et al., Reference Belayneh, Lee, Petrakis, Aluh, Onu and Newton-Howes2026). Despite this high and variable prevalence, the use of RCPs has been associated with significant adverse outcomes, including psychological distress, trauma and reduced trust in healthcare services. These concerns have led to increasing calls for policy reform and the implementation of less restrictive, patient-centered approaches.
The use of RCPs is now widely regarded as nontherapeutic, and these practices are recommended only as a last resort (De Cuyper et al., Reference De Cuyper, Vanlinthout, Vanhoof, van Achterberg, Opgenhaffen and Nijs2023), after all reasonable and less restrictive alternatives have been tried and proven ineffective for a specific situation (Riahi et al., Reference Riahi, Thomson and Duxbury2020). Consequently, various strategies and policy reforms (Oostermeijer et al., Reference Oostermeijer, Brasier, Harvey, Hamilton, Roper and Martel2021; Belayneh et al., Reference Belayneh, Lee, Haines, Aluh, Onu, Newton-Howes, Masters, Kohn, Sin, Goulet, Husum, Jelastopulu, Bakola, Opgenhaffen, Gowda, Mekuriaw, De Cuyper, Muir-Cochrane, Canteloupe, Diviney, Staggs and Petrakis2025a) have been introduced to minimize the use of restrictive interventions, promoting safer, more compassionate and patient-centered approaches to care (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin, Forrester-Bowling and McLure2024a; Kim and Nam, Reference Kim and Nam2024). However, significant variability exists in the reported rates of these practices across settings and contexts (Belayneh et al., Reference Belayneh, Chavulak, Lee, Petrakis and Haines2024). While such variability highlights differences in implementation and reporting, it does not in itself explain the effectiveness of reduction strategies. Indeed, emerging evidence demonstrates that several interventions, including trauma-informed care, the safe wards model, de-escalation training, staff education, recovery-oriented approaches and organizational restraint-reduction programs, can effectively reduce the use of restrictive practices (Bowers, Reference Bowers2014; Goulet et al., Reference Goulet, Larue and Dumais2017; Barbui et al., Reference Barbui, Purgato, Abdulmalik, Caldas-de-Almeida, Eaton, Gureje, Hanlon, Nosè, Ostuzzi, Saraceno, Saxena, Tedeschi and Thornicroft2021). However, their successful implementation and uptake are often influenced by practitioner-related factors, such as staff attitudes, beliefs, knowledge, confidence and clinical experience, as well as contextual factors including organizational culture, leadership support, staffing levels, resource availability, workload and institutional policies (Health NCCfM, 2015; Huckshorn et al., Reference Huckshorn2005; World Health Organization, 2021). Furthermore, a sole focus on monitoring prevalence is insufficient; there is a need for more robust evaluation of the processes and outcomes associated with reduction efforts (Savage et al., Reference Savage, Lepping, Newton-Howes, Arnold, Staggs and Kisely2024).
In mental health care settings, the use of RCPs presents complex ethical and legal dilemmas (Bellesheim, Reference Bellesheim2016). It requires balancing an individual’s freedom of movement and autonomy with the perceived need to prevent immediate harm to the individual or others, while recognizing that the use of RCPs is itself contested, with no-restraint approaches arguing that these practices may cause significant physical, psychological and human rights harms and should be avoided wherever possible (Barr et al., Reference Barr, Wynaden and Heslop2019). This often places healthcare professionals in challenging decision-making situations (Hupé et al., Reference Hupé, Larue and Contandriopoulos2024; Belayneh et al., Reference Belayneh, Lee, Petrakis, Aluh, Onu, Newton-Howes, Kim, Kohn, Sin, Goulet, Husum, Jelastopulu, Bakola, Leung, De Cuyper, Muir-Cochrane, Canteloupe, Diviney, Barr, Ridley, Demassosso and Haines2025b). In addition to ethical concerns, legal dilemmas may arise when clinicians must determine whether a situation meets the legal criteria for involuntary intervention or the use of restraint. For example, uncertainty about whether a patient poses a “serious and imminent risk” can create tension between respecting legal rights and avoiding potential legal liability if harm occurs. Decision-making around RCPs occurs within a multilayered context that includes individual, organizational and systemic or policy-level influences (Belayneh et al., Reference Belayneh, Chavulak, Lee, Petrakis and Haines2024). At the individual level, clinicians must assess patient risk, clinical presentation and immediate safety concerns. At the organizational level, factors such as institutional culture, staffing levels, training and resource availability shape practice (Riahi et al., Reference Riahi, Thomson and Duxbury2016). At the broader systemic and policy level, legal frameworks, national guidelines and cultural norms influence how and when RCPs are applied. These intersecting layers create tensions for healthcare professionals, who must ensure safety while maintaining therapeutic relationships and avoiding unnecessary physical and psychological harm (Riahi et al., Reference Riahi, Thomson and Duxbury2016). Similar challenges have been highlighted in international literature, emphasizing the role of historical, cultural and organizational contexts in shaping coercive practices (Whittington et al., Reference Whittington, Aluh and Caldas-de-Almeida2023).
This complexity contributes to subjectivity in professional assessment and decision-making (Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024). Although international bodies such as the World Health Organization (WHO) provide definitions and guidelines on the use of restrictive practices, their adoption and operationalization vary across jurisdictions and clinical settings. This lack of standardization contributes to variability in interpretation and implementation, thereby complicating clinical decision-making and leading to inconsistencies in practice (Hupé et al., Reference Hupé, Larue and Contandriopoulos2024; Muluneh et al., Reference Muluneh, Chavulak, Lee, Petrakis and Haines2025). For example, interpretations of what constitutes “serious harm” may vary significantly between practitioners and institutions, influencing decisions about when restrictive interventions are considered necessary (Donovan, Reference Donovan2022; Chavulak et al., Reference Chavulak, Smyth, Sutcliffe and Petrakis2024; Muluneh et al., Reference Muluneh, Chavulak, Lee, Petrakis and Haines2025). Consequently, behaviors that warrant restraint in one setting may be managed differently in another (Duffy et al., Reference Duffy, Boyle and Del Villar2023). Disagreements regarding when and under what conditions RCPs should be applied hinder efforts to reduce their use (Byskov, Reference Byskov2019; Duxbury et al., Reference Duxbury, Baker, Downe, Jones, Greenwood and Thygesen2019). In some cases, efforts to reduce one form of restrictive practice may result in the unintended consequence of increased reliance on another, potentially more coercive intervention (Duffy et al., Reference Duffy, Boyle and Del Villar2023; Zeng et al., Reference Zeng, Zhang and Yang2024). For example, initiatives aimed at reducing the use of mechanical restraint have, in some settings, been associated with increased use of chemical restraint, such as administering sedative medications to manage patient behavior (Hempeler et al., Reference Hempeler, Braun, Faissner, Gather and Scholten2024; Kim and Nam, Reference Kim and Nam2024). Even though intended to avoid mechanical restraint, chemical restraint is not a benign alternative and is associated with significant safety concerns, including over-sedation, respiratory depression, cardiovascular complications, falls, prolonged hospitalization and medication-related adverse events. Consequently, substituting one restrictive practice for another may undermine efforts to reduce coercion and promote least restrictive, person-centered care (Paul et al., Reference Paul, Ganie, Dar, Saikia and Banerjee2024). Reducing restrictive practices requires comprehensive, rights-based approaches, including staff training, de-escalation strategies, organizational support and service-user involvement, rather than simply replacing one form of restraint with another (Chakkera et al., Reference Chakkera, Sieg, Khofi, Ayieko and Knettel2025; Eladi et al., Reference Eladi, Sanga and Ambikile2026).
Existing literature indicates that several factors influence professionals’ decision-making regarding the use of restrictive practices in adult mental health inpatient settings, where acute and severe mental health conditions are often managed (Riahi et al., Reference Riahi, Thomson and Duxbury2016; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024). However, existing evidence remains fragmented, with limited synthesis across regions, care settings and professional disciplines, making it difficult to fully understand how contextual factors shape decision-making around restrictive coercive practices (Goulet et al., Reference Goulet, Larue and Dumais2017; Barbui et al., Reference Barbui, Purgato, Abdulmalik, Caldas-de-Almeida, Eaton, Gureje, Hanlon, Nosè, Ostuzzi, Saraceno, Saxena, Tedeschi and Thornicroft2021; Whittington et al., Reference Whittington, Aluh and Caldas-de-Almeida2023), and much of the current research focuses on individual or institutional factors within specific professional groups or considers only particular forms of RCPs (Park and Jang, Reference Park and Jang2018). This leaves a gap in understanding how broader systemic, cultural and policy-related influences shape decision-making processes (Haugom et al., Reference Haugom, Ruud and Hynnekleiv2019). Despite the growing body of literature on restrictive coercive practices, existing evidence remains fragmented across disciplines and contexts, with limited efforts to integrate these findings into a comprehensive framework. As a result, there is a lack of an overarching conceptual model that systematically captures the interplay of individual, organizational and systemic factors influencing professional decision-making.
This umbrella review aimed to systematically examine and synthesize the existing literature to identify and summarize how individual, organizational and systemic factors interact to shape health professionals’ decision-making regarding the implementation of restrictive practices and mental health surveys. Umbrella reviews provide a higher-level summary of existing evidence, making it easier to understand broader trends and conclusions across different research studies that can inform the development of standardized frameworks for guiding decision-making across diverse clinical environments (Papatheodorou and Evangelou, Reference Papatheodorou, Evangelou and Patole2022).
Methods
Study design
This umbrella review summarized the findings of qualitative reviews, with all results reported according to the Preferred Reporting Items for Overviews of Reviews (PRIOR) checklist (Supplementary File S1) (Pollock et al., Reference Pollock, Fernandes, Pieper, Tricco, Gates, Gates and Hartling2019). The PRIOR checklist was used throughout the preparation of the manuscript to ensure transparent, complete and consistent reporting of the review methods and findings. The checklist guided the reporting of all components of this review, including the title and abstract, rationale and objectives, eligibility criteria, information sources, search strategy, study selection, data collection, data items, methodological quality assessment, synthesis methods, reporting bias and certainty assessments, presentation of results, discussion, limitations, interpretation of findings, funding and conclusions. The umbrella review method was chosen to draw clear conclusions about the multiple factors influencing professionals’ decision-making in the implementation of RCPs (Choi and Kang, Reference Choi and Kang2022). It enables a comprehensive analysis and integration of existing literature by synthesizing previously published systematic reviews (Theodoulou et al., Reference Theodoulou, Lindson, Fanshawe, Thomas, Nollen, Ahluwalia, Leavens and Hartmann-Boyce2021). In accordance with PRIOR recommendations, we considered the potential for overlap of primary studies across the included systematic reviews. However, because this umbrella review synthesized qualitative review findings and did not quantitatively pool primary study data, a formal overlap matrix and Corrected Covered Area (CCA) analysis were not performed. The protocol for this review has been registered in PROSPERO (CDR: 42024581848).
Eligibility assessment
The eligibility of each study was assessed using the Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) framework (Cooke et al., Reference Cooke, Smith and Booth2012) to determine whether it met the inclusion criteria. Any type of review (qualitative or mixed methods) that reported relevant qualitative data on the factors and contexts influencing professionals’ decision-making regarding various forms of restrictive practices was included in this umbrella review. This review includes studies conducted among any health professionals, including nurses, psychiatrists, psychologists, social workers, general practitioners and combinations of them. Regarding settings, we specifically focus on studies conducted in inpatient mental health services without geographical limitations. Adult inpatient psychiatric care settings, hospital-based mental health services providing 24-h assessment, treatment and care for adults with acute or severe mental health conditions requiring admission. The types of RCPs included were physical restraints, mechanical restraints, seclusion, involuntary admission and chemical restraint, as well as informal coercive practices such as psychological threats, compulsion and other less visible forms (Table 1).
The SPIDER eligibility assessment criteria
Table 1. Long description
The table consists of two columns titled S P I D E R framework and Items.
* S-Sample participants: Healthcare professionals.
* P I-Phenomenon of Interest: Restrictive practice use.
* D-Design: Any type of review (systematic reviews or meta-analyses of qualitative, quantitative or mixed methods) that reported qualitative data.
* E-Evaluation: Factors involved in health care professional’s decision-making.
* R-Research type: Umbrella review.
A final row spans both columns and provides definitions. R C P is defined to include restraints (mechanical, physical or chemical), seclusion, forced medication, involuntary admission and other coercive measures. Professionals refers to individuals working as health professionals in adult mental health inpatient settings.
This umbrella review included systematic reviews of qualitative studies and mixed-methods reviews with separately reported qualitative findings because its primary objective was to understand how and why healthcare professionals make decisions regarding restrictive care practices. Qualitative evidence was prioritized because decision-making is a complex, context-dependent process shaped by professionals’ experiences, perceptions, values, ethical considerations, interpersonal interactions and organizational contexts. It also provides rich, in-depth data through participants’ narratives, interviews, focus groups and verbatim accounts, enabling a deeper understanding of the reasoning and circumstances underlying clinical decisions that cannot be adequately captured through quantitative measures alone. Mixed-methods reviews were eligible only when qualitative findings were reported separately, and only these data were extracted and synthesized according to the predefined eligibility criteria. This approach enabled the development of an integrated conceptual framework describing decision-making processes rather than quantifying the relative importance or predictive strength of individual factors influencing restrictive care practice use.
Search strategy and study selection
For this umbrella review, we conducted a systematic literature search across seven electronic databases: MEDLINE, Scopus, CINAHL, Embase, PsycINFO, Web of Science Collections and Cochrane Systematic Reviews. In addition, supplementary search methods were undertaken, including backward citation chasing by screening the reference lists of relevant reviews, forward citation chasing by identifying studies that cited the included reviews and searches of gray literature designed to minimize the risk of missing relevant systematic reviews. A supplementary gray literature search was conducted to identify potentially eligible systematic reviews not indexed in the selected databases. Gray literature sources were searched using predefined search terms relevant to restrictive care practices, healthcare professionals, decision-making and adult mental health inpatient settings. This search was undertaken alongside citation searching to maximize the completeness of the evidence identification process. Records identified through the gray literature search were screened using the same eligibility criteria as records retrieved from the electronic databases. The search was guided by the SPIDER criteria, and we developed a comprehensive search string using keywords and MeSH terms related to each review concept. The author team discussed and developed search strategies reflecting three main concepts using PICO (Population, Intervention, Context and Output) (Supplementary File S2):
P: Represents any health care professionals working in mental health inpatient settings.
I: Represents concepts related to different types of RCPs.
C: Represents adult populations in mental health inpatient settings
O: Refers to concepts related to factors affecting professionals’ decision-making for RCPs.
We utilized Boolean operators (AND, OR) and truncation symbols (#, $, *, ’’) according to the specific requirements of each database to construct complex search strings, allowing us to capture variations in word endings and spellings (Supplementary File S2) (Rao and Moon, Reference Rao, Moon and Patole2021). The final search strategies were piloted to assess whether or not they identified known relevant studies in the field. Based on this pilot test, minor amendments have been made to some terminologies and concepts to accommodate it and to address the diverse reporting methods. Then the actual database search was conducted from May 2025 and updated on the 10 May 2026. The search was limited to review studies published in English. Additionally, we manually checked the reference lists of included studies to identify potentially eligible reviews for this umbrella review.
All retrieved articles were imported into COVIDENCE (Babineau, Reference Babineau2014) software to manage duplicates. Two authors (TS and ZB) independently screened the titles, abstracts and full texts of each article using predefined inclusion criteria. Before the actual screening, the two authors conducted a blind review of a sample of articles to ensure a common understanding of the eligibility assessment criteria. Studies where both assessors agreed were included. For studies for which agreement existed only for one of the assessors, a third author (GK) was involved to resolve conflicts. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to present the research results and study selection processes (Figure 1).
A PRISMA flowchart detailing the systematic review process from 2,447 initial records to 21 included studies.
Figure 1. Long description
The flowchart begins at the top with two identification boxes. The left box lists Studies from electronic databases/registers (n = 2,439), including M E D L I N E (n = 357), Cinhal plus (n = 98), Psyc I N F O (n = 387), Embase (n = 350), Scopus (n = 921), and Chocrance systematic reviews (n = 326). The right box lists References from other sources (n = 8), including Citation searching (n = 5) and Grey literature (n = 3).
These combine and lead to a box on the right labeled References removed (n = 1,782), which includes Duplicates identified manually (n = 9) and Duplicates identified by Covidence (n = 779).
The main path continues down to Studies screened (n = 665). An arrow to the right points to Studies excluded after title/abstract screening (n = 553).
The main path continues to Studies sought for retrieval (n = 112). An arrow to the right points to Studies not retrieved (n = 0).
The main path continues to Studies assessed for eligibility (n = 112). An arrow to the right points to a large exclusion box labeled Studies excluded (n = 91). Reasons for exclusion include: Wrong setting (n = 20), Wrong outcomes (n = 15), Wrong indication (n = 6), Wrong intervention (n = 20), Wrong study design (n = 11), Wrong patient population (n = 14), Absence of necessary data (n = 3), and Unclear methodology (n = 2).
The final box at the bottom of the main path indicates Studies included in review (n = 21).
Quality assessment
The JBI Critical Appraisal Checklist for Systematic Reviews (Aromataris et al., Reference Aromataris, Fernandez, Godfrey, Holly, Khalil and Tungpunkom2015) was used to assess the quality of each study. Two authors independently conducted a double appraisal and collaboratively resolved discrepancies with a third author. This checklist consists of 11 questions that evaluate key methodological aspects, including clearly stated objectives, the appropriateness of study inclusion criteria, the adequacy of the literature search strategy, the justification of study selection methods, the assessment and documentation of study quality and the appropriateness of methods used to combine findings. Each criterion aims to ensure the rigorous and transparent conduct of systematic reviews. Responses are categorized as “Yes,” “No,” “Unclear” or “Not Applicable,” with points assigned as “1” for each “Yes” response and “0” for the other responses, facilitating an overall quality assessment (Supplementary File S3). Considering the aim of this review to explore diverse factors and contexts that are involved in clinicians’ decision-making, the author team decided to include review studies with low quality assessment scores.
Data extraction
Data from eligible studies were extracted using a Microsoft Excel spreadsheet initially prepared by authors TS and ZB. To ensure that the spreadsheet effectively addressed the research questions and captured diverse data presentations, it was pilot-tested with a sample of the included studies. Minor revisions were made to the spreadsheet structure based on this pilot testing. Using the refined template, textual descriptions of factors influencing professionals’ decision-making regarding restrictive practices in adult mental health inpatient settings were extracted and entered into the spreadsheet. In instances where these factors were not explicitly stated, implicit statements (Giovannini and Schiemer, Reference Giovannini and Schiemer2021) that indirectly suggested variables influencing decision-making were also considered. For example, for studies mentioning that “Nurses sometimes manage aggression by isolating a person in a quiet space,” we extracted “patient aggression” as a factor contributing to seclusion use. This approach ensured a comprehensive understanding of both explicit and implied messages, thereby maintaining data validity. For mixed-method studies, only qualitative data (verbatim descriptions) of factors involving clinicians’ decision-making for the use of RCPs were extracted when available. Additionally, original characteristics of the included reviews, such as the names of the first authors, publication years, review methods (e.g., type, number of databases searched, number of primary studies included, analysis methods and quality assessment of included studies) and the primary aims of the studies were extracted.
The data extraction process was conducted independently by TS and ZB, and any disagreements that arose between the two authors were resolved with the involvement of a third author (GK) for the conflicting studies.
Data analysis and synthesis
The data analysis process for this umbrella review employed inductive content analysis (Kyngäs, Reference Kyngäs, Kyngäs, Mikkonen and Kääriäinen2020; Vears and Gillam, Reference Vears and Gillam2022) and followed five key steps. First, (1) researchers read and reread the verbatim extracts from each study to develop a comprehensive understanding of the overall message and implications of the data. In the second step, (2) variables influencing professionals’ decision-making (e.g., patient behavior, staff experience and organizational policies) were identified and systematically listed in a table along with their corresponding meaning units (Supplementary File S4). This constituted the initial round of coding. The third step involved (3) a second round of coding, during which these identified variables were tagged to specific portions of the data that represented distinct concepts or themes. In the fourth step, (4) the coded meanings were condensed into a smaller number of broader categories that encompassed multiple codes with similar concepts. Finally, in the fifth step, (5) the condensed categories were further categorized into emergent themes by identifying commonalities and patterns to create higher-order categories (themes):
Theme one: Factors related to healthcare professionals
Theme two: Institutional and organizational factors
Theme three: Patient-related factors
Theme four: The influence of other people suggestion (family or support worker)
Theme five: External influences and pressures
A purely inductive, de novo approach was selected because the literature on restrictive care practices is characterized by substantial conceptual inconsistency and a lack of universally accepted frameworks. Using a deductive framework may have constrained the analysis within existing assumptions and overlooked novel insights. Therefore, an inductive approach was considered most appropriate to allow themes to emerge directly from the data and capture contextual and stakeholder-specific perspectives beyond existing frameworks.
Results
Search outcomes
In this umbrella review, a total of 2,439 articles were retrieved from the electronic database search, and eight studies were identified through citation searches and gray literature. Of the total studies, 1,782 references were removed, and 665 articles were screened based on their titles and abstracts. Of these, 553 were excluded during the title/abstract screening, and 112 studies proceeded to a further full-text review. During this phase, 91 studies were excluded for the following reasons, including ineligible study setting (Emergency Departments [Eds]) (Owiti and Bowers, Reference Owiti and Bowers2011; Hansen et al., Reference Hansen, Hazelton, Rosina and Inder2020), non-inpatient mental health settings (Hidayat et al., Reference Hidayat, Lawn, Muir-Cochrane and Oster2020), ineligible population (children and adolescents [Nielson et al., Reference Nielson, Bray, Carter and Kiernan2021], geriatric populations, populations with primary neurodevelopmental or cognitive disorders), forensic psychiatric inpatient settings and ineligible review type (e.g., narrative reviews or reviews without a qualitative synthesis). Finally, 21 review studies met the inclusion criteria and were included in the synthesis for this umbrella review (Figure 1).
Characteristics of included reviews
The majority of the included reviews took a global perspective, although only one focused solely on Norwegian studies (Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014). Some reviews had predefined publication timeframes, while others considered all articles available online up to the time of the review. The overall publication years of the included studies spanned from 1990 (Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a) to 2022 (Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023). We also identified differences in the outcomes of interest across the reviews. Some reviews used general terms such as “restrictive intervention,” “restrictive practice” or “coercion” to encompass multiple types of intervention practices, while others focused on specific RCPs (Table 2).
Original characteristics of systematic review studies included in this umbrella review
Table 2. Long description
The table consists of nine columns: Study/publication year, Databases searched, Outcomes examined, Publication years of included studies, Aims, Population Focus, Number of studies included, Quality appraisal tools used, and Current quality assessment score.
Key entries include:
* Goethals et al., 2012a: Searched C I N A H L, Embase, Medline, PsycINFO, and Web of Science. Focused on physical restraint and seclusion decision-making by nurses. Included 12 studies with a quality score of 10.
* Sugiura et al., 2020: Searched C I N A H L, E R I C, M E D L I N E, PsycINFO, and Japanese databases. Examined involuntary admission experiences. Included 37 studies with a quality score of 11.
* Doedens et al., 2020: Focused on attitudes of nurses toward seclusion, physical restraint, and forced medication. Included 84 studies with a quality score of 10.
* Pedersen et al., 2023: Synthesized evidence on nurses’ decision-making in rapid tranquilization. Included 11 studies with a quality score of 11.
* Muir-Cochrane et al., 2020: Examined trends in chemical restraint for emergency management. Included the largest sample of 311 studies with a quality score of 10.
* Bennetts et al., 2024a: Explored perceptions of restrictive practice elimination from user and practitioner perspectives. Included 44 studies with a quality score of 11.
* Elwyn et al., 2025: Explored restraint and seclusion as human rights violations. Included 62 studies with a quality score of 11.
Commonly used databases across all studies include C I N A H L, Medline, Embase, and PsycINFO. Quality assessment scores range from 8 to 11, with most studies scoring 11. Appraisal tools mentioned include C A S P, M M A T, and the Newcastle-Ottawa Scale.
The terminology included physical restraint (and the combined use of seclusion) (Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a); seclusion and restraint (Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013); seclusion, mechanical restraint, physical restraint and compulsory medication (Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020); restraint, seclusion, involuntary admission and other coercive measures (Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014); physical/mechanical and chemical restraint (Jarrett et al., Reference Jarrett, Bowers and Simpson2008); seclusion, restraint and compulsory medications (Jackson et al., Reference Jackson, Baker and Berzins2018); and restrictive practices in general (Butterworth et al., Reference Butterworth, Wood and Rowe2022). In contrast, some reviews strictly operationalized a single form of restrictive intervention in their review process, such as involuntary admission (Sugiura et al., Reference Sugiura, Pertega and Holmberg2020), chemical restraint (Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023), coercive medication (Chieze et al., Reference Chieze, Clavien, Kaiser and Hurst2021a) and physical/mechanical restraint (Riahi et al., Reference Riahi, Thomson and Duxbury2016; Wong and Bressington, Reference Wong and Bressington2022).
Regarding study participants, 10 reviews involved only nurses (Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Riahi et al., Reference Riahi, Thomson and Duxbury2016; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Hansen et al., Reference Hansen, Hazelton, Rosina and Inder2020; Butterworth et al., Reference Butterworth, Wood and Rowe2022; Wong and Bressington, Reference Wong and Bressington2022; Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023), while several others did not specify the types of professionals involved and instead used the general term “staff.” Regarding the specific professional roles influencing decision-making regarding restrictive care practices particularly nurses and psychiatrists, across the included qualitative reviews, nurses generally described making immediate decisions based on continuous patient observation, safety concerns and de-escalation efforts, whereas psychiatrists were more commonly responsible for authorizing restrictive interventions and balancing clinical, legal and ethical considerations. These differing responsibilities resulted in variations in the thresholds for initiating restrictive care practices. Only 14 of the reviewed studies explicitly reported the quality assessment tools they used to evaluate their studies (Table 2).
Factors involved in healthcare professionals’ decision-making to use RCPs
Across the included reviews, a diverse range of contexts has been identified as influencing professionals’ decision-making regarding the use of restrictive practices in adult mental health inpatient settings (Supplementary File S4). These factors include patient-related variables such as sociodemographic characteristics, clinical presentations and personal beliefs about RCPs and mental health. Healthcare provider-related factors were also highlighted, including personal values, knowledge, experience, sociodemographic characteristics, emotional well-being and feelings of safety. Furthermore, input from other individuals such as staff suggestions, managerial directives, physicians’ orders and family or caregiver preferences was recognized as shaping professionals’ clinical decisions. External factors, including laws, policies, cultural norms, public opinion and research funding, were also noted for their direct or indirect impact on the decision-making process regarding the application of RCPs (Table 3). This umbrella review identified five emergent themes summarizing the broad spectrum of factors influencing professionals’ decision-making to apply restrictive practices (Figure 2).
Emergent themes, categories and codes identified as factors influencing healthcare professionals’ decision-making regarding the use of restrictive practices in adult mental health inpatient settings
Table 3. Long description
The table is organized into three columns: Generated emergent themes, Categories included within each theme, and Conceptual codes identified and grouped within each category.
Theme one: Factors related to healthcare professionals.
- Personal attitude and perspectives: Includes attitudes toward mental illness, moral values, fear of harm, and perception of R C P as a nursing intervention.
- Workplace dynamics and emotional well-being: Includes professional burnout, workload, role conflict, and organizational culture.
- Level of knowledge and experience: Includes familiarity with alternatives, prior experience with violence, and awareness of physical complications.
- Sociodemographic characteristics: Includes gender, age, ethnicity, and education level.
Theme two: Organizational factors.
- Staffing system: Includes patient-staff ratios, staff composition, and communication methods.
- Ward environment: Includes physical design, ward type, overpopulation, and patient-staff relationships.
- Availability of resources: Includes access to safety protocols, training programs, and resource constraints.
Theme three: Patient-related factors.
- Sociodemographic characteristics: Includes gender, age, and socioeconomic status.
- Current clinical presentation: Includes severity of symptoms, risk of harm, refusal of treatment, and substance use.
- Previous history: Includes prior exposure to R C P, history of aggression, and response to de-escalation.
- Service users’ views: Includes feelings of safety, trust in staff, and desire for independence.
Theme four: Influence of other people’s suggestion.
- Family or caregivers involvement: Includes family perspectives on R C P and their relationship with the patient.
- Influence of other staff: Includes physician orders and team consensus.
- Influence of hospital management: Includes monitoring mechanisms and resource allocation.
- Patient rights advocacy: Includes influence of advocacy groups.
Theme five: External factors.
- Legal and regulatory requirements: Includes national laws and local hospital protocols.
- Cultural norms: Includes community attitudes and public trust.
- Additional factors: Funding opportunities, legal protections, media influence, and research findings.
A footer defines R C P (Restrictive Care Practices) as interventions like physical, mechanical, or chemical restraint, seclusion, and forced medication.
The interrelation of conceptual themes identified from factors influencing healthcare practitioners’ decision-making process to implement restrictive care practices in adult mental health inpatient settings.
Figure 2. Long description
At the top center is a pink circle labeled Healthcare professionals’ decision to use or not to use. Surrounding this central point are five blue rectangular boxes representing different themes.
* Theme One: Professional related contexts is located in the center-left and has double-headed arrows connecting it to the central pink circle, Theme Two, and Theme four.
* Theme Two: Institutional related factors is located in the center-right and has double-headed arrows connecting it to the central pink circle, Theme One, Theme Three, and Theme 5.
* Theme Three: Patient related factors is located at the top-right and has double-headed arrows connecting it to the central pink circle and Theme Two.
* Theme four: Involvement of other people is located at the top-left and has double-headed arrows connecting it to the central pink circle, Theme One, and Theme 5.
* Theme 5: The influence of external is located at the bottom center and has double-headed arrows pointing upward to Theme four and Theme Two, and a single-headed arrow pointing to Theme One.
Each theme encompasses various conceptual categories and codes derived from qualitative data extracted from the included reviews (Table 3). However, the specific effects of certain variables, such as whether they increase or decrease the likelihood of professionals deciding to use restrictive practices, were often unclear. For instance, while age (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) and gender (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) were frequently reported, only a few studies specified which age groups or gender characteristics influenced these decisions. Additionally, variations were observed in how certain factors affected clinical decision-making. Variables identified as motivating factors for healthcare professionals to use restrictive practices in some studies were considered preventive factors in others.
Theme one: Factors related to healthcare professionals
This theme highlights the various intrinsic and extrinsic factors tied to healthcare professionals’ characteristics that influence their decision-making regarding the use of RCPs. It encompasses four key categories: sociodemographic characteristics of healthcare professionals, personal attitudes and perspectives, emotional well-being and levels of knowledge and experience. In addition, workplace dynamics, such as burnout, workload, role conflict, staffing system and type of shift (day or night), are also included in healthcare professional-related factors. Together, these categories provide a comprehensive understanding of how healthcare professional-related factors shape decisions regarding RCPs (Table 3).
Sociodemographic factors, including gender (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), age (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), ethnicity (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), educational background (Jackson et al., Reference Jackson, Baker and Berzins2018; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) and years of experience (Jackson et al., Reference Jackson, Baker and Berzins2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) were identified as significantly influencing on professionals’ decision-making processes regarding the implementation of RCPs in adult mental health inpatient settings. For example, some of the included reviews noted that younger professionals or those with less experience might be more inclined to use restrictive practices due to lower confidence levels and limited safety control (Jarrett et al., Reference Jarrett, Bowers and Simpson2008). Additionally, specific professional roles, such as nurses versus psychiatrists, were found to shape differing responsibilities and thresholds for healthcare professionals’ decision-making processes for implementing RCPs (Wong and Bressington, Reference Wong and Bressington2022; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026).
The second category within this theme focuses on the personal attitudes and perspectives of healthcare professionals, which exert a considerable impact on their decisions. Professionals with strong moral or ethical objections to restrictive practices may prefer noncoercive alternatives (Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024), while others may view these practices as necessary to ensure safety (Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Wynn, Reference Wynn2018; Sugiura et al., Reference Sugiura, Pertega and Holmberg2020; Wong and Bressington, Reference Wong and Bressington2022). Emotional responses, such as guilt, distress or fear of harm, further influence these choices (Wong and Bressington, Reference Wong and Bressington2022; Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b). Additionally, perceptions of restrictive practices as either unavoidable in severe cases or as tools for maintaining security highlight the complexity of reasoning in high-risk scenarios (Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021; Wong and Bressington, Reference Wong and Bressington2022). Decisions about implementing RCPs are profoundly shaped by professionals’ individual training, experience, and personal beliefs regarding patient care and safety (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021) (Table 3).
Workplace dynamics and healthcare professionals’ subjective perceptions of emotional well-being also play critical roles in decision-making and are included as a third category in this theme. Factors such as burnout, high workload, role conflict and time constraints during shifts can lower the threshold for using RCPs (Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Riahi et al., Reference Riahi, Thomson and Duxbury2016; Jackson et al., Reference Jackson, Baker and Berzins2018; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Butterworth et al., Reference Butterworth, Wood and Rowe2022; Wong and Bressington, Reference Wong and Bressington2022; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Emotional responses, such as frustration or anger following aggressive incidents, further complicate the decision-making process (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Riahi et al., Reference Riahi, Thomson and Duxbury2016; Wong and Bressington, Reference Wong and Bressington2022). Additionally, concerns about workplace safety and inadequate staffing intensify the challenges professionals face, making it more difficult to arrive at balanced and ethically sound decisions (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Butterworth et al., Reference Butterworth, Wood and Rowe2022; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Jackson et al., Reference Jackson, Baker and Berzins2018; Kim and Nam, Reference Kim and Nam2024; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Wong and Bressington, Reference Wong and Bressington2022).
The fourth category, level of knowledge and experience, highlights the critical role of expertise in shaping healthcare professionals’ decision-making processes regarding RCPs. Professionals with a strong understanding of de-escalation techniques and a heightened awareness of the risks associated with RCPs are more inclined to consider these measures as a last resort (Riahi et al., Reference Riahi, Thomson and Duxbury2016; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Butterworth et al., Reference Butterworth, Wood and Rowe2022; Wong and Bressington, Reference Wong and Bressington2022; Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Kim and Nam, Reference Kim and Nam2024). Experience in handling violent situations or applying RCPs enhances their capacity to assess threats and explore alternative approaches, such as voluntary medication (Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Jackson et al., Reference Jackson, Baker and Berzins2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021). Furthermore, familiarity with individual patients and their histories allows professionals to better anticipate potential outcomes and customize interventions, fostering safer and more patient-centered care (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013) (Table 3).
Theme two: Institutional and organizational factors
This theme describes the systemic and structural factors influencing healthcare professionals’ decision-making processes regarding the implementation of RCPs. It encompasses three conceptual categories, each including multiple identified codes reported across reviewed studies that affect healthcare professionals’ decision-making. These categories include staffing systems and structures within hospitals, the ward environment and atmosphere and the availability of resources and alternative intervention mechanisms within hospitals, wards or units (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Jackson et al., Reference Jackson, Baker and Berzins2018; Kim and Nam, Reference Kim and Nam2024; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Wong and Bressington, Reference Wong and Bressington2022; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) (Table 3).
For the first category, most of the reviewed studies identified several factors influencing healthcare professionals’ reliance on RCPs, including inadequate patient-to-staff ratios, insufficient full-time staff and the impact of patient-staff ratios on maintaining control in inpatient settings (Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Jackson et al., Reference Jackson, Baker and Berzins2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). The adequacy of full-time nursing staff within teams, staff composition and diversity and the effectiveness of support systems for staff were also recognized as significant factors (Jackson et al., Reference Jackson, Baker and Berzins2018; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Wong and Bressington, Reference Wong and Bressington2022; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). A small number of studies highlighted the importance of staff diversity in decision-making (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Wong and Bressington, Reference Wong and Bressington2022; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). A multidisciplinary team with effective communication, shared decision-making and collaboration among professionals such as nurses, psychiatrists, psychologists and social workers is better equipped to manage aggression through de-escalation techniques rather than coercive interventions (Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020).
For the second category, ward environment and atmosphere, factors such as the physical design and size of the ward, the type of ward (e.g., specialized psychiatric inpatient units or psychiatric units within general hospitals), the mix of individuals with different behaviors or diagnoses, teamwork, staff collaboration, patient-staff relationships, overall team culture, staff communication and the availability of support within the ward were identified as key variables influencing healthcare professionals’ decision-making (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Jackson et al., Reference Jackson, Baker and Berzins2018; Kim and Nam, Reference Kim and Nam2024; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026; Wong and Bressington, Reference Wong and Bressington2022). Overcrowding or poor ward layouts can increase tension, making it more challenging to manage patient behavior and raising the likelihood of relying on RCPs. Support from management and a cohesive staff support system are vital for enhancing professionals’ confidence to manage aggression without resorting to restrictive measures (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021; Sugiura et al., Reference Sugiura, Pertega and Holmberg2020). Furthermore, effective communication among healthcare professionals, their colleagues and line managers, combined with a strong sense of teamwork, was included in this theme (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b).
The third category focuses on technological and resource-driven factors that influence healthcare professionals’ decision-making processes regarding the use of RCPs in adult mental health inpatient settings. Key elements identified within this category include access to safety measures, such as protocols for aggression management, and the availability of decision-making support systems within hospital settings (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Jackson et al., Reference Jackson, Baker and Berzins2018; Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Kim and Nam, Reference Kim and Nam2024; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026; Wong and Bressington, Reference Wong and Bressington2022). The presence of alternative, less restrictive interventions, such as de-escalation strategies, therapeutic options or crisis management teams, has also been found to play a critical role in guiding decisions away from the use of restrictive practices (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Wong and Bressington, Reference Wong and Bressington2022). Additionally, the frequency and quality of staff training programs are vital, as ongoing education enhances professionals’ ability to handle aggression in noncoercive ways (Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Kim and Nam, Reference Kim and Nam2024). Effective documentation tools also support clinical decision-making by ensuring clear records of patient behavior and the actions taken, thereby facilitating transparency and accountability (Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) (Table 3).
Theme three: Patient-related factors
The third theme highlights the various patient-related characteristics and behaviors that influence healthcare professionals’ decisions to implement RCPs. The key contexts included within this framework were socio-demographic characteristics (Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014), current clinical conditions and symptom presentations (Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026; Wong and Bressington, Reference Wong and Bressington2022), prior medical history (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020) and the perspectives of service users (Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021) (Table 3).
For the first category, several factors, including gender (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), age (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), ethnicity (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Jackson et al., Reference Jackson, Baker and Berzins2018; Wynn, Reference Wynn2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), educational level (Jackson et al., Reference Jackson, Baker and Berzins2018; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), years of experience (Jackson et al., Reference Jackson, Baker and Berzins2018; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), occupational background (Jackson et al., Reference Jackson, Baker and Berzins2018; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) and socioeconomic status (Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), have been reported across numerous studies as key contexts that subtly influence healthcare professionals’ perceptions of patient behaviors and their subsequent risk assessments. These sociodemographic variables shape how healthcare providers interpret and respond to patient actions, particularly when deciding whether or not to apply RCPs, which represented the second category in this theme (Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Age, for example, might influence how a professional views the behavior of an older adult versus a younger patient, as aggressive behavior in younger patients may be perceived as more threatening than similar behavior in older adults (Wynn, Reference Wynn2018), while gender or ethnic stereotypes may shape perception of aggression, noncompliance or dangerousness (Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Furthermore, healthcare professionals’ educational level, professional training and occupational experience can influence their understanding of mental health conditions, risk assessments and decisions regarding the use of RCPs (Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). For example, professionals with specialized mental health training may be more likely to use de-escalation strategies instead of coercive interventions. Additionally, healthcare professionals’ socioeconomic backgrounds may influence their empathy, understanding of patients’ social circumstances and decisions regarding restrictive and coercive practices.
The second category addresses patient-related clinical factors that influence healthcare professionals’ decision-making when applying RCPs. This category includes several conceptual codes that were frequently cited across the reviewed studies. These factors encompass the patient’s current clinical presentation, such as the severity of symptoms, the presence of intense mood disturbances (e.g., mania or severe depression), the risk of harm to self or others, suicidal ideation and aggressive behaviors (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo and De Rosa2014; Wynn, Reference Wynn2018; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021; Wong and Bressington, Reference Wong and Bressington2022; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Patients displaying acute agitation, severe psychosis or suicidal tendencies are more likely to be subjected to RCPs due to the immediate risks they pose to themselves or others (Wynn, Reference Wynn2018; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Additionally, factors such as the level of cognitive and functional impairment, patient treatment adherence, substance use and intoxication, as well as the duration and progression of symptoms can alter healthcare professionals’ decision-making processes regarding the implementation of RCPs (Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Furthermore, the type of admission, whether voluntary or involuntary, and whether the admission is emergency-based or scheduled, were also reported as crucial contexts shaping healthcare professionals’ presence to apply restrictive care (Wynn, Reference Wynn2018; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Sugiura et al., Reference Sugiura, Pertega and Holmberg2020; Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). The level of cognitive impairment, substance use and coexisting medical conditions further heighten these risks, often prompting professionals to decide on the use of RCPs (Riahi et al., Reference Riahi, Thomson and Duxbury2016; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) (Table 3).
The third category within this theme highlights factors related to the service user’s perspective on healthcare professionals’ decision-making regarding the implementation of RCPs. Patients’ feelings of safety within the care environment were reported as a determining factor (Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Sugiura et al., Reference Sugiura, Pertega and Holmberg2020; Wong and Bressington, Reference Wong and Bressington2022; Kim and Nam, Reference Kim and Nam2024). A sense of security can influence their willingness to comply with treatment plans, while a lack of safety may increase the likelihood of RCP application (Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Riahi et al., Reference Riahi, Thomson and Duxbury2016; Doedens et al., Reference Doedens, Vermeulen, Boyette, Latour and de Haan2020; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Kim and Nam, Reference Kim and Nam2024; Elwyn et al., Reference Elwyn, Clarke and Jones2025; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Service users’ insight into their illness is another important factor mentioned across reviewed studies; patients who have a clearer understanding of their condition may be less resistant to care, potentially reducing the need for restrictive measures (Riahi et al., Reference Riahi, Thomson and Duxbury2016; Wong and Bressington, Reference Wong and Bressington2022). Consent to be exposed to RCPs plays a significant role (Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024). Patient perspectives on shared decision-making are also key, as those who feel more involved in their care are less likely to require restrictive interventions (Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023). Furthermore, the trust and relationship between the patient and staff significantly impact the application of RCPs (Wong and Bressington, Reference Wong and Bressington2022). Additionally, a patient’s awareness of potential risks, their desire for independence and attitudes toward mental health care and RCPs specifically were reported as factors shaping their interactions with healthcare providers and influencing decision-making in inpatient settings (Wynn, Reference Wynn2018; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021) (Table 3).
Theme four: The influence of other people suggestion (family or support worker)
This theme explored the impact of other individuals on healthcare professionals’ clinical decision-making regarding the implementation of RCPs in adult mental health inpatient settings. It describes how various people, including family members, informal caregivers, colleagues, managers and advocacy groups, influence decision-making processes in these settings (Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Sugiura et al., Reference Sugiura, Pertega and Holmberg2020; Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023; Kim and Nam, Reference Kim and Nam2024; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Each of these groups is represented in a different category within the theme, highlighting the diverse ways in which they shape healthcare professionals’ approaches to RCPs (Table 3).
Family members and informal caregivers often provide crucial insights into the patient’s history, preferences and previous experiences, which can influence decisions about the necessity and appropriateness of restrictive measures (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Goethals et al., Reference Goethals, Gastmans and Dierckx de Casterlé2012b; Kim and Nam, Reference Kim and Nam2024; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026; Sugiura et al., Reference Sugiura, Pertega and Holmberg2020; Wong and Bressington, Reference Wong and Bressington2022). Their perspectives may either support or challenge the healthcare professional’s assessment, impacting the level of care applied. Colleagues and managers play a vital role through collaboration and guidance, with their professional opinions potentially affecting how restrictive care is viewed and enacted (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Peer discussions and management protocols may either reinforce or question decisions around RCPs, depending on the situation and the team dynamic (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Kim and Nam, Reference Kim and Nam2024; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Advocacy groups also have an important influence, advocating for patient rights and promoting alternatives to restrictive interventions, which can encourage healthcare professionals to reconsider or refine their approach to patient care (Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Elwyn et al., Reference Elwyn, Clarke and Jones2025; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026) (Table 3).
Theme five: External influences and pressures
The fifth theme summarized external factors and pressures beyond the hospital setting, including legal, societal, cultural and public media influences that can shape healthcare professionals’ decision-making regarding the use of RCPs. These external elements interact with patient characteristics, healthcare professionals, caregivers and management teams, influencing when and how RCPs are implemented in clinical settings (Table 3).
Legal factors, including national and international legislation, human rights conventions, policy frameworks and institutional protocols, are prominently reported in the majority of the reviewed studies (Jarrett et al., Reference Jarrett, Bowers and Simpson2008; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021; Wong and Bressington, Reference Wong and Bressington2022; Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Kim and Nam, Reference Kim and Nam2024; Elwyn et al., Reference Elwyn, Clarke and Jones2025; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). These factors play a critical role in shaping healthcare professionals’ decision-making regarding the application of RCPs in psychiatric inpatient settings. The reviewed studies also highlighted that clarity and consistency in laws and protocols are essential, as ambiguity can lead to confusion in decision-making (Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Kim and Nam, Reference Kim and Nam2024; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Furthermore, clinicians sometimes consider the legal repercussions during their clinical decision-making processes when applying RCPs as a means of protecting themselves from legal accountability due to the improper or unnecessary use of these practices (Wong and Bressington, Reference Wong and Bressington2022; Kim and Nam, Reference Kim and Nam2024; Elwyn et al., Reference Elwyn, Clarke and Jones2025; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026).
Across the reviewed studies, societal factors, such as public attitudes and perspectives toward mental health, were identified as significantly influencing how healthcare professionals perceive and respond to patients (Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Riahi et al., Reference Riahi, Thomson and Duxbury2016; Wynn, Reference Wynn2018; Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Wong and Bressington, Reference Wong and Bressington2022; Kim and Nam, Reference Kim and Nam2024). This, in turn, affects their language and the types of RCPs they select and apply. Stigma surrounding mental illness is viewed as a factor that leads to a more punitive approach (Hawsawi et al., Reference Hawsawi, Power, Zugai and Jackson2020), while broader movements advocating for patient rights may promote less restrictive measures (Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Elwyn et al., Reference Elwyn, Clarke and Jones2025; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Many studies reported cultural influences, including the values and beliefs held by healthcare teams, patients and communities, as variables that impact the perception and application of RCPs (Riahi et al., Reference Riahi, Thomson and Duxbury2016; Muir-Cochrane et al., Reference Muir-Cochrane, Oster and Grimmer2020; Muir-Cochrane and Oster, Reference Muir-Cochrane and Oster2021; Butterworth et al., Reference Butterworth, Wood and Rowe2022; Wong and Bressington, Reference Wong and Bressington2022; Kim and Nam, Reference Kim and Nam2024; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Additionally, public trust and media portrayals were identified as key factors shaping the implementation of RCPs; negative media coverage or public backlash may pressure healthcare institutions to reduce their use, prompting a shift toward alternative approaches (Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Kim and Nam, Reference Kim and Nam2024; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026). Other contexts, such as funding and resource allocation, research findings and their interpretations (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Goethals et al., Reference Goethals, de Casterlé and Gastmans2012a; Jackson et al., Reference Jackson, Baker and Berzins2018; Wong and Bressington, Reference Wong and Bressington2022; Olaye et al., Reference Olaye, Mitra, Erohubie and Oriji2026), and political commitment including the integration of different approaches, such as least restrictive care and recovery-oriented strategies within national and local health initiatives, were also found to have direct or indirect effects on healthcare professionals’ decisions to implement RCP techniques (Laiho et al., Reference Laiho, Kattainen, Åstedt-Kurki, Putkonen, Lindberg and Kylmä2013; Pedersen et al., Reference Pedersen, Gildberg, Laulund, Jørgensen and Tingleff2023; Cortinhal et al., Reference Cortinhal, Correia and Deodato Fernandes2024; Elwyn et al., Reference Elwyn, Clarke and Jones2025) (Table 3).
Discussion
In mental healthcare settings, professionals frequently employ RCPs, such as physical restraint, mechanical restraint, seclusion and other coercive measures, to manage challenging behaviors and ensure safety (Di Lorenzo et al., Reference Di Lorenzo, Baraldi, Ferrara, Mimmi and Rigatelli2012). However, the use of these practices remains highly controversial due to their associated physical and psychological harms (Chiba and Subramaney, Reference Chiba and Subramaney2015). Clinicians therefore frequently encounter ethical and legal dilemmas when determining whether and how to implement RCPs, with decision-making shaped by a range of interrelated factors (Hamann et al., Reference Hamann, John, Holzhüter, Siafis, Brieger and Heres2020).
The findings of this umbrella review extend existing literature by integrating evidence across multiple systematic reviews, settings and professional domains to provide a more comprehensive understanding of decision-making processes. Unlike individual systematic reviews that typically focus on specific interventions, settings or populations, this synthesis demonstrates that the use of RCPs is shaped by an interconnected set of factors operating at multiple levels, including healthcare professional characteristics, patient-related factors, institutional and contextual conditions, interpersonal influences and broader external pressures such as legal frameworks, international conventions and cultural norms. Importantly, this review shows that these factors do not operate in isolation but interact dynamically, producing variability in practice across and within settings.
By synthesizing evidence across diverse contexts, this umbrella review highlights a key contribution that has not been fully articulated in previous individual reviews: the cumulative and interacting nature of influences on decision-making, rather than single-factor explanations. This integrated perspective helps explain why inconsistencies in the use of RCPs persist despite existing guidelines and reduction efforts. In particular, the review identifies how unconscious biases, institutional norms and external regulatory pressures converge to shape clinical judgment (Chieze et al., Reference Chieze, Courvoisier, Kaiser, Wullschleger, Hurst and Bardet-Blochet2021b).
These findings suggest that improving practice requires not only awareness of individual factors but also recognition of their interaction across system levels. Accordingly, targeted training programs that address both conscious and unconscious influences may support more consistent decision-making (Staggs, Reference Staggs2020; Griffith et al., Reference Griffith, Meyer, Maguire, Ogloff and Daffern2021). Furthermore, fostering collaborative, multidisciplinary decision-making frameworks may help reduce variability and promote ethically grounded practice across settings (Hupé et al., Reference Hupé, Larue and Contandriopoulos2024; Savage et al., Reference Savage, Lepping, Newton-Howes, Arnold, Staggs and Kisely2024).
This umbrella review demonstrates that decision-making regarding RCPs is a complex, system-level process rather than solely an individual clinical act, extending the findings of individual systematic reviews by providing an integrated conceptual understanding (Noda et al., Reference Noda, Sugiyama, Sato, Ito, Sailas and Putkonen2013). The synthesis indicates that healthcare professionals’ decisions emerge from the interaction of clinical judgment with organizational, legal, ethical and sociocultural influences rather than any single factor. While service users’ preferences, mental state and therapeutic relationships remain central to decision-making (Chiba and Subramaney, Reference Chiba and Subramaney2015), institutional policies, legal frameworks, organizational culture, resource availability, staffing levels and the influence of caregivers and administrative or legal stakeholders collectively shape how decisions are made in practice (Di Lorenzo et al., Reference Di Lorenzo, Baraldi, Ferrara, Mimmi and Rigatelli2012; Haefner et al., Reference Haefner, Dunn and McFarland2021; De Monte et al., Reference De Monte, Veitch, Dark, Meurk, Wyder and Wheeler2023). These findings suggest that reducing the use of RCPs requires system-level interventions in addition to individual clinician competence. Developing evidence-based organizational policies, ethical decision-making frameworks and supportive workplace environments can help healthcare professionals make consistent, transparent, and patient-centered decisions while balancing patient autonomy, safety and regulatory requirements (Janssen et al., Reference Janssen, Noorthoorn, Nijman, Bowers, Hoogendoorn, Smit and Widdershoven2013; Lickiewicz et al., Reference Lickiewicz, Adamczyk, Hughes, Jagielski, Stawarz and Makara-Studzińska2020; Belayneh et al., Reference Belayneh, Chavulak, Lee, Petrakis and Haines2024). Furthermore, strengthening monitoring systems and legal accountability for the inappropriate use of RCPs may promote evidence-informed practice, reduce unnecessary restrictive interventions and improve the quality and safety of inpatient mental health care (Staggs, Reference Staggs2020; Ambrosi et al., Reference Ambrosi, Debiasi, Longhini, Giori, Saiani, Mezzalira and Canzan2021).
The conceptual themes identified in this review are not independent but dynamically interrelated, with the presence or absence of one factor influencing others. For example, the clinical presentation of service users, particularly symptom severity, was consistently identified as a key determinant of decisions to apply RCPs. However, assessments of symptom severity are not purely objective; they are shaped by clinicians’ subjective interpretations, which are influenced by their training, experience, cultural norms and moral values (Bowers et al., Reference Bowers, Alexander, Simpson, Ryan and Carr-Walker2004). In turn, these professional factors interact with relational and environmental conditions. For instance, the quality of the therapeutic relationship and the broader ward environment can influence patient behavior, where dissatisfaction with care or restrictive environments may precipitate aggression (Larue et al., Reference Larue, Dumais, Boyer, Goulet, Bonin and Baba2013).
This umbrella review extends existing frameworks by demonstrating how these factors operate across multiple, interacting levels: individual (clinician and patient), interpersonal (therapeutic relationships), organizational (institutional culture and resources) and systemic (legal, cultural and policy contexts). While prior models have often examined these domains in isolation, the integrative conceptual model developed in this review highlights their dynamic interplay and cumulative influence on decision-making. This provides a more comprehensive explanation for the variability observed in the use of RCPs across settings. The model also offers practical implications by identifying key leverage points for intervention, including clinician training, organizational culture and policy alignment. It can be applied to guide the development of structured decision-making frameworks, training programs and institutional policies aimed at reducing bias and improving consistency in practice (Huckshorn, Reference Huckshorn2006; Hext et al., Reference Hext, Clark and Xyrichis2018; Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b). Furthermore, the model is amenable to empirical testing, for example, through examining how interactions between clinician characteristics, environmental conditions and policy constraints influence RCP use across different settings. Understanding these interrelationships is essential for advancing more consistent, ethical and evidence-informed approaches to the use of restrictive practices in mental health care (Muluneh et al., Reference Muluneh, Chavulak, Lee, Petrakis and Haines2025).
While the majority of included studies identified similar variables, the direction and strength of their influence on the use of RCPs were often inconsistent. For example, service user age was frequently reported as a relevant factor; some studies suggest that younger patients are more likely to be subjected to RCPs, whereas others report higher use among older individuals. Similarly, although greater professional experience is often associated with reduced reliance on restrictive measures and increased use of de-escalation techniques, other studies indicate that less experienced staff may either resort more quickly to RCPs due to uncertainty or, conversely, avoid their use due to concerns about legal accountability and institutional expectations. Rather than reflecting contradictory evidence alone, these inconsistencies highlight the importance of situational and contextual conditions in shaping how such factors operate. This umbrella review suggests that individual-level characteristics such as age or professional experience do not independently determine the use of RCPs; instead, their influence is contingent on the contexts in which they are embedded. For instance, staffing levels, institutional culture, availability of training, legal frameworks and the acuity of the clinical environment may either amplify or mitigate the effect of these factors on decision-making. This finding extends previous literature by demonstrating that variability in RCP use is not simply attributable to differences in individual characteristics, but to the interaction between these characteristics and broader organizational and systemic conditions. It also reinforces the need to move beyond single-factor explanations and toward context-sensitive approaches that account for how environmental and situational dynamics shape clinical decisions. Addressing this complexity is essential for developing more effective and contextually appropriate strategies to reduce the use of restrictive practices (Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin, Forrester-Bowling and McLure2024a).
Implication and future recommendations
This review provides valuable insights into the complexities of professional decision-making and supports the development of more ethical and effective approaches to managing challenging behaviors in mental health settings (Hamann et al., Reference Hamann, John, Holzhüter, Siafis, Brieger and Heres2020). The findings have important implications for clinical practice and future research by informing the design of structured decision-support tools, standardized training in de-escalation and ethical decision-making and multidisciplinary approaches that promote consistent, evidence-informed decisions regarding restrictive care practices (Staggs, Reference Staggs2020; Griffith et al., Reference Griffith, Meyer, Maguire, Ogloff and Daffern2021). Understanding the factors influencing decision-making can also support individualized care planning and the early identification of situations in which less restrictive alternatives may be appropriate, thereby promoting patient-centered care (Ye et al., Reference Ye, Wang, Xiao, Xia, Yu and Lin2019).
Overall, this study demonstrates that clinicians’ decisions regarding RCPs are influenced by multiple interacting contextual factors, which may result in inconsistent practices across settings and professionals when decisions rely primarily on subjective clinical judgment (Belayneh et al., Reference Belayneh, Chavulak, Lee, Petrakis and Haines2024). The absence of common definitions, together with differing perspectives on mental health and RCPs, further contributes to variability in decision-making (Gonzalez-Torres et al., Reference Gonzalez-Torres, Fernandez-Rivas, Bustamante, Rico-Vilademoros, Vivanco, Martinez, Vecino, Martín, Herrera, Rodriguez and Saenz2014). In addition, healthcare organizations, administrative policies, caregivers and legal frameworks shape healthcare professionals’ decisions, highlighting that improvements require system-level as well as individual-level interventions (Välimäki et al., Reference Välimäki, Lam, Hipp, Cheng, Ng and Ip2022). These findings support the development of standardized definitions, evidence-based clinical guidelines, structured decision-making frameworks and consistent legal and organizational policies to guide the appropriate use of RCPs (Donovan, Reference Donovan2022; Chavulak et al., Reference Chavulak, Smyth, Sutcliffe and Petrakis2024). Such measures could strengthen multidisciplinary collaboration, improve transparency and consistency in clinical decision-making, reduce unwarranted variation in practice and promote a more patient-centered and ethically responsible mental health care system (Huckshorn, Reference Huckshorn2006; Hext et al., Reference Hext, Clark and Xyrichis2018; Bennetts et al., Reference Bennetts, Pepin, Moylan, Carolin and Lucas2024b).
Limitations
The primary limitation of our review stems from the inherent challenge of synthesizing evidence related to various forms of RCPs. As a result, we were unable to separately analyze and present the factors involved in healthcare practitioners’ decision-making for different forms of RCPs, such as physical restraint, seclusion, forced medication and others. This means that variables significantly affecting a clinician’s decision-making regarding physical restraint may not have the same impact on decisions related to other forms of practice, such as chemical restraint. This limitation arises because many of the reviewed studies reported factors in a general manner for all RCPs, without distinguishing between the different forms. Future research should separately analyze the factors influencing healthcare practitioners’ decision-making for various forms of RCPs to provide a more nuanced understanding of the specific influences on each practice (Al-Maraira and Hayajneh, Reference Al-Maraira and Hayajneh2019; van Dorp et al., Reference van Dorp, Nijhof, Mulder and Popma2021).
The second limitation is that this review summarized and synthesized factors involved in the decision-making of various healthcare professionals, including general nurses, psychiatric nurses, psychiatrists, general practitioners and others working in adult mental health inpatient settings. However, it did not examine factors that may be specifically applicable to different professional groups. To mitigate this limitation, a key recommendation is to collect and separately synthesize data tailored to the type of restrictive practice and the specific professional groups involved. This nuanced approach would significantly enhance our understanding by enabling direct comparisons of factors and their varying influences on professionals’ decision-making.
The third limitation of our umbrella review is its qualitative nature. While the qualitative approach provides valuable insights into the subjective experiences and perceptions of professionals, it lacks the capacity to perform statistical estimations on the extent to which each factor and context influences healthcare professionals’ decision-making in the implementation of RCPs in adult mental health inpatient settings. We recommend that future large-scale surveys or longitudinal studies be conducted to quantify the influence of different factors on healthcare professionals’ decision-making and should integrate qualitative and quantitative evidence through mixed-methods or mixed-evidence syntheses to examine both the contextual mechanisms underlying healthcare professionals’ decision-making and the relative contribution of individual, organizational and systemic factors in predicting restrictive care practice use. This would provide a clearer understanding of the actual effects of different factors and the relationships between them, enabling valid comparisons across diverse settings and professional groups. In addition, the overlap of primary studies across the included systematic reviews was not formally assessed using an overlap matrix or Corrected Covered Area (CCA), as the review synthesized qualitative findings rather than quantitatively pooling primary study data. Thus, future reviews should incorporate formal overlap assessment to strengthen the interpretation of synthesized evidence.
Furthermore, this umbrella review found that most included qualitative reviews were based on studies from high-income settings, with limited LMIC evidence. Therefore, the proposed framework reflects the current evidence base rather than a universally applicable global model. Its transferability to LMIC settings should be interpreted cautiously until context-specific evidence validates and refines the framework. Thus, future research should prioritize qualitative studies and evidence syntheses in LMICs to validate and refine the proposed framework, examining how legal, organizational, resource and sociocultural contexts shape healthcare professionals’ decision-making regarding restrictive care practices.
The exclusive inclusion of studies published in the English language presents a significant limitation. By focusing solely on English-language studies, the review may overlook relevant findings and insights from non-English-speaking regions, potentially constraining the scope and generalizability of the conclusions drawn. Future reviews should consider incorporating studies in multiple languages to ensure a more comprehensive synthesis of global evidence and provide a more inclusive understanding of the topic.
Conclusions
The findings of this umbrella review highlight that the use of restrictive care practices in mental health inpatient settings is shaped by a complex interplay of factors that extend beyond the control of healthcare professionals and service users. Organizational dynamics, environmental contexts, the roles of other stakeholders and external pressures such as policy requirements and cultural norms significantly influence healthcare professionals’ decision-making. This complexity often leads to ethical and legal dilemmas regarding whether restrictive care practices are necessary in specific situations and which techniques are most appropriate, contributing to subjectivity and variations in clinical practice. Addressing these challenges requires establishing holistic and consistent frameworks to guide clinicians’ decision-making processes. Such frameworks can help healthcare professionals navigate these multifaceted factors and reconcile them with their clinical judgments, ultimately fostering greater consistency in practice and improving patient outcomes through the delivery of safe, least restrictive and evidence-based care. Moreover, the proposed framework represents an evidence-informed synthesis of the existing literature rather than a universally applicable global model. While it offers a useful conceptual foundation for understanding decision-making, its applicability across diverse healthcare systems, particularly in LMICs, requires further empirical evaluation and contextual refinement.
Relevance for clinical practice
This study systematically identified and summarized a range of factors and contexts that influence clinicians’ decision-making regarding the use of RCPs in adult mental health inpatient settings. By synthesizing qualitative reviews, it highlights key determinants such as ethical considerations, staff training, patient behavior and organizational culture that affect healthcare professionals’ individual clinical decisions and contribute to inconsistencies in clinical practice. These insights provide healthcare professionals with comprehensive evidence to help them navigate the multiple dimensions involved in decisions about applying these practices. Furthermore, the findings support the development of targeted interventions, policy reforms and training programs that foster ethical, consistent and evidence-based care. This ultimately contributes to reducing the unnecessary use of RCPs and promotes least restrictive, recovery-oriented approaches that enhance safety and accelerate individuals’ recovery journeys.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10315.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2026.10315.
Acknowledgments
The authors would like to acknowledge all authors of included reviews for their contribution to the field.
Author contributions
Conceptualization, data curation, formal analysis, investigation, methodology, project administration, software, resources, supervision, visualization, validation, interpretation of data, writing – original draft, writing – review and editing: T.S. Acquisition of data, software, interpretation of data, review and editing: G.K. Acquisition of data, resources, supervision, review and editing: M.A. Acquisition of data, interpretation of data, review and editing: A.M. Acquisition of data, interpretation of data, review and editing: Y.A. Acquisition of data, interpretation of data, review and editing: G.N. Acquisition of data, interpretation of data, review and editing: T.E. Acquisition of data, software, review and editing: B.Y. Acquisition of data, software, review and editing: Y.R. Acquisition of data, software, review and editing: M.T. Acquisition of data, software, review and editing: T.W. Acquisition of data, software, review and editing: N.A. Acquisition of data, resources, interpretation of data, review and editing: E.S. Conceptualization, data curation, formal analysis, investigation, methodology, project administration, software, resources, supervision, visualization, validation, interpretation of data, review and editing: Z.B. All authors read and approved the final manuscript critically for important intellectual content. All authors have given final approval of the present version to be published.
Competing interests
The authors declare no competing interests.
Data availability statement
Data or details of the underlying processes of this umbrella review are available upon request from the corresponding author.
Ethics and approvals
This study did not involve primary data collection, and all the data reported in this article were extracted from previously published studies, where ethical approval was not required.
Funding statement
This work did not receive any specific funding.
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