City Research Online

Abstract

Aims
Efforts to reduce restrictive practices (RPs) in mental health care are growing internationally. Yet, inconsistent definitions and perspectives often challenge the consistent implementation and evaluation of reduction strategies. This study explored which scenarios different mental health stakeholders classify as RPs, examined the contextual factors influencing these classifications and compared classification patterns across clinicians, researchers, service users and family caregivers.

Methods
An international cross-sectional survey was conducted using a multilingual online questionnaire hosted on the Qualtrics platform. A total of 851 stakeholders participated, including clinicians (n = 517), service users (n = 80), family caregivers (n = 89) and researchers (n = 165). Participants were presented with 44 potential RP case scenarios and asked to rate whether each scenario should be classified as an RP using a four-point Likert scale (Definitely yes, Probably yes, Probably no, Definitely no). The scenarios were organized into 22 paired comparisons, each sharing the same core context but differing in specific details. Paired comparisons were analyzed one pair at a time, allowing us to identify classification patterns between the scenarios and isolate the effects of particular contextual factors using ordered logistic regression. Interaction analyses were then conducted to assess how classification patterns varied across stakeholder groups.

Results
Substantial discrepancies exist both within and between stakeholder groups regarding whether a given action should be considered an RP or not. Physically visible actions were often identified as RPs across all groups, while less visible forms often went unrecognized. Contextual differences, such as the healthcare professional’s intention, duration of the action, methods used, presence or absence of consent, door-locking status, and the severity of anticipated harm to be prevented influenced whether a given action was classified as an RP. Service users classified more scenarios as RPs than other groups; however, their decisions were more context-sensitive, shifting notably even with minor changes in scenario details. Among the 22 paired scenarios compared, 13 (59.09%) showed significant differences (p < 0.01) within at least one stakeholder group and eight demonstrated differences between groups.

Conclusions
Mental health stakeholders’ interpretations of RPs were often shaped not only by the inherent coercive nature of actions but also by the context in which they occurred and the professional role of the assessors. This underscores the need for harmonized definitions and classification frameworks for RPs, co-designed with diverse stakeholders. Addressing less visible forms of RPs in policy and clinical practice is also essential.

Publication Type:	Article
Additional Information:	This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited. © The Author(s), 2025. Published by Cambridge University Press.
Publisher Keywords:	classification, coercion, interpretation, perspective, restraint, restrictive practices, seclusion, sedation, stakeholder perspectives, stakeholders
Subjects:	R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Departments:	School of Health & Medical Sciences School of Health & Medical Sciences > Department of Nursing & Midwifery
SWORD Depositor:	Symplectic Administrator

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