The Barriers and Enablers to the Use of Alternative Approaches to Restrictive Practices: A Scoping Review and Causal Loop Diagram.

aimThe use of restrictive practices in acute mental health services has long been a contentious issue globally, with well-documented harms for both service users and the practitioners required to implement them. Existing research examining what influences the uptake of alternative approaches could benefit from synthesis through a qualitative systems thinking lens, enabling deeper insights into key leverage points and the development of dynamic hypotheses. This study aimed to review the literature and develop a Causal Loop Diagram (CLD) to visualise how interconnected pathways within the literature describe the potential elimination of restrictive practices in adult acute mental healthcare services.

designA scoping review informed by Arksey and O'Malley's framework was undertaken, combined with a qualitative systems thinking approach to synthesise findings into a CLD.

methodsA systematic search and inclusion strategy identified 20 relevant articles exploring barriers and enablers to alternative approaches to restrictive practices. Key findings were extracted and synthesised, then mapped into a CLD comprising four domains: (1) peer support, relationships and communication; (2) staff capacity and the clinical environment; (3) practitioner decision-making processes; and (4) transforming practice away from the status quo.

resultsThe CLD illustrates how multiple, interdependent factors interact to influence the use of restrictive practices. It highlights the dynamic relationships between relational practices, workforce capacity, environmental conditions and clinical decision-making. The model provides a systems-level representation of the 'topography' of the literature and identifies potential feedback loops and leverage points for change, supporting the development of hypotheses for reducing restrictive practices. PATIENT OR PUBLIC CONTRIBUTION: No patients or members of the public were involved in the design, conduct, or reporting of this research.