Open research questions in Healthcare Decision-Making and Restraints

What the literature leaves open

• Current tests of capacity are limited in their ability to assess the impact of comorbid depression on decision-making capacity. The proposed assisted dying legislation does not adequately consider comorbid mental illness. There is a need for more nuanced approaches to assessing capacity in terminally ill patients with comorbid depression.

  Comorbid depression can compromise capacity: a consequential complication for assisted dying considerations · 2026 · DOI

• Further research is needed to evaluate the value of seclusion or restraint in serious mental illness, - studies should investigate the effects of specific components of EIP care on restrictive interventions

  From early intervention in psychosis to intensive care: correlates of restrictive psychiatric practice in a national retrospective cohort study · 2026 · DOI

• Limited understanding of the factors associated with the use of restrictive interventions in psychosis treatment. Lack of evidence on the impact of specific EIP components on the need for restrictive practice. Need for studies using population-level routine outcome data to examine the associations between EIP care components and restrictive interventions.

  From early intervention in psychosis to intensive care: correlates of restrictive psychiatric practice in a national retrospective cohort study · 2026 · DOI

• There is a lack of robust, context-specific evidence on patient safety in psychiatric settings. Gaps in oversight and organisational learning deficits have been identified in acute in-patient mental health services. The paper seeks to address the gap in understanding how to improve accountability in these settings.

  Accountability in acute in-patient mental healthcare: advancing structural and cultural change · 2026 · DOI

• The lack of evidence for neuroprogression - The presence of logical errors in the assumptions made by Vieta - The need for alternative explanations for the observed phenomena

  When wrong is assumed right: a response to vieta · 2024 · DOI

• While patient-related factors have been extensively studied, staff-related factors remain insufficiently understood.

  Staff attitudes towards coercion in psychiatry: The role of violence, emotional burden, and insecurity – Evidence from a nationwide study using multiple regression and moderation analyses · 2026 · DOI

• However, limited evidence exists on how Italian mental health nurses (MHNs) perceive the appropriateness of such practices and the influencing factors.

  Mental Health Nurses' Perceived Appropriateness of Coercive Measures and Security Technologies in Psychiatric Settings: A National Cross‐Sectional Study · 2026 · DOI

• Conclusion Despite mixed results, the evaluation offers support that structured therapeutic responding helps minimise restrictive practices, without evidence suggesting a substitution of one form of coercion for another.

  Maximising relational capabilities and minimising restrictive practices in acute mental health units: the Safe Steps for De-escalation evaluation · 2025 · DOI

• Relational and legal factors were most consistently associated with perceived coercion, while individual and clinical factors showed inconsistent findings.

  Factors Associated with Perceived Coercion in Adults Receiving Psychiatric Care: A Scoping Review · 2025 · DOI

• Although skin-to-skin care (SSC) in intubated infants receiving mechanical ventilation (MV) is challenging, its impact on the incidence of UEs has not been reported.

  Risk factors and short-term respiratory outcomes associated with unplanned extubations during neonatal intensive care · 2025 · DOI

• Aim: The aim of this study is to evaluate the validity and reliability of three instruments developed to fill this gap in the literature, the World Health Organization's QualityRights (WHO QR) Knowledge questionnaire, the WHO QR Attitudes questionnaire, and the WHO QR Practices questionnaire.

  Evaluating the psychometric properties of three WHO instruments to assess knowledge about human rights, attitudes toward persons with mental health conditions and psychosocial disabilities, and practices related to substitute decision-making and coercion in mental health · 2024 · DOI

• Despite this, little is known about how often these interventions are used for children and adolescents.

  Detention of children and adolescents under mental health legislation: a scoping review of prevalence, risk factors, and legal frameworks · 2024 · DOI

• There is a lack of explicit recognition of supported decision-making in federal research regulations. There are legal barriers to the greater use of supported decision-making.

  The Legal Landscape for Supported Decision-Making in the United States and its Application to Clinical Research · 2026 · DOI

• There is limited evidence on patients' experiences in low-resource settings, including Tanzania. The use of physical restraint in psychiatric care remains controversial due to ethical concerns and the risk for physical and psychological harm.

  Patients’ experiences and perceptions of physical restraint in psychiatric care: A descriptive qualitative study at Muhimbili National Hospital · 2026 · DOI

• Future research should focus on multisite and mixed-methods studies to examine the prevalence, determinants, and outcomes of restraint, evaluate the effectiveness and implementation of restraint-reduction strategies and alternatives in resource-limited settings, and gener- ate comparative evidence across Tanzania and sub-Saharan Africa to inform context-appropriate, rights-based policies and practice.

  Patients’ experiences and perceptions of physical restraint in psychiatric care: A descriptive qualitative study at Muhimbili National Hospital · 2026 · DOI

• The challenge of determining a patient's decision-making capacity. The challenge of making decisions for patients who lack decision-making capacity. The challenge of balancing the patient's autonomy with their need for care.

  Treating against a stated refusal · 2026 · DOI

• The gap in understanding how to support patients with diminished decision-making capacity. The need for an ethical decision-making process that honors the patient's values and promotes person-centered care.

  Treating against a stated refusal · 2026 · DOI

• Existing infusion guidelines are not specifically designed for psychiatric patients with aggressive behavior. There is a need for a protocol that addresses the unique challenges of intravenous infusion management in these patients.

  Development of a protocol for intravenous infusion management in patients with aggressive behavior due to mental disorders: A Donabedian framework approach · 2026 · DOI

• The current system is fragile and has significant effects on resident safety. There is a need for a practical, evidence-based framework to improve resident safety and care coordination in post-acute care settings.

  From bedside observation to systems improvement: A practical framework for strengthening resident safety and care coordination in post-acute care settings · 2026 · DOI

• Future research should investigate the implementation of epistemic adequacy in mental health systems. Future research should examine the impact of artificial intelligence on epistemic adequacy in mental health. Future research should explore the development of criteria for functional adequacy and cross-context consistency.

  Epistemic Adequacy: A Ground for Human Rights in Psychiatry · 2026 · DOI

• The paper identifies a gap between normative commitments and clinical reality in mental health. The paper identifies a gap in the system's capacity for context-sensitive judgment. The paper identifies a gap in the consideration of epistemic adequacy in decision-making processes.

  Epistemic Adequacy: A Ground for Human Rights in Psychiatry · 2026 · DOI

• The current policies and practices may not be sufficient to protect the safety and dignity of individuals with serious mental illness, - There is a need for alternative proposals to provide sustainable care to individuals with serious mental illness, - Racial disparities and social determinants of health contribute to poor mental health outcomes

  Policy Analysis of Involuntary Psychiatric Hospital Admission in New York · 2026 · DOI

• Expanding involuntary hospitalization is not sufficient to support long-term treatment for people with severe mental health issues. This paper advocates for alternative proposals, including allocating funding for Assertive Community Treatment programs, strengthening cultural competency in mental health care, providing complete discharge planning and continuity of care, and improving the quality of care at inpatient psychiatric hospitals. ALLOCATE FUNDING FOR ASSERTIVE COMMUNITY TREATMENT PROGRAMS Evidence-based community mental health treatments are more cost-effective and can reduce acute care and hospital stays (Saunders & Rudowitz, 2025). Assertive Community Treatment (ACT) is an accessible form of treatment that can effectively address psychosocial complexities and improve social determinants of health (Balasuriya et al., 2020). ACT involves mobile, evidence-based, intensive, multidisciplinary teams that deliver 24/7 care for people with serious mental illness at risk of psychiatric crisis and hospitalization (Duch et al., 2025). ACT services include psychiatric evaluation, medication management, therapy, supported employment, supported housing, case management, and peer support (Duch et al., 2025). 46 | COLUMBIA SOCIAL WORK REVIEW, VOL. XXIV STEPHANIE CHENG Though ACT is considered an alternative to decrease inpatient care costs, the cost can still be substantial due to its intensive nature, costing an average of $21,481 per person per year, which can limit the extent of its usage (Duch et al., 2025). But these costs will be offset and will decrease in the long term, as inpatient admissions and criminal justice system–related expenses will decrease and use of regular outpatient care will increase (Duch et al., 2025). Value-based payment based on provider performance has been shown to decrease expenditures for ACT and shift high-cost inpatient expenditures to community-based care (Duch et al., 2025). STRENGTHEN CULTURAL COMPETENCY IN MENTAL HEALTH CARE Increased diversity and collaborative care can foster trust in mental health services for people of color with severe mental illness (Maura & Weisman de Mamani, 2017). Integrating cultural perspectives and increasing patients’ involvement in treatment decisions can improve treatment engagement. This can include asking patients about their preferences on treatment and providing options (Maura & Weisman de Mamani, 2017). Cultural competency training can strengthen communication with patients and avoid stigmatizing them (McGregor et al., 2019). Care providers need to maintain cultural humility through ongoing self-reflection and adaptation, and reflect on their own biases and cultural identities, which can affect how they interact with patients (Delfish & Chadha, 2025). Providers can limit implicit bias by attending workshops or seminars to broaden their knowledge about cultural diversity in mental health care (Delfish & Chadha, 2025).

  Policy Analysis of Involuntary Psychiatric Hospital Admission in New York · 2026 · DOI

• The possibility that surrogate authority may be exercised by proxies whose motives are shaped by financial or personal self-interest has received limited attention in the philosophical literature. The structural vulnerability of the substituted judgment standard has not been fully addressed.

  Autonomy under uncertainty: the structural limits of substituted judgment in clinical practice · 2026 · DOI

• The substituted judgment standard emerged within Anglo-American bioethics and legal theory as an attempt to extend patient autonomy beyond the loss of decisional capacity. Rather than determining what is objectively best for the patient — the alternative best interests standard — it requires the surrogate to reconstruct the decision the patient would have made under current circumstances. The normative ambition 1 3B. Nikolic is substantial: it treats incapacitated patients as subjects with continuing autonomous histories rather than as objects of beneficent intervention. The model’s philosophical presuppositions are demanding. It assumes that patients possess coherent and stable values, that those values have been adequately communicated to and retained by surrogates, and that surrogates are willing and able to set aside their own preferences in favour of faithful reconstruction. Advance directives represent the paradigmatic institutional expression of this aspiration: a mechanism by which patients may speak prospectively into situations they may not be able to address in the moment. The epistemic difficulties of the model are well documented. Patients rarely articulate preferences for every clinically relevant scenario, requiring surrogates to extrapolate from fragmentary evidence. Empirical research has consistently demonstrated that surrogate decision-makers frequently misjudge patient preferences even when acting in demonstrable good faith (Shalowitz et al. 2006, Fagerlin et al. 2004, Rid and Wendler 2014). Reconstruction is necessarily interpretive, and interpretation is subject to systematic distortion. Buchanan and Brock’s foundational account acknowledges these difficulties while maintaining that substituted judgment remains normatively preferable to abandoning the aspiration of autonomy-preservation altogether (Buchanan and Brock 1989, Sulmasy and Snyder 2010). Philosophical accounts of relational autonomy have further enriched this picture. Mackenzie and Stoljar’s influential framework emphasises that autonomy is not merely an intrinsic property of individual agents but a condition that can be supported or undermined by social relationships and institutional structures (Mackenzie and Stoljar 2000). Pellegrino’s virtue-based account of clinical medicine directs attention to the dispositional character of the practitioner as an essential component of ethically adequate care — a dimension that procedural frameworks alone cannot fully capture (Pellegrino and Thomasma 1993). O’Neill’s analysis of trust in bioethics argues that autonomy-respecting procedures must take seriously the conditions under which trust can be legitimately extended or withheld (O’Neill 2002). What these accounts have examined less thoroughly is a distinct form of failure: motivational corruption at the level of the surrogate relationship itself.

  Autonomy under uncertainty: the structural limits of substituted judgment in clinical practice · 2026 · DOI

Most-cited papers in Healthcare Decision-Making and Restraints

• Coming to Terms With the Terms of Risk · Archives of General Psychiatry · 1997 · 1,085 citations
• Dropping out of treatment: A critical review. · Psychological Bulletin · 1975 · 769 citations
• Patient non-compliance: Deviance or reasoned decision-making? · Social Science & Medicine · 1992 · 569 citations
• A New Brief Instrument for Assessing Decisional Capacity for Clinical Research · Archives of General Psychiatry · 2007 · 558 citations
• Tests of competency to consent to treatment · American Journal of Psychiatry · 1977 · 447 citations
• THE PSYCHIATRIC NURSE AS A BEHAVIORAL ENGINEER1 · Journal of the Experimental Analysis of Behavior · 1959 · 407 citations
• Critical dimensions in the choice and maintenance of successful treatments: Strength, integrity, and effectiveness. · Journal of Consulting and Clinical Psychology · 1981 · 397 citations
• Patient-focused research: Using patient outcome data to enhance treatment effects. · Journal of Consulting and Clinical Psychology · 2001 · 361 citations
• Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial · International Journal of Nursing Studies · 2015 · 344 citations
• Assessing Decisional Capacity for Clinical Research or Treatment: A Review of Instruments · American Journal of Psychiatry · 2006 · 337 citations

Most recent work

• Restrictive vs Liberal Physical Restraint Strategies in Critically Ill Patients · JAMA · 2026
• Examining Better Access use by Australian adults using data from two longitudinal studies (Ten to Men and the Australian Longitudinal Study on Women’s Health) · Australian & New Zealand Journal of Psychiatry · 2026
• The Protective Paradox: When the Shield Becomes the Wound. Institutional Bifurcation, Statutory Breach, and the Systematic Abandonment of Neurodivergent Individuals by the Systems Designed to Protect Them · Zenodo (CERN European Organization for Nuclear Research) · 2026
• The Legal Landscape for Supported Decision-Making in the United States and its Application to Clinical Research · Journal of Law, Medicine & Ethics · 2026
• Capacity to give informed consent in patients with severe mental disorder in different treatment settings · Frontiers in Psychiatry · 2026
• Capable, Unbearably Suffering, and Excluded: People With Mental Illness and the Ethics of Canada's Assisted‐Dying Regime · Bioethics · 2026
• Who uses Better Access treatment services? A re-analysis of data from the usual care arms of two randomised controlled trials · Australian & New Zealand Journal of Psychiatry · 2026
• Nurses' Emotional Regulation Capacity as a Determinant of Attitudes and Practice Toward Physical Restraint in Psychiatric Institutions: A Quantitative Survey · Journal of Psychosocial Nursing and Mental Health Services · 2026
• The Psychotherapist-Patient Privilege in Group Therapy · The Journal of Psychodrama Sociometry and Group Psychotherapy · 2026
• Practical dilemmas and communication reconstruction of patients' right to informed consent under the Civil Code · Frontiers in Public Health · 2026

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