A systematic scoping review and interpretive ethical synthesis of ethical decision-making about physical restraints for older adults in Confucian-influenced care contexts

AIM: This study aims to map and interpret the evidence on ethical decision-making in the use of physical restraints for older adults, with particular attention to Confucian-influenced family-centred care contexts and comparative international evidence. DESIGN: This study applied a systematic scoping review design combined with an interpretive ethical synthesis. METHODS: The review was guided by the Joanna Briggs Institute approach to scoping reviews and reported with reference to PRISMA principles. Medline/PubMed, CINAHL Plus, CNKI, Google Scholar and ResearchGate were searched for English and Chinese literature published from 1 January 2015 to 30 September 2025. Searches combined terms for physical restraint, older adults, decision-making, ethics, family/proxy decision-making and Confucian or filial-piety contexts. Of 757 records identified, 526 records remained after duplicate removal, 46 full-text reports were assessed, and eight studies were included. Because the evidence base combined qualitative, quantitative and review studies, findings were integrated through a staged interpretive ethical synthesis. Empirical findings were first coded descriptively, then compared across evidence types, and finally interpreted through bioethical concepts including autonomy, relational autonomy, beneficence, non-maleficence, dignity, substituted judgement, vulnerability and culturally situated family responsibility. Primary empirical studies were given greater analytic weight than review articles, which were used mainly for conceptual contextualisation. RESULTS: Four analytically linked themes were identified: contextual determinants of restraint decisions in care settings; balancing autonomy, relational autonomy, beneficence and non-maleficence; nurses' ethical dilemmas and moral distress; and family or proxy decision-making shaped by substituted judgement, vulnerability, filial responsibility and culturally situated expectations of care.