ABSTRACT

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals’ experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid’s mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice

KEYWORDS:
Mental Health; Physical Restraint; Immobilization; Qualitative Research; Human Rights; Coercion; Spain

INTRODUCTION

The context

The use of mechanical restraint and other coercive measures has existed in the discipline of psychiatry since its very origin. ⁽¹1. Huertas García-Alejo R. Historia cultural de la psiquiatría. Madrid: La Catarata; 2012.^,22. Kallert TW, Mezzich JE, Monahan J. Coercive treatment in psychiatry: Clinical, legal and ethical aspects. West Sussex: John Wiley & Sons; 2011.^,33. Kirk SA, Gomory T, Cohen D. Mad Science: Psychiatric coercion, diagnosis, and drugs. New Brunswick: Transaction Publishers; 2013. From a conceptual point of view, the definition of the term mechanical restraint varies among authors. In Spanish it is common for the terms sujeción mecánica [mechanical restraint] and inmovilización terapéutica [therapeutic immobilization] to be used interchangeably. In this study we will use the term mechanical restraint to refer to any procedure that, through a mechanical device, limits a person’s freedom of movement through immobilizing one or more parts of their body.⁴4. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. Means of restraint in psychiatric establishments for adults (Revised CPT standards) [Internet]. Estrasburgo; 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://rm.coe.int/16807001c3 .
https://rm.coe.int/16807001c3... We dismiss other terminologies as we consider them ambiguous (a person can be contained without being restrained) o euphemistic (presupposing a therapeutic action).

The use of mechanical restraints in health contexts is permitted in Spain. Nevertheless, in contrast to involuntary commitments “due to psychic disorder” that are regulated by law,⁵5. España, Jefatura del Estado. Ley 1/2000, de 7 de enero, de Enjuiciamiento Civil [Internet]. BOE-A-2000-323 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/w7dywu9f .
https://tinyurl.com/w7dywu9f... there is no regulation of mechanical restraint through any specific legal precept whatsoever, and such oversight is left to local ordinances and hospital protocols. The relevance of the critical reflection regarding mechanical restraint and coercion in psychiatry has focused on different factors⁶6. Inchauspe Aróstegui JA, Valverde Eizaguirre M. La coerción en Salud Mental: conceptos, procesos y situación. En: Beviá B, Bono Á, editores. Coerción y salud mental: revisando las prácticas de coerción en la atención a las personas que utilizan los servicios de salud mental. Madrid: Asociación Española de Neuropsiquiatría; 2017. p. 13-89.^,77. Kallert TW, Mezzich JE, Monahan J. Introduction. En: Kallert TW, Mezzich JE, Monahan J, editors. Coercive treatment in psychiatry: Clinical, legal and ethical aspects. West Sussex: John Wiley & Sons; 2011. p. xi-xxii.: the elevated frequency of these practices,⁸8. Mayoral F, Torres F, Group Eunomia. Use of coercive measures in psychiatry. Actas Españolas de Psiquiatría. 2005;33(5):331-338.^,99. Kallert TW, Glöckner M, Onchev G, Raboch J, Karastergiou A, Solomon Z, et al. The EUNOMIA project on coercion in psychiatry: study design and preliminary data. World Psychiatry. 2005;4(3):168-172. their ubiquity,¹⁰10. Simpson SA, Joesch JM, West II, Pasic J. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). General Hospital Psychiatry. 2014;36(1):113-118. doi: http://dx.doi.org/10.1016/j.genhosppsych.2013.09.009.^,1111. Raguan B, Wolfovitz E, Gil E. Use of physical restraints in a general hospital: a Cross-sectional observational study. Israel Medical Association Journal. 2015;17:633-638.^,1212. Krüger C, Mayer H, Haastert B, Meyer G. Use of physical restraints in acute hospitals in Germany : A multi-centre cross-sectional study. International Journal of Nursing Studies. 2013;50:1599-1606. doi: 10.1016/j.ijnurstu.2013.05.005.^,1313. Foebel AD, Onder G, Finne-soveri H, Lukas A, Denkinger MD, Carfi A, et al. Physical restraint and antipsychotic medication use among nursing home residents with dementia. Journal of the American Medical Directors Association. 2016;17(2):184.e9-184.e14.^,1414. Hui A, Middleton H, Völlm B. The uses of coercive measures in forensic psychiatry: A literature review. In: Völlm B, Nedopil N, editors. The use of coercive measures in forensic psychiatric care: Legal, ethical and practical challenges. Switzerland: Springer; 2016. p. 151-184.^,1515. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. CPT/Inf (2017) 34, Section: 24/41, Date: 06/04/2017, B Prison establishments, 5 Means of restraint [Internet]. 2017 [10 mar 2020]. Disponible en: https://tinyurl.com/5h53bdym.
https://tinyurl.com/5h53bdym... the variability of the normative frameworks that regulate them,¹⁶16. Steinert T, Lepping P. Legal provisions and practice in the management of violent patients: A case vignette study in 16 European countries. European Psychiatry. 2009;24(2):135-141. doi: 10.1016/j.eurpsy.2008.03.002.^,1717. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology. 2010;45(9):889-897. doi: 10.1007/s00127-009-0132-3. the controversies surrounding their use²2. Kallert TW, Mezzich JE, Monahan J. Coercive treatment in psychiatry: Clinical, legal and ethical aspects. West Sussex: John Wiley & Sons; 2011.^,1616. Steinert T, Lepping P. Legal provisions and practice in the management of violent patients: A case vignette study in 16 European countries. European Psychiatry. 2009;24(2):135-141. doi: 10.1016/j.eurpsy.2008.03.002.^,1717. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology. 2010;45(9):889-897. doi: 10.1007/s00127-009-0132-3.^,1818. Sashidharan S, Mezzina R, Puras D. Reducing coercion in mental healthcare. Epidemiology and Psychiatric Sciences. 2019;28(6):605-612. doi: 10.1017/S2045796019000350.^,1919. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015. in relation to human rights violations, the Convention on the Rights of Persons with Disabilities²⁰20. Organización de las Naciones Unidas. Convención sobre los derechos de las personas con discapacidad [Internet]. Nueva York; 2006 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/49f6p5bn .
https://tinyurl.com/49f6p5bn... and the recommendations of organizations dedicated to the defense of these rights,²⁰20. Organización de las Naciones Unidas. Convención sobre los derechos de las personas con discapacidad [Internet]. Nueva York; 2006 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/49f6p5bn .
https://tinyurl.com/49f6p5bn... ^,2121. Naciones Unidas, Asamblea General. Informe del Relator Especial sobre la tortura y otros tratos o penas crueles, inhumanos o degradantes [Internet]. Naciones Unidas; 2016 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/dvw9t34e .
https://tinyurl.com/dvw9t34e... ^,2222. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf... the ethical conflicts in everyday clinical practice,²²22. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf... ^,2323. Szmukler G. Compulsion and “coercion” in mental health care. World Psychiatry. 2015;14(3):259-261. doi: 10.1002/wps.20264.^,2424. Brodwin P. The ethics of ambivalence and the practice of constraint in US psychiatry. Culture, Medicine and Psychiatry. 2014;38(4):527-549. doi: 10.1007/s11013-014-9401-z.^,2525. Sweeney A, Filson B, Kennedy A, Collinson L, Gillard S. A paradigm shift: relationships in trauma-informed mental health services. BJPsych Advances. 2018;24(5): 319-333. the lack of evidence regarding their therapeutic effects,²2. Kallert TW, Mezzich JE, Monahan J. Coercive treatment in psychiatry: Clinical, legal and ethical aspects. West Sussex: John Wiley & Sons; 2011.^,2626. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database Syst Rev. 2000;(1):CD001163. doi: 10.1002/14651858.CD001163.^,2727. Luciano M, Sampogna G, Vecchio V Del, Pingani L, Palumbo C, Rosa C De, et al. Use of coercive measures in mental health practice and its impact on outcome: a critical review. Expert Review of Neurotherapeutics. 2014;14(2):131-141. doi: 10.1586/14737175. 2014.874286. their harmful consequences in users and professionals,²⁵25. Sweeney A, Filson B, Kennedy A, Collinson L, Gillard S. A paradigm shift: relationships in trauma-informed mental health services. BJPsych Advances. 2018;24(5): 319-333.^,2828. Cusack P, Cusack FP, McAndrew S, McKeown M, Duxbury J. An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursirg. 2018;27(3):1162-1176.^,2929. Cusack P, Mcandrew S, Cusack F, Warne T. Reviewing evidence of the effects of restraint from the perspective of service users and mental health professionals in the United Kingdom (UK). International Journal of Law and Psychiatry. 2016;46:20-26. http://dx.doi.org/10.1016/j.ijlp.2016.02.023.^,3030. Rose D, Evans J, Laker C, Wykes T. Life in acute mental health settings: experiences and perceptions of service users and nurses. Epidemiology of Psychiatric Sciences. 2015;24(1):90-96.^,3131. Duxbury JA. The Eileen Skellern Lecture 2014: physical restraint : in defence of the indefensible? Journal of Psychiatric and Mental Health Nursing. 2015;22(2):92-101. https://doi.org/10.1111/jpm.12204.^,3232. Rakhmatullina M, Taub A, Jacob T. Morbidity and mortality associated with the utilization of restraints: A review of literature. The Psychiatric Quarterly. 2013;84(4):499-512. doi: 10.1007/s11126-013-9262-6.^,3333. Muskett C. Trauma-informed care in inpatient mental health settings : A review of the literature. International Journal of Mental Health Nursing. 2014;23(1):51-59. doi: 10.1111/inm.12012. the risk of abuse,²¹21. Naciones Unidas, Asamblea General. Informe del Relator Especial sobre la tortura y otros tratos o penas crueles, inhumanos o degradantes [Internet]. Naciones Unidas; 2016 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/dvw9t34e .
https://tinyurl.com/dvw9t34e... and the rise in and increasing pressure from user organizations³⁴34. Colectivo Locomún. #0 Contenciones [Internet]. 2018 [citado 25 sep 2019]. Disponible en: Disponible en: https://tinyurl.com/hmwpnzx6 .
https://tinyurl.com/hmwpnzx6... when known alternatives exist.³⁵35. Gooding P, Mcsherry B, Roper C, Grey F. Alternatives to coercion in mental health settings : A literature review [Internet]. Melbourne: Melbourne Social Equity Institute, University of Melbourne; 2018 [citado 10 sep 2019]. Disponible en: Disponible en: https://tinyurl.com/3y7jf98y .
https://tinyurl.com/3y7jf98y...

This controversy is also observed in Spain.³⁴34. Colectivo Locomún. #0 Contenciones [Internet]. 2018 [citado 25 sep 2019]. Disponible en: Disponible en: https://tinyurl.com/hmwpnzx6 .
https://tinyurl.com/hmwpnzx6... ^,3636. Comisión de Sanidad y Servicios Sociales. Proposición no de Ley presentada por el Grupo Parlamentario Ciudadanos, relativa a la eliminación de las sujeciones mecánicas en el ámbito asistencial: Aprobación con modificaciones así como enmiendas formuladas. Boletín Oficial de las Cortes Generales Madrid [Internet]. 2017 [citado 10 sep 2019]. Disponible en: Disponible en: https://tinyurl.com/pw4kvsww .
https://tinyurl.com/pw4kvsww... However, despite various efforts to transform mental health systems,¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.^,3535. Gooding P, Mcsherry B, Roper C, Grey F. Alternatives to coercion in mental health settings : A literature review [Internet]. Melbourne: Melbourne Social Equity Institute, University of Melbourne; 2018 [citado 10 sep 2019]. Disponible en: Disponible en: https://tinyurl.com/3y7jf98y .
https://tinyurl.com/3y7jf98y... the use of these practices is still widespread both in nearby countries¹⁷17. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology. 2010;45(9):889-897. doi: 10.1007/s00127-009-0132-3.^,3737. Hem MH, Gjerberg E, Husum TL, Pedersen R. Ethical challenges when using coercion in mental healthcare: A systematic literature review. Nursing Ethics. 2016;25(1):92-110. doi: 10.1177/0969733016629770.^,3838. Winship G. Further thoughts on the process of restraint. Psychiatric and Mental Health Nursing. 2006;13:55-60. doi: 10.1111/j.1365-2850.2006.00913.x and in Spain itself.¹⁷17. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology. 2010;45(9):889-897. doi: 10.1007/s00127-009-0132-3.^,3939. Beviá B, Girón M. Poder, estigma y coerción: Escenarios para una práctica no autoritaria en salud mental. Revista de la Asociación Española de Neuropsiquiatría. 2017;37(132):321-329. doi: 10.4321/s0211-57352017000200001^,4040. Canvin K, Rugkåsa J, Sinclair J, Burns T. Leverage and other informal pressures in community psychiatry in England. International Journal of Law and Psychiatry. 2013;36(2):100-106. doi: 10.1016/j.ijlp.2013.01.002^,4141. Raboch J, Kališová L, Nawka A, Kitzlerová E, Onchev G, Karastergiou A, et al. Use of Coercive Measures During Involuntary Hospitalization: Findings From Ten European Countries. Psychiatr Services. 2010;61(10):1012-1017. doi: 10.1176/ps.2010.61.10.1012

In general, there is a lack of studies of quality regarding the use of coercive measures¹⁸18. Sashidharan S, Mezzina R, Puras D. Reducing coercion in mental healthcare. Epidemiology and Psychiatric Sciences. 2019;28(6):605-612. doi: 10.1017/S2045796019000350. and to date no clear conclusions can be reached regarding their relation to sociodemographic variables (certain population groups) or clinical variables (specific disorders or symptoms). Nevertheless, a number of studies highlight the importance of the experience of professionals and the characteristics of the context in understanding factors related to the use of restraints.⁴²42. Duxbury J, Whittington R. Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing. 2005;50(5):469-478. doi: 10.1111/j.1365-2648.2005.03426.x^,4343. Petti TA, Mohr WK, Somers JW, Sims L. Perceptions of Seclusion and Restraint by Patients and Staff in an Intermediate-Term Care Facility. Journal of Child and Adolescent Psychiatric Nursing. 2001;14(3):115-127. doi: 10.1111/j.1744-6171.2001.tb00303.x Some authors¹⁷17. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology. 2010;45(9):889-897. doi: 10.1007/s00127-009-0132-3. and organizations⁴⁴44. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. Means of restraint in a psychiatric hospital. Estrasburgo: CTP; 2006. suggest that the use of these practices depends more on non-clinical variables - such as the philosophy of the service,⁴⁵45. Marangos-Frost S, Wells D. Psychiatric nurses’ thoughts and feelings about restraint use: a decision dilemma. Journal of Advanced Nursing. 2000;31(2):362-369. doi: 10.1046/j.1365-2648.2000.01290.x values and customs,⁴⁶46. El-Badri S, Mellsop G. Patient and staff perspectives on the use of seclusion. Australasian Psychiatry. 2008;16(4):248-252. doi: 10.1080/10398560802027302. characteristics of the centers⁸8. Mayoral F, Torres F, Group Eunomia. Use of coercive measures in psychiatry. Actas Españolas de Psiquiatría. 2005;33(5):331-338. or cultural, educational and organizational factors⁴²42. Duxbury J, Whittington R. Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing. 2005;50(5):469-478. doi: 10.1111/j.1365-2648.2005.03426.x - than clinical issues (diagnoses, user characteristics).

After carrying out an extensive search of the literature, we found different types of qualitative studies that look into the experiences of users,⁴⁷47. Brophy LM, Roper CE, Hamilton BE, Tellez JJ, McSherry BM. Consumers and Carer perspectives on poor practice and the use of seclusion and restraint in mental health settings: Results from Australian focus groups. International Journal of Mental Health System. 2016;10(6). doi: 10.1186/s13033-016-0038-x.^,4848. Gudde CB, Olsø TM, Whittington R, Vatne S. Service users’ experiences and views of aggressive situations in mental health care: A systematic review and thematic synthesis of qualitative studies. Journal of Multidisciplinary Healthcare. 2015;8:449-462. as well as multiple quantitative studies on the frequency, demographic characteristics and other epidemiological data¹⁷17. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology. 2010;45(9):889-897. doi: 10.1007/s00127-009-0132-3.^,4949. Cornaggia CM, Beghi M, Pavone F, Barale F. Aggression in psychiatry wards: A systematic review. Psychiatry Research. 2011;189(1):10-20. doi: 10.1016/j.psychres.2010.12.024. regarding mechanical restraint and other coercive measures, but very little based on the experiences of professionals.⁵⁰50. Happell B, Harrow A. Nurses’ attitudes to the use of seclusion: A review of the literature. International Journal of Mental Health Nursing. 2010;19(3):162-168. doi: 10.1111/j.1447-0349.2010.00669.x.^,5151. Van Der Merwe M, Muir-Cochrane E, Jones J, Tziggili M, Bowers L. Improving seclusion practice: Implications of a review of staff and patient views. Journal of Psychiatry Mental Health Nursing. 2013;20(3):203-215. doi: 10.1111/j.1365-2850.2012.01903.x. The absence of studies on professionals in training is particularly marked.⁵²52. Cocho Santalla C, Nocete Navarro L, López Álvarez I, Carballeira Carrera L, Fernández Liria A. Experiencia y actitudes de los profesionales de salud mental en torno a las prácticas coercitivas directas: revisión bibliográfica de estudios cualitativos. Revista de la Asociación Española de Neuropsiquiatría. 2018;38(134):419-449. doi: 10.4321/S0211-57352018000200005.

Our study

Despite the generalized belief that coercion is damaging to the liberty of the people who experience it and therefore should be considered erroneous, there is also a strong social tendency to justify it as necessary for the proper functioning of our societies.⁵³53. Anderson S. Coercion. The Stanford Encyclopedia of Philosophy (Winter 2017) [Internet]. Edward NZ; 2017. Disponible en: https://tinyurl.com/8nrydmau.
https://tinyurl.com/8nrydmau... Situations that are (potentially) violent challenge professionals to respond in a way that guarantees safety, without overlooking the users’ needs for support and care in moments of maximum vulnerability.⁵⁴54. Lovell A, Smith D, Johnson P. A qualitative investigation into nurses’ perceptions of factors influencing staff injuries sustained during physical interventions employed in response to service user violence within one secure learning disability service. Journal of Clinical Nursing. 2015;24(13-14):1926-1935. doi: 10.1111/jocn.12830. Due to its consequences for the users, mechanical restraint has been defined as a high-risk procedure.⁵⁵55. Strout TD. Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. International Journal of Mental Health Nursing. 2010;19(6):416-427. doi: 10.1111/j.1447-0349. 2010.00694.x.^,5656. Moreno Pérez A, Fernández Liria A. La contención mecánica como acontecimiento centinela: propuesta para avanzar hacia su eliminación. Boletín la Asociación Madrileña de Salud Mental. 2020;46. Such consequences are emotional (fear, traumatization, impotence, dehumanization),⁵⁵55. Strout TD. Perspectives on the experience of being physically restrained: An integrative review of the qualitative literature. International Journal of Mental Health Nursing. 2010;19(6):416-427. doi: 10.1111/j.1447-0349. 2010.00694.x. as well as physical⁵⁷57. Knowles SF, Hearne J, Smith I. Physical restraint and the therapeutic relationship. The Journal of Forensic Psychiatry & Psychology. 2015;26(4):461-475. doi: 10.1080/14789949.2015.1034752. to the point of being mortal.¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.^,3232. Rakhmatullina M, Taub A, Jacob T. Morbidity and mortality associated with the utilization of restraints: A review of literature. The Psychiatric Quarterly. 2013;84(4):499-512. doi: 10.1007/s11126-013-9262-6.^,5858. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Canadian journal of psychiatry. 2003;48:330-337. doi: 10.1177/070674370304800509. It has been suggested that it is also relevant to study this phenomenon in relation to professionals, as the impact for them is also significant.¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.^,3232. Rakhmatullina M, Taub A, Jacob T. Morbidity and mortality associated with the utilization of restraints: A review of literature. The Psychiatric Quarterly. 2013;84(4):499-512. doi: 10.1007/s11126-013-9262-6.^,4343. Petti TA, Mohr WK, Somers JW, Sims L. Perceptions of Seclusion and Restraint by Patients and Staff in an Intermediate-Term Care Facility. Journal of Child and Adolescent Psychiatric Nursing. 2001;14(3):115-127. doi: 10.1111/j.1744-6171.2001.tb00303.x

The research we present here seeks to study the experience of mental health professionals in training (residents) in relation to mechanical restraint. We understand experience as the knowledge derived or acquired from having personally undergone a situation or circumstance,⁵⁹59. Real Academia Española. Experiencia [Internet]. Diccionario de la Lengua Española. 2017 [citado 6 feb 2017]. Disponible en: Disponible en: https://tinyurl.com/5zrrnzn4 .
https://tinyurl.com/5zrrnzn4... a type of knowledge acquired from what one has encountered. The questions that have guided our research are: 1) How do health professionals in training describe their experience in relation to the decision to use or carry out mechanical restraint? and 2) What aspects of this experience influence professionals when deciding to use mechanical restraints, and in what way? Preliminary results of this study, prior to the development of the grounded theory, can be found in a technical document of the Asociación Española de Neuropsiquiatría.⁶⁰60. Nocete Navarro L, Carballeira Carrera L, López Álvarez I, Cocho Santalla C, Fernández Liria A. Percepciones y actitudes de los profesionales de salud mental en la contención mecánica. En: Coerción y salud mental: revisando las prácticas de coerción en la atención a las personas que utilizan los servicios de salud mental. Madrid: Asociación Española de Neuropsiquiatría; 2017. p. 109-168.

METHODOLOGY

Study design and theoretical framework

In order to adequately answer these questions, we adopted a qualitative methodology using focus groups. Qualitative methods assume reality and knowledge to be multiple and complex, influenced by the context and sociocultural values and also constructed by what people think, feel and do.⁶¹61. Berenguera A, Fernandez de Sanmamed MJ, Pons M, Pujol E, Rodríguez D, Saura S. Escuchar, observar y comprender: Recuperando la narrativa en las Ciencias de la Salud: Aportaciones de la investigación cualitativa [Internet]. Barcelona: Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP J. Gol); 2014. Disponible en: www.idiapjgol.org.
www.idiapjgol.org... ^,6262. Onocko Campos RT, Furtado JP. Narrativas: utilização na pesquisa qualitativa em saúde. Revista de Saúde Publica. 2008;42(6):1090-1096. doi: 10.1590/S0034-89102008005000052. The choice of this approach allows us, through dialogue, interaction and discourse analysis, to understand the experiences from the perspective of the people who personally encounter the phenomenon of restraints, in the natural timeframe and sociocultural context in which they are situated.⁶³63. Prieto Rodríguez MA, March Cerdá JC. Paso a paso en el diseño de un estudio mediante grupos focales. Atención Primaria. 2002;29(6):366-373. This approach is carried out from a phenomenological perspective, that emphasizes how the world makes itself present int the subjectivity of the participants and in the meanings that they offer, in their own terms.⁶⁴64. Laza Vásquez C, Pulido Acuña GP, Castiblanco Montañez RA. La fenomenología para el estudio de la experiencia de la gestación de alto riesgo. Enfermería Global. 2012;11(4):295-305. Our method is hermeneutical, based on a theory of interpretation that is especially useful for generating hypotheses that give meaning to a complex and conflictive issue about which there is little research.⁶⁵65. Eatough V, Smith J. I was like a wild wild person: Understanding feelings of anger using interpretative phenomenological analysis. British Journal of Psychology. 2006;(97):483-498. doi: 10.1348/000712606X97831. The data collection was carried out using focus groups, which allowed participants the opportunity to freely express their ideas and opinions⁶⁶66. Denzin NK, Lincoln YS. The SAGE Handbook of Qualitative Research. Newbury Park: SAGE Publications; 2011. through interactions and discussion based on the attitudes, points of view and discourses of each participant, supporting the exploration, clarification and deepening of individual contributions. Interactions involve attentive listening and observation in which knowledge emerges in the interplay among the subjectivity of the researchers, the context, and the object of research.⁶⁴64. Laza Vásquez C, Pulido Acuña GP, Castiblanco Montañez RA. La fenomenología para el estudio de la experiencia de la gestación de alto riesgo. Enfermería Global. 2012;11(4):295-305.

Selection strategy and type of sampling

The strategy for participant selection was intentional and judgmental. The participants were chosen in relation to their representativity and the variability of discourses existing in the population and not using statistical probability. The selection was carried out in the following way: 1) profiles with certain characteristics were defined (based on the experience of the research team, consulted experts and the literature reviewed) to create specific groups relevant for representing the structure of the reference population (structural sample); 2) the selection was carried out through key informants who could identify professionals with the characteristics we were looking for and, once located, an informative sheet and informed consent form were provided; 3) when an adequate number was reached, the distribution into groups was carried out in such a way as to favor the richness and heterogeneity of the discourses. During the selection process, great effort was made to assure that the participants did not have a close relationship with other participants or with the team. Nevertheless, it was inevitable that some participants had previously crossed paths in other spaces, given the specificity of the reference population and the existence of shared educational environments outside the workplace. In the few cases in which people already knew one another, it was assured the relationship between them was not close and that each person’s participation would not be conditioned by the presence of the other.

As inclusion criteria, those considered were mental health professionals in training, who worked in the public health network of the Community of Madrid and who volunteered to participate. As we mentioned, in order for the experiences of the participants to be as similar as possible to those in the natural population to which they belong, profiles were defined that were then used as a reference for the selection of the sample. In the creation of the profiles, different variables were taken into account that divide the population and that it was thought would have a significant influence upon the phenomenon under study.

Professional category

The population was divided into professions of origin: nursing (EIR), psychology (PIR) and medicine (MIR). Although clinical psychologists have less direct contact with the use of mechanical restraint during their training and professional development (they do not usually participate in indicating its use nor in the procedure itself), their implication in the paradigm that sustains these practices is nevertheless important. The study sought balanced participation from all the categories in the focus groups. Contrary to specialized professionals, residents are not assigned to a specific unit or service. However, during their training, especially at the beginning, they all pass through spaces in which the use of restraint occurs more or less frequently. For this reason, it was not necessary to classify professionals according to their workplace.

The area of the hospital or the teaching unit

It is common knowledge among mental health professionals in the region of Madrid that the model of training differs, in part, according to the philosophy or work culture that exists in each teaching unit. In this way, areas can be found with a greater tendency towards theories and practices that are more social, community-oriented and psychotherapeutic, and others that are more medical, biologicist and hegemonic, and therefore related to positions more or less critical of the use of coercive measures in mental health. However, belonging to a particular teaching unit does not necessarily guarantee that that the professionals in training share the general position of support or rejection of mechanical restraints. For this reason, the population was divided into three profiles reflecting the presumed attitude of the professional in training towards these measures: critical (“they should not be used”), pragmatic (“sometimes they are necessary for safety”), and positive/therapeutic (“they are necessary for treatment”).⁶⁷67. Husum TL, Bjørngaard JH, Finset A, Ruud T. Staff attitudes and thoughts about the use of coercion in acute psychiatric wards. Social Psychiatry and Psychiatric Epidemioly. 2011;46(9):893-901. doi: 10.1007/s00127-010-0259-2. To attempt to guarantee that the profile of the professional in training was aligned with what we were looking for in each area, we relied on the informants. Residents of 9 of the 22 teaching units were included.

Other characteristics: gender and years of training

Issues related to gender and years of professional development¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.^,6868. Wynn R, Kvalvik AM, Hynnekleiv T. Attitudes to coercion at two Norwegian psychiatric units. Nordic Journal of Psychiatry. 2011;65(2):133-137. doi: 10.3109/ 08039488.2010.513068. can influence the experiences of participants and were therefore taken into account so that the sample would reflect these differences among the population.

Using these variables, participants were included that covered the largest possible span of characteristics, in such a way that in the focus groups the different experiences and discourses of mental health professionals in training were “represented” as accurately as possible. At the start of the study, no set number of participants and groups was defined. As the groups were carried out, a preliminary analysis of the data was developed, based upon which the following participants were defined, with the objective of finding profiles and data that had not appeared, reaching theoretical saturation and refining the emerging theory (theoretical sampling). Participant recruiting was ended when conceptual saturation was reached; although such saturation is never totally complete, it was necessary to establish limits based on time and resources.

Description of the population and the spatial distribution of the study

The study included 21 residents, distributed into three different focus groups with seven people each. One resident decided not participate in a group due to time constraints and could be replaced. The day the focus groups met, two people were unable to attend, and the total number was reduced to 19 residents: seven residents of psychiatry (MIR), six nursing residents (EIR) and six residents of clinical psychology (PIR). The participants included twelve women and seven men, with different amounts of training (some were just beginning, others were well within the training process and others were coming to the end of the specialization). Initially participants from eleven public hospitals of the Community of Madrid were included, but with the loss of two participants, nine hospitals remained in the sample, although the different theoretical positions according to the different teaching units continued to be represented. During the training period all the residents carry out rotations through hospital units in which they come in contact with mechanical restraints and the decision-making process that surrounds them.

Data collection

The focus groups were conducted during the year 2017. Each encounter had a duration of approximately an hour and a half, and were carried out using a semi-structured guide developed by the research team under the supervision of the most experienced researcher. The guide did not act as a rigid questionnaire, but rather as a flexible framework for exploring areas of interest, using open questions to obtain unconditioned answers, as well as focused questions to obtain unique and useful answers. The guide also served to homogenize the interventions of the different moderators, including instructions previously agreed upon by the team regarding how to carry out the interview process. The most important themes centered on the experiences of the professionals with mechanical restraint (attitudes, thoughts, emotions, and actions). The groups took place outside of the hospital, in a calm environment that facilitated an unstructured atmosphere without institutional pressures. Before starting the group, the nature of the study was again explained and informed consent was requested to verify that the information was clear and that participation was voluntary. Instructions were then given to facilitate the proper functioning of the focus group, reminding the participants that they were free to express themselves and converse, without the need to come to an agreement on anything. During the groups, the conversation was fluid and dynamic, with adequate interaction among participants. The groups were conducted by a moderator who was responsible for facilitating and guiding participation and discourse elaboration, while another person observed without intervening in the natural development of the interview, taking note of what happening and recording the content of interview in both audio and video formats.

Data analysis

As a guide, we used the recommendations of Berenguera et al.⁶¹61. Berenguera A, Fernandez de Sanmamed MJ, Pons M, Pujol E, Rodríguez D, Saura S. Escuchar, observar y comprender: Recuperando la narrativa en las Ciencias de la Salud: Aportaciones de la investigación cualitativa [Internet]. Barcelona: Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP J. Gol); 2014. Disponible en: www.idiapjgol.org.
www.idiapjgol.org... and Charmaz’s constructivist reading of Glaser and Strauss.⁶⁹69. Thornberg R, Charmaz K. Grounded Theory and Theoretical Coding. En: Flick U, (ed). The SAGE Handbook of Qualitative Data Analysis. London: SAGE Publications; 2014. p. 153-169.^,7070. Tweed A, Charmaz K. Grounded Theory Methods for Mental Health Practitioners. En: Harper D, Thompson AR (eds). Qualitative Research Methods in Mental Health and Psychotherapy: A Guide for Students and Practitioners. West Sussex: John Wiley & Sons; 2012. p. 131-146. Our analysis was a progressive process starting with the description of the data, continuing with the construction and ordering of concepts and categories, and ending with theorization (Figure 1). The recordings of the groups were literally transcribed by the researchers, and notes were added regarding the nonverbal information. The names of the informants were not transcribed, but rather they were assigned alphanumeric codes. The content of the transcriptions was unified in a single textual corpus to facilitate reading and analysis and was read several times by all the researchers to assure familiarity with the raw data. In the re-readings, preliminary notes were made regarding possible thematic codes and categories, and this exercise was discussed as a team, based on our first intuitions and ideas (“naive reading”).⁷¹71. Olofsson B, Gilje F, Jacobsson L, Norberg A. Nurses’ narratives about using coercion in psychiatric care. Journal of Advanced Nursing . 1998;28(1):45-53. doi: 10.1046/j.1365-2648.1998.00687.x. The qualitative data analysis program Atlas.ti version 1.6.0 for Mac was used as an auxiliary tool for the labeling and coding. An initial coding was assigned by fragmenting the text into quotations (lines or paragraphs) that act as a unit of meaning regarding some aspect of the experience. The first codes are descriptive, connected to the literal content of the quotation. The coding process becomes increasingly sophisticated during the analysis through the iterative and detailed reading of what emerges.⁷²72. Corbin J, Holt NL. Grounded Theory. En: Somekh B, Lewin C (eds). Research Methods in the Social Sciences. London: SAGE Publications; 2005. p. 49-55. Through the constant comparative method and reiterative interpretation and abstraction, relations are sought among the codes to refine them and group them into conceptual categories, that make up more descriptive categories, reaching the central categories and subcategories (axial coding) when data saturation is adequate. Lastly, theoretical coding takes place, relating the results and the hypotheses with the data, with the objective of understanding the emerging meanings.⁷²72. Corbin J, Holt NL. Grounded Theory. En: Somekh B, Lewin C (eds). Research Methods in the Social Sciences. London: SAGE Publications; 2005. p. 49-55. During the process, the categorization and coding of the content is compared to verify that the emerging theory has its base in what was said, in a logical, systematic and explanatory schema of the constructed concepts.

Strategies to guarantee the quality and rigor of the research

The manner of evaluating the quality of qualitative research is an important object of debate.⁷³73. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodoly. 2008;8(45). doi: 10.1186/1471-2288-8-45. To guarantee the quality of our research, the proposals of a number of authors were followed.⁶¹61. Berenguera A, Fernandez de Sanmamed MJ, Pons M, Pujol E, Rodríguez D, Saura S. Escuchar, observar y comprender: Recuperando la narrativa en las Ciencias de la Salud: Aportaciones de la investigación cualitativa [Internet]. Barcelona: Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP J. Gol); 2014. Disponible en: www.idiapjgol.org.
www.idiapjgol.org... ^,7474. Calderón C. Criterios de calidad en la investigación cualitativa en salud (ICS): apuntes para un debate necesario. Revista Española de Salud Pública. 2002;76(5):473-482.^,7575. Strauss A, Corbin J. Bases de la investigación cualitativa: técnicas y procedimientos para desarrollar la teoría fundamentada. Medellín: Editorial Universidad de Antioquia; 2002. An effort was made to illustrate the methodological agreement among objectives, methodology and methods, carrying out a detailed monitoring of the rigor of the design and the steps taken in a commitment to transparency. To increase the reliability and validity of the study, rigorous sampling and analysis were carried out, employing triangulation techniques to verify the results and their representativity: triangulation of data, researchers, and theories. A critical, careful and reflexive attitude was maintained regarding the construction of our study, in relation to the object of study as well as in relation to our subjectivity as researchers.

Ethical aspects

All participants received information regarding the study, offered oral and written informed consent, and voluntarily and anonymously agreed to participate. They were aware that they were free to leave the study at any time and that their participation would not be compensated. To assure compliance with ethical requirements, the evaluation of the Research Ethics Committee of the Hospital Universitario La Paz (code HULP: PI-2928) was requested, and the study was approved in October 2017. Subjects were selected fairly, without discrimination among those who met the requirements sought. Possible risks related to known participation in the study were taken into account, and great care was taken to assure anonymity, intimacy and confidentiality in relation to the data and participants.⁷⁶76. Emanuel EJ, Wendler D, Grady C. What Makes Clinical Research Ethical? Journal of the American Medical Association. 2000;283(20):2701-2711. doi: 10.1001/jama.283.20.2701. Treatment and communication of data was carried out according to local normative frameworks, ARCO rights, and the principles of the Declaration of Helsinki.⁷⁸78. Asociación Médica Mundial. Declaración de Helsinki de la Asociación Médica Mundial: Principios Éticos para las Investigaciones Médicas en Seres Humanos [Internet]. Asociación Médica Mundial Helsinki; 1964. Disponible en: https://tinyurl.com/5v6ypvd6.
https://tinyurl.com/5v6ypvd6...

RESULTS

In the data analysis, 978 purely descriptive codes were identified in vivo. After ordering them into more abstract conceptual categories, a total of 86 codes were obtained, presented in three overarching categories of meaning in relation to the object of experience, in combination with three other categories related to the origin of the experience (Figure 2).

In this schema, the subcategories and different codes that answer the first research question are organized. The results presented in this article are developed based on the subsequent analysis that lays the base for a grounded theory regarding the use of mechanical restraint in professionals in training, responding to the second research question regarding the different aspects of the professionals’ experiences and the way in which they influence the indication and use of mechanical restraint. Three large thematic categories are developed: A. Experiences preceding mechanical restraint, B. Experiences during the indication of mechanical restraint, and C. Experiences after the use of mechanical restraint.

Figure 3 offers a graphic representation of the grounded theory. The meanings underlying the codes and categories are sustained in the excerpts of discourse (quotations), and it is from this place that sense is made of them (Table 1, Table 2, and Table 3).

Experiences preceding mechanical restraint

Factors related to the environment and the work context

In general, the professionals make reference to a series of circumstances related to the context and work environment when discussing mechanical restraint. They highlight the importance of the different spaces, structure and material means, but also the interaction among professionals, the dynamics of the teams, and the institutional functioning, and consider that their influence is crucial in making decisions regarding mechanical restraint.

Structural and material deficiencies

When the professionals refer to the material and structural conditions in which they work, they relate them to a greater use of mechanical restraint. They name a series of deficiencies that, in their experience, make it more difficult to carry out alternative actions and favor the indication of mechanical restraint: lack of personnel in the teams, professionals that are not specialized (nurses, support workers and others, who work in mental health), and the precarious training regarding both the restraints and their alternatives. They perceive the lack of material means, funding or time, that the areas for care are inadequate with relation to users’ needs, that there are no formal opportunities to reflect regarding incidents that end in mechanical restraint, and all of that contributes to their use.

Dynamics of the teams and institution

For the residents, discrepancies regarding coercive measures exist between psychiatrists and nurses, as does a lack of coordination and communication in the context of mechanical restraint, which facilitates the appearance of conflicts over the norms and over these measures. In fact, one of the motives for carrying out restraints is to avoid conflict among personnel. The existence of a hierarchy in deciding mechanical restraint can be perceived, in which the criteria of the psychiatric doctors in the end prevails. When there is disagreement, the hierarchy is experienced with frustration as well as relief for not having to take responsibility for a decision considered to be difficult. They also describe a series of attitudes and actions in the teams that can lead to conflicts that end up justifying mechanical restraint: deceptions, incoherent messages (contradictions among different shifts), imposing attitudes and lack of dialogue, yelling and threats, etc. This is something that affects professionals from other specialties who care for people with mental suffering, especially in Urgent Care. In these professionals, the residents perceive a lack of interest or collaboration, derogatory language or attitudes, and unequal treatment towards people with psychic suffering. Lastly, in relation to the institution, they feel that little support exists to implement alternative measures and that it would be necessary to change the institutional organization and culture.

Belief systems of the professionals

The experiences of the residents reveal their beliefs regarding mechanical restraint. They consider them to be mechanisms that “work,” that are “effective” because they meet the objective for which they were designed. Although some participants recognize that in other places they have been eliminated, the majority sees them as a measure that cannot (and even should not) be eliminated, expressing distrust and suspicion regarding the possibility of care without mechanical restraint, which they consider necessary in order to guarantee safety. Nevertheless, the majority do not think that mechanical restraint is therapeutic in itself. Various participants consider it necessary to specify in what way it is effective or therapeutic, considering these to be ambiguous and interpretable terms. They express, for example, that the restraints can have an indirect therapeutic effect when they avoid the risk of physical of harm, seeing mechanical restraints in this case as a form of protection.

It is interesting that, although considering restraints to be effective, necessary and even therapeutic, when focusing on the consequences in the people who are restrained, the residents recognize that the impact is generally negative, describing psychological, physical, moral and behavioral harms that can be inflicted even just by observing others being restrained. In their experience, this harm can also extend to the therapeutic relationship, which can even break down entirely. Some associate this effect in the therapeutic relationship with the conditions in which the mechanical restraint was carried out, the prior characteristics of the relationship between user and professional and other factors. The nurses experience this rupture in the therapeutic relationship particularly closely.

Lastly, one experience that repeatedly appeared was that of feeling that, even though there are attempts to establish certain criteria for the application of mechanical restraint, the decisions that motivate their indication are in the end personal and subjective. Although common sense is often invoked, the de facto criteria appear as interpretable, with high inter and intrapersonal variability (due to emotions, beliefs, etc.) and other external variables. In addition, they find that there is a personal tendency to apply them or not. The residents express that often they do not fully understand the reason mechanical restraint was indicated, that is, the criteria and objectives in which they are based. To them, the protocols are ambiguous and therefore or not helpful for guiding indications.

Collective belief systems: the culture of coercion

In the discourse analysis, a transversal category emerged that we have called culture of coercion. The culture of coercion can be understood as a set of assumptions that structure the institution, the teams and the professionals, that defines the tasks and organization, and that operates constantly, whether or not one is aware of it, shaping what is and is not possible to do within the conditions imposed by the institutional/group/social context itself. This collective belief system becomes internalized in such a way that it permeates the actions, thoughts and emotions of the professionals in the development of their practice. According to the interviews, some of the common elements that characterize the culture of psychiatric units are: predominance of the biomedical model and the discourse of risk management, paternalism, appealing to the norms and authorities (hierarchy) in treatment, or the naturalization of coercion as part of the job. These elements are reflected within other categories throughout this work, for example: that the majority of alternatives to mechanical restraint are similarly coercive, the group pressure felt to carry out restraints, the perception of mechanical restraint as indispensable, etc. In relation to the biomedical model, the residents state that mechanical restraint is indicated according to diagnostic categories and/or illness insight, which influences the distress or conflict they experience regarding the decision.

Behavior of users (conscious justification of the use of restraint)

Although the residents acknowledge the influence the previous aspects have in the decision to use mechanical restraint, they justify that its use has a place in situations that occur due to certain actions on the part of users, with a variability that enters into tension with the pressures of the context and their beliefs and values. The most common reasons for indicating restraints are: 1) interference in the functioning of the institution and opposition to the established treatment, 2) risk prevention, 3) avoiding absconding, and 4) defensive use. In their experience, it is commonplace to indicate mechanical restraint to enforce measures considered therapeutic and necessary (hospital admissions, pharmacological treatments, observation in the emergency room, bedrest after meals, etc.) despite the express refusal of the users and in fact because of their refusal, although restraint is also carried out when the person interferes with the functioning of the institution, without there being a clear opposition to treatment nor imminent risk. The prevention of risks (whether specific or undetermined) is another justification that sustains the use of mechanical restraint, in which restraint acts as a security measure regarding something the professional fears will occur. The third point (avoiding absconding) refers to the restraints indicated to prevent users from leaving the hospital. Although this point shares elements with the first (opposition to treatment against medical criteria) and the second (prevention of a possible risk), it is included separately given the frequency of its appearance as a specific element in the discourse. The defensive use of the restraints refers to the actions of the users (opposing treatment, attempting to leave the hospital against medical criteria, possibility of changes in behavior, etc.) that elicit an indication of mechanical restraint on the part of the professional out of fear of legal or institutional consequences if the restraint is not carried out. Lastly, the residents perceive that mechanical restraint is often used as a disciplinary measure, that is, as a punishment, to correct a behavior, establish authority, etc., which is highly alarming.

Experiences during the indication of mechanical restraint

The majority state that there are two types of “pressures” that push them to make the decision to indicate mechanical restraint, and these appear as a consequence of the interaction among the previous points: the environmental and contextual factors, the behavior of users, and the prior belief systems of each professional. These pressures can be experienced as fear of the consequences of not carrying out a restraint, and/or as external pressures for them to be carried out. The residents frequently describe the indication to be inappropriate. The factors that can move the decision in a different direction or reinforce the indication of mechanical restraint are considered further on.

Perception of being pressured to restrain: trapped among conflicting demands

The residents describe the sensation of finding themselves trapped among conflicting demands that are difficult to resolve: legal responsibility versus the will of the user, or institutional mandates that in themselves are contradictory. They highlight feeling pressured to carry out mechanical restraint on the part of different agents: other residents, doctors, colleagues of other professions, the institution, as part of their professional duty in terms of social control, etc. This pressure can be released if they carry out mechanical restraint, but if they do not, it persists as source of conflict or tension.

Fear

This is one of the most relevant points. Fear takes a central place in the emotional experience of professionals in relation to the indication to restrain. The results are presented in order of the frequency of appearance of the object with which this fear is related (most to least frequent), although often different feared situations might be in succession to one another, for example: fear that the user will abscond from the hospital and get hurt, and that that will lead to institutional repercussions in addition to possible legal responsibilities.

Inappropriate use of mechanical restraint

According to the residents, mechanical restraint should be used as a last resort, in certain situations of risk and after having exhausted all of the alternatives. Nevertheless, the residents highlight as commonplace the inappropriate use of the indication of mechanical restraint beyond what would be expected according to the protocols: use outside of the expected indications in objective and manner; inappropriate spaces and times of use; poor preparation, procedure, participation and coordination; overutilization; lack of care in the emergency room; etc. The improper use of mechanical restraint was one of the primary categories referenced, and supports the idea that at present there is a high risk of improper use and abuse.

Indications alternative to mechanical restraint

The professionals identify practices and strategies that serve as substitutes or alternatives to mechanical restraint. A group of such practices are not truly alternatives to the exercise of coercive measures but rather represent other forms of compulsion or coercive equivalents. Among these, we can find: 1) threatening the use of mechanical restraint; 2) leaving the restraints on the bed; 3) admission in closed units; 4) presence of security personnel; 5) physical containment; 6) seclusion; 7) forced transfers; and 8) informal coercion. Nevertheless, practices and measures that would reduce or avoid the use of restraints without being themselves coercive were also identified: individualizing the strategies for confronting the crisis, therapeutic contracts and psychiatric advance directives, accompaniment on the part of a loved one, verbal support, exercises based on attention or emotional regulation, padded rooms, open units, and home-based care and hospitalization. Some of these alternatives are structural, some have to do with anticipating the moments of crisis, and others have to do with handling the crisis itself.

Experiences after the use of mechanical restraint

Among the experiences stemming from the use of restraints, we can find a number of categories worth highlighting.

Emotional impact

Despite the difficulties encountered in attempting to delve into the emotional life of the participants, the discourse analysis reveals that the use of restraints produces in the majority a negative emotional impact, with the use of restraints described as unpleasant, tough or uncomfortable. Using restraints generates guilt and remorse, impotence, frustration, and even outrage, when the residents seek out alternatives but do not find them. The restraints can mark the experience of the professionals. They even consider some experiences to be traumatic.

Relief from the pressure and fear

With much less frequency, the residents make reference to feelings of relief, security and peace of mind regarding the availability and use of mechanical restraints. These feelings do not appear as explicitly and directly as others. Nevertheless, we consider them to be a fundamental element in the perpetuation of the indication of restraints: their use alleviates the tension generated by the context and the fears stimulated by the behavior of the users, reducing concerns over risks and legal and institutional repercussions.

Experiences in conflict

The use of mechanical restraint places the residents before conflicting or contradictory experiences. According to the data analysis, these experiences can be divided into three separate albeit related categories:

Processes of adaptation to the conflictive experience

If mechanical restraint generates emotional distress and dissonant experiences at the moral level, and yet the residences experience that there is no way of refusing to use them (in the context of safety, hierarchy and fear of consequences), it is understandable that in order to work in this contradictory and harmful situation, different adaptation processes take place. The participants describe changes over time in their feelings (the restraints cause them less distress), their thought processes (they reflect less regarding restraints), and their actions, which they define as a habituation to mechanical restraints, a desensitizing in their reactions and an automatization in their indication.

Strategies and mechanisms to relieve the distress that restraints produce

The professionals recognize the development of involuntary (unconscious) mechanisms as well as conscious strategies and actions to reduce the distress generated by the application of mechanical restraints in their work. Among them, they describe distraction mechanisms, mechanisms of distancing themselves from the emotional experience (intellectualization-negation-normalization) and mechanisms for venting/emotional expression.

DISCUSSION

Culture of coercion, biomedical model and disabling environments

One of the most significant aspects that emerges from this study is the existence of an institutional culture of coercion with its base in the biomedical model and the management of individual and social risks. Our results support the observations of Dainius Pūras, Special Rapporteur of the United Nations, in his report on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,²²22. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf... regarding the underlying justifications of coercive measures: “medical necessity” and “dangerousness.” The findings support that this approach is so relevant that it impregnates the entire institutional organization and the subjective experiences of the professionals,⁵²52. Cocho Santalla C, Nocete Navarro L, López Álvarez I, Carballeira Carrera L, Fernández Liria A. Experiencia y actitudes de los profesionales de salud mental en torno a las prácticas coercitivas directas: revisión bibliográfica de estudios cualitativos. Revista de la Asociación Española de Neuropsiquiatría. 2018;38(134):419-449. doi: 10.4321/S0211-57352018000200005. at the same time that it connects to the normative and contextual frameworks in which professionals develop their practice, favoring a work model based on paternalism and beneficence, protection⁷⁹79. Szmukler G, Appelbaum PS. Treatment pressures, leverage, coercion, and compulsion in mental health care. Journal of the American Medical Association. 2008;17(3):233-244. doi: 10.1080/09638230802052203. and risk avoidance.⁸⁰80. Bentall R. Too much coercion in mental health services. The Guardian [Internet]. 2013. Disponible en: https://tinyurl.com/2588jjz9.
https://tinyurl.com/2588jjz9...

Our research reflects the integration of the positivist biomedical model on the part of the professionals through the concept of “lack of illness insight” and the influence of diagnostic labels in the interpretation of the behaviors and discourses of users and the actions that they carry out. Although authors and organizations exist that have defended the need to expand the biomedical model as a means to reducing stigma,⁸¹81. Martin JK, Pescosolido BA, Tuch SA. Of fear and loathing: The role of “disturbing behavior,” labels, and causal attributions in shaping public attitudes toward people with mental illness. Journal of Health and Social Behavior. 2000;41(2):208-223. doi: 10.2307/2676306.^,8282. Malla A, Joober R, Garcia A. Mental illness is like any other medical illness: A critical examination of the statement and its impact on patient care and society. Journal of Psychiatry & Neuroscience. 2015;40(3):147-150. doi: 10.1503/jpn.150099.^,8383. Angermeyer medidas coercitivas, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness: Systematic review of population studies. The British Journal of Psychiatry: the Journal of Mental Science. 2011;199(5):367-372. doi: 10.1192/bjp.bp.110.085563. our results support the idea that such an approach, which explains mental suffering using neurobiological theory, does not (sufficiently) take into account contexts and relationships,²²22. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf... intensifies stigmatization,⁸⁴84. Read J, Haslam N, Magliano L. Prejudice, stigma and “schizophrenia’’: the role of the bio-genetic ideology.” En: Read J, Dillon J (eds). Models of Madness: Psychological, Social and Biological approaches to psychosis. 2nd ed. East Sussex: Routledge; 2013. favors paternalist attitudes, and strips people with mental suffering of their rights, justifying damages to their liberty with the objective of achieving a higher good.⁶6. Inchauspe Aróstegui JA, Valverde Eizaguirre M. La coerción en Salud Mental: conceptos, procesos y situación. En: Beviá B, Bono Á, editores. Coerción y salud mental: revisando las prácticas de coerción en la atención a las personas que utilizan los servicios de salud mental. Madrid: Asociación Española de Neuropsiquiatría; 2017. p. 13-89.^,7979. Szmukler G, Appelbaum PS. Treatment pressures, leverage, coercion, and compulsion in mental health care. Journal of the American Medical Association. 2008;17(3):233-244. doi: 10.1080/09638230802052203. Additionally, this model promotes training that provides few tools to facilitate an effective relationship with users.⁸⁰80. Bentall R. Too much coercion in mental health services. The Guardian [Internet]. 2013. Disponible en: https://tinyurl.com/2588jjz9.
https://tinyurl.com/2588jjz9... In our study, a tendency was observed to justify the use of mechanical restraint based on the need to intervene in behaviors (or possible behaviors) of the people who receive mental health care, when it is considered that they require an indispensable treatment, whether or not the person has demonstrated “dangerous” behaviors, if the professional considers that the patient does not have an adequate understanding of what is best for them. This internalized concept of the lack of illness insight serves as an epistemological base for the professionals to limit or suspend the subject’s autonomy, and facilitates a shift in attention from the meanings of values of the person who suffers to their behaviors and the evaluation of these behaviors, as their discourse is not considered beyond the illness itself.⁶6. Inchauspe Aróstegui JA, Valverde Eizaguirre M. La coerción en Salud Mental: conceptos, procesos y situación. En: Beviá B, Bono Á, editores. Coerción y salud mental: revisando las prácticas de coerción en la atención a las personas que utilizan los servicios de salud mental. Madrid: Asociación Española de Neuropsiquiatría; 2017. p. 13-89.

In this sense, our research makes evident the priority given to the evaluation and management of risk or danger in everyday practice. Placed above the needs of the individual, risk management is an essential principle in mental health.¹⁸18. Sashidharan S, Mezzina R, Puras D. Reducing coercion in mental healthcare. Epidemiology and Psychiatric Sciences. 2019;28(6):605-612. doi: 10.1017/S2045796019000350. Other studies have also suggested²⁸28. Cusack P, Cusack FP, McAndrew S, McKeown M, Duxbury J. An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursirg. 2018;27(3):1162-1176. that coercion is one of the first responses to appear in personnel when they perceive that their own safety or that of others is at risk,⁸⁵85. Perkins E, Prosser H, Riley D, Whittington R. Physical restraint in a therapeutic setting; a necessary evil? The International Journal of Law and Psychiatry. 2012;35:43-49. doi: 10.1016/j.ijlp.2011.11.008.^,8686. Foster C, Bowers L, Nijman H. Aggressive behaviour on acute psychiatric wards. prevalence, severity and management. Journal of Advanced Nursing . 2007;58(2):140-149. doi: 10.1111/j.1365-2648.2007.04169.x. but an overestimation of risk also exists based on an assessment of the behavior of the user,²⁸28. Cusack P, Cusack FP, McAndrew S, McKeown M, Duxbury J. An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursirg. 2018;27(3):1162-1176.^,8686. Foster C, Bowers L, Nijman H. Aggressive behaviour on acute psychiatric wards. prevalence, severity and management. Journal of Advanced Nursing . 2007;58(2):140-149. doi: 10.1111/j.1365-2648.2007.04169.x. and this overestimation of the threat perceived by professionals is related to fear from previous violent incidents, which impedes the exploration of non-coercive care alternatives.²⁸28. Cusack P, Cusack FP, McAndrew S, McKeown M, Duxbury J. An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursirg. 2018;27(3):1162-1176.^,8585. Perkins E, Prosser H, Riley D, Whittington R. Physical restraint in a therapeutic setting; a necessary evil? The International Journal of Law and Psychiatry. 2012;35:43-49. doi: 10.1016/j.ijlp.2011.11.008. Indeed, the consideration of people diagnosed with mental disorders as dangerous does not hold with the evidence⁸⁷87. Peterson JK, Skeem J, Kennealy P, Bray B, Zvonkovic A. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? Law and Human Behavior. 2014;38(5):439-449. doi: 10.1037/lhb0000075. and tends to be justified through inappropriate prejudices.²²22. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf... On the other hand, it is paradoxical that the professionals consider mechanical restraint to be a safety measure when they admit the harmful impact they have on themselves as professionals as well as on the users and the therapeutic relationship, a finding supported by other authors.²⁵25. Sweeney A, Filson B, Kennedy A, Collinson L, Gillard S. A paradigm shift: relationships in trauma-informed mental health services. BJPsych Advances. 2018;24(5): 319-333.^,3333. Muskett C. Trauma-informed care in inpatient mental health settings : A review of the literature. International Journal of Mental Health Nursing. 2014;23(1):51-59. doi: 10.1111/inm.12012.^,8888. Riahi S, Thomson G, Duxbury J. An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint. Journal of Psychiatric and Mental Health Nursing. 2016;23:116-128. doi: 10.1111/jpm.12285.^,8989. Bigwood S, Crowe M. ‘It’s part of the job, but it spoils the job’: A phenomenological study of physical restraint: Feature Article. International Journal of Mental Health Nursing. 2008;17(3):215-222. doi: 10.1111/j.1447-0349.2008.00526.x.^,9090. Sequeira H, Halstead S. The psychological effects on nursing staff of administering physical restraint in a secure psychiatric hohspital: When I go home, it’s then that I think about it. British Journal of Forensic Practice. 2004;6(1):3. doi: 10.1108/14636646200400002. For these and other reasons, it has been considered necessary to move from a model in which mechanical restraint is considered a tool that provides safety to a model in which its use is considered a sentinel event, an undesirable, unexpected event that is accompanied by risks and damages, some of them severe, and that therefore requires the implementation of measures to reduce and eliminate it.⁵⁶56. Moreno Pérez A, Fernández Liria A. La contención mecánica como acontecimiento centinela: propuesta para avanzar hacia su eliminación. Boletín la Asociación Madrileña de Salud Mental. 2020;46.

This conceptualization has clinical consequences, as the majority of the alternatives proposed have to do with developing other ways of controlling behavior and avoiding risks, rather than transforming the paradigm that generates and sustains such measures.³⁵35. Gooding P, Mcsherry B, Roper C, Grey F. Alternatives to coercion in mental health settings : A literature review [Internet]. Melbourne: Melbourne Social Equity Institute, University of Melbourne; 2018 [citado 10 sep 2019]. Disponible en: Disponible en: https://tinyurl.com/3y7jf98y .
https://tinyurl.com/3y7jf98y... Our analysis suggest that coercion functions in a continuous spectrum, in such a way that having experienced a coercive measure in the past or present predisposes one to new coercive measures in the future.³3. Kirk SA, Gomory T, Cohen D. Mad Science: Psychiatric coercion, diagnosis, and drugs. New Brunswick: Transaction Publishers; 2013.^,66. Inchauspe Aróstegui JA, Valverde Eizaguirre M. La coerción en Salud Mental: conceptos, procesos y situación. En: Beviá B, Bono Á, editores. Coerción y salud mental: revisando las prácticas de coerción en la atención a las personas que utilizan los servicios de salud mental. Madrid: Asociación Española de Neuropsiquiatría; 2017. p. 13-89.

The attribution of dangerousness and incapacity to people with emotional suffering in the residents’ discourses finds resonance in the set of legal-normative systems that not only legitimize but pressure and force professionals to use coercive measures, preventively even, as a social mandate,⁶6. Inchauspe Aróstegui JA, Valverde Eizaguirre M. La coerción en Salud Mental: conceptos, procesos y situación. En: Beviá B, Bono Á, editores. Coerción y salud mental: revisando las prácticas de coerción en la atención a las personas que utilizan los servicios de salud mental. Madrid: Asociación Española de Neuropsiquiatría; 2017. p. 13-89. blaming the professionals if violent behaviors appear⁸⁰80. Bentall R. Too much coercion in mental health services. The Guardian [Internet]. 2013. Disponible en: https://tinyurl.com/2588jjz9.
https://tinyurl.com/2588jjz9... ; behaviors that, on the other hand, are always difficult to predict.⁹¹91. Bowers L. On conflict, containment and the relationship between them. Nursing Inquiry. 2006;13(3):172-180. doi: 10.1111/j.1440-1800.2006.00319.x. Some authors mention the feelings of professionals regarding being observed and assessed.³⁹39. Beviá B, Girón M. Poder, estigma y coerción: Escenarios para una práctica no autoritaria en salud mental. Revista de la Asociación Española de Neuropsiquiatría. 2017;37(132):321-329. doi: 10.4321/s0211-57352017000200001 Indeed, the discourses of residents regarding mechanical restraint cannot be separated from terms related to norms, duty and safety. A recent review⁹²92. Saya A, Brugnoli C, Piazzi G, Liberato D, Ciaccia G Di, Niolu C, et al. Criteria, procedures, and future prospects of involuntary treatment in psychiatry around the world: A narrative review. Front Psychiatry. 2019;10. doi: 10.3389/fpsyt.2019.00271. highlights the particularity of the legal framework in Spain as compared to other countries, as the legal precept that regulates involuntary hospitalization⁵5. España, Jefatura del Estado. Ley 1/2000, de 7 de enero, de Enjuiciamiento Civil [Internet]. BOE-A-2000-323 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/w7dywu9f .
https://tinyurl.com/w7dywu9f... does not mention at any time the involuntary nature of the treatment, in such a way that the responsibility of applying, after the hospitalization, any other measure considered necessary, including mechanical restraint, falls directly upon the professionals.

The general lack of resources of mental health systems put into evidence by the Rapporteur²²22. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf... coincides with the experience of the participants, who denounce the material and structural deficiencies as well as the lack of adaptation of work spaces that, rather than promoting wellbeing, are disabling spaces that impede the use of non-coercive alternatives.⁸⁸88. Riahi S, Thomson G, Duxbury J. An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint. Journal of Psychiatric and Mental Health Nursing. 2016;23:116-128. doi: 10.1111/jpm.12285.^,9393. Bowers L. Safewards: A new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing. 2014;21(6):499-508. doi: 10.1111/jpm.12129. Some researchers do not consider there to be definite proof to show that differences in the incidence of coercive measures are due to lacks in professional training, the funding of mental health services or the user-professional ratio, and suggest that the differences are essentially due to cultural factors, policies, and the traditions of each setting.¹⁷17. Steinert T, Lepping P, Bernhardsgrütter R, Conca A, Hatling T, Janssen W, et al. Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends. Social Psychiatry and Psychiatric Epidemiology. 2010;45(9):889-897. doi: 10.1007/s00127-009-0132-3. Nevertheless, others consider that in order to avoid the use of mechanical restraint resources are fundamental, including the amount of time professionals can spend with users.¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015. Indeed, structural and material deficiencies stemming from underfunding has been proposed as one of the elements favoring the violation of human rights in psychiatry.²²22. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf...

Residents identify dynamics in the teams that favor the use of restraints. The hierarchy, in symbolic form or manifested as a direct order, is considered a defining factor in the use of restraints, which professionals indicate despite feeling distress or disagreeing with the decision. As Pértega highlights, certain medical orders are experienced as difficult to question even when others (residents, nurses, etc.) have to execute them.¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015. The contribution of the hierarchical structure in this dynamic is crucial, as it generates asymmetry in the distribution of the assigned resources, responsibilities and the separation of roles, spaces and tasks. Residents are part of those who are not experts, that, even though they spend a great deal of time with the user, do not have the same resources nor abilities to resolve certain situations, resorting to power and force.

Risk of abuse and improper use of mechanical restraint

The narratives of the residents regarding the experience of tendencies toward an inappropriate use of mechanical restraint contradicts other studies in which professionals show themselves to be mostly in agreement that the use made of restraints is “correct.”⁹⁴94. Wynn R. Staff’s attitudes to the use of restraint and seclusion in a Norwegian university psychiatric hospital. Nordic Journal of Psychiatry. 2003;57(6):453-459. doi: 10.1080/08039480310003470. In our opinion, this finding emphatically encourages the use of these practices to be reexamined; however, we have not found other studies in our region with which to compare these results. On the other hand, the results highlight concepts that could be considered problematic: “agitation,” “therapeutic,” “dangerousness,” “illness insight,” “risk of absconding,” “last resort,” etc.⁸⁸88. Riahi S, Thomson G, Duxbury J. An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint. Journal of Psychiatric and Mental Health Nursing. 2016;23:116-128. doi: 10.1111/jpm.12285.^,9595. Laiho T, Kattainen E, Åstedt-Kurki P, Putkonen H, Lindberg N, Kylmä J. Clinical decision making involved in secluding and restraining an adult psychiatric patient: An integrative literature review. Journal of Psychiatric and Mental Health Nursing. 2013;20(9):830-839. doi: 10.1111/jpm.12033. All of these terms are central to the creation of a discourse that justifies the use of restraints and, nevertheless, in the experience of the professionals, are also unspecific, polysemic, and subjective. These terms are open to wide interpretation, they are not supported by research, and, according to the Rapporteur,²²22. Consejo de Derechos Humanos. Informe del Relator Especial sobre el derecho de toda persona al disfrute del más alto nivel posible de salud física y mental [Internet]. 2017 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/wcj85urf
https://tinyurl.com/wcj85urf... they can favor arbitrariness in the use of mechanical restraint.²¹21. Naciones Unidas, Asamblea General. Informe del Relator Especial sobre la tortura y otros tratos o penas crueles, inhumanos o degradantes [Internet]. Naciones Unidas; 2016 [citado 10 mar 2020]. Disponible en: Disponible en: https://tinyurl.com/dvw9t34e .
https://tinyurl.com/dvw9t34e... The perception of the residents regarding the criteria for restraints is that, similar to the diagnosis, the assessment of users and of risks has an important subjective component and the protocols do not effectively guide the actions of professionals regarding these measures. Other works have similar findings.¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.

Belief systems, fears, insecurity and uncertainty

Parallel to Bourdieu’s concept of habitus, we consider there to be a correspondence between mental and social-institutional structures.⁹⁶96. Bourdieu P. La distinción: Criterio y bases sociales del gusto. Madrid: Gruop Santillana de Ediciones; 1998. In this way, the perceptions and experiences of the professionals, their categories of representations and views of the world, are the product of the incorporation of structures of the social space. That is, beyond objective events, their experience depends on the internalization of certain schema regarding the world that informs their perceptions, feelings and actions. Based on the interaction between the professional-subject and the group and institutional culture, a system of dispositions that are both structural and structuring are built.⁹⁷97. Capdevielle J. El concepto de habitus: “con Bordieu y contra Bordieu.” Anduli: Revista Andaluza de Ciencias Sociales. 2011;(10):31-46. In this way, what we have called the culture of coercion influences the symbolic systems and informs the perceptions and actions of the residents who, at the same time, are active agents in the construction of reality in the clinical-institutional space. The power relations, hierarchies, conceptualizations of suffering based on the biomedical model and other elements of this culture are internalized and incline the residents to perceive the clinic as it stands today as evident and natural. The consideration of mechanical restraint as indispensable, fear regarding the elimination of its use, the assimilation over time of restraint as something that forms part of their work, and the tendency to justify its use could be understood as the product of the internalization of this culture that they perpetuate through reproduction. These experiences have also been presented by other researchers.⁹⁸98. Fisher WA. Restraint and Seclusion: A Review of the Literature. The American Journal of Psychiatry. 1994;151:1584-1591. doi: 10.1176/ajp.151.11.1584.^,9999. Jacob JD, Holmes D, Corneau P, Macphee C. Convergence and divergence : An analysis of mechanical restraints. Nursing Ethics. 2019;26(4):1009-1026. doi: 10.1177/0969733017736923.

A transposition appears to exist regarding the feeling of insecurity and unpredictability of the social toward the mental health network. The existence of similar experiences and elements have been described by Pértega¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.: the failure to establish objective criteria that aid professionals faced with the social (and legal) mandates delegated to them to evaluate and manage risk, added to the real impossibility of preventing and controlling all instability in the environments and behaviors of users, submerges the residents in an uncertainty-insecurity in which mechanical restraint serves to generate certainties for the professionals responsible for an impossible task. Indeed, in a number of participants concern was observed regarding the possible elimination of mechanical restraint, without which they felt unprotected.

In relation to the psychological process that underlies the use of mechanical restraint in this situation, fear appears as a primordial part of the professional experiences, fear of both real physical harm and the consequences that can arise if such harm is produced. In this climate of uncertainty, avoiding risk prevails over any potential degradation of rights and other harms that might appear. Although it could be argued that the fear of professionals has a solid base in prior experiences in which, for example, professionals have been harmed due to postponing the indication of mechanical restraint,¹⁰⁰100. Moylan LB, Cullinan M. Frequency of assault and severity of injury of psychiatric nurses in relation to the nurses’ decision to restrain. Journal of psychiatric and mental health nursing. 2011;18(6):526-534. doi: 10.1111/j.1365-2850.2011.01699.x.^,101101. Khadivi AN, Patel RC, Atkinson AR, Levine JM. Association between seclusion and restraint and patient-related violence. Psychiatric Services. 2004;55(11):1311-1312. doi: 10.1176/appi.ps.55.11.1311. we consider it indispensable that in the analysis of phenomena as complex as aggression or psychomotor agitation other factors be taken into account (for example, relational factors) or that reflections take place regarding how the lack of preparation or awareness of the influence one’s presence and the environment exert on others can determine whether or not a situation of these characteristics occurs.⁹³93. Bowers L. Safewards: A new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing. 2014;21(6):499-508. doi: 10.1111/jpm.12129.^,102102. Moore G, Pfaff JA. Assessment and emergency management of the acutely agitated or violent adult. En: Waltham MA, Robert S Hockberger (ed). Uptodate; 2020. Along these same lines, Dozza uses the concept “dreaded scenes”¹⁰³103. Kesselman H, Pavlovsky E, Frydlevsky L. Las escenas temidas del coordinador de grupos. Clínica y Análisis Grupal. 1976;1(1):1-9. to name those imagined situations that we fear will occur, and that are accompanied by disorientation, not knowing how to respond, a sense of lacking the abilities and tools to resolve the imagined situation¹⁰⁴104. Dozza de Mendoça L. Escenas temidas en salud mental [Internet]. Madrid; 2016 [citado 10 dic 2019]. Disponible en: Disponible en: https://tinyurl.com/y9whfp44
https://tinyurl.com/y9whfp44... ; this could explain the influence the collective beliefs exercise in the decision-making of the professionals. From their discourses it can be understood that, on occasion, the use of restraints is more directed at avoiding this dreaded scene than toward the needs and care that the user requires. Such scenes are closely related to “catastrophic fantasies,” that is, situations for which a professional could be judged or penalized by the institution (suicides, murders, fights) or those that could result in physical harm to the professional themselves (physically, psychologically, or in relation to their work, etc.).¹⁰⁴104. Dozza de Mendoça L. Escenas temidas en salud mental [Internet]. Madrid; 2016 [citado 10 dic 2019]. Disponible en: Disponible en: https://tinyurl.com/y9whfp44
https://tinyurl.com/y9whfp44... These fantasies, that in general are not conscious, produce a series of emotions and cognitions that push professionals to adopt conservative and overprotective behaviors, often stereotyped, in order to avoid risks. Often the fantasies and scenes are shared collectively (in the institution, society, teams, etc.) and have a significative influence in subjects initiating their training through the work cultures and philosophy.¹⁰⁵105. Vedana KGG, da Silva DM, Ventura CAA, Giacon BCC, Zanetti ACG, Miasso AI, et al. Physical and mechanical restraint in psychiatric units: Perceptions and experiences of nursing staff. Archives of Psychiatric Nursing. 2018;32(3):367-372. doi: 10.1016/j.apnu.2017.11.027.

Emotional impact and processes of adaptation

The negative impact of mechanical restraint at the emotional and psychological level has been referenced in a number of studies.²⁵25. Sweeney A, Filson B, Kennedy A, Collinson L, Gillard S. A paradigm shift: relationships in trauma-informed mental health services. BJPsych Advances. 2018;24(5): 319-333.^,106106. Knight C. Trauma-Informed Social Work Practice: Practice Considerations and Challenges. Clinical Social Work Journal. 2015;43(1):25-37. doi: 10.1007/s10615-014-0481-6. Guilt, remorse, impotence, rage and frustration are emotions frequently referenced.⁵²52. Cocho Santalla C, Nocete Navarro L, López Álvarez I, Carballeira Carrera L, Fernández Liria A. Experiencia y actitudes de los profesionales de salud mental en torno a las prácticas coercitivas directas: revisión bibliográfica de estudios cualitativos. Revista de la Asociación Española de Neuropsiquiatría. 2018;38(134):419-449. doi: 10.4321/S0211-57352018000200005. In this sense, Bloom uses the concept of parallel processes to address the symmetrical effect that the use of power to manage behavioral alterations has in professionals and users: on the one hand, it makes users fear and distrust the staff and makes them less collaborative and participatory and, at the same time, it incites professionals to feel frustrated and unsatisfied, which favors them using power and control even more.¹⁰⁷107. Bloom SL. Human service systems and organizational stress: Thinking & feeling our way out of existing organizational dilemmas [Internet]. Community Works; 2006 [citado 10 dic 2019]. Disponible en: Disponible en: https://tinyurl.com/w6ymrxs .
https://tinyurl.com/w6ymrxs... But how does one move beyond the impact following the use, acceptance and reproduction of these measures? Among the psychological processes observed, the residents describe the development of forms of adaptation similar to those detailed by Pértega.¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015. The participants narrate a transformation over time in the way in which they experience mechanical restraint. According to their statements, progressively, and through different passive and active psychological mechanisms, desensitization, habituation and automatization regarding the use of restraints take place, with a reduction in the associated distress and the integration of these measures as part of their everyday practice, diminishing the conflict generated by ethical dilemmas and the dissonance between beliefs and actions. The process identified by Pértega can explain the adaptation of residents during three consecutive phases of their training: 1) traumatization and estrangement in the first mechanical restrains; 2) rationalization, frustration and impotence as a defense toward the distress that these measures generate; and 3) incorporation and acceptance of mechanical restraint, when they begin to be considered “part of the job.”¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.^,8989. Bigwood S, Crowe M. ‘It’s part of the job, but it spoils the job’: A phenomenological study of physical restraint: Feature Article. International Journal of Mental Health Nursing. 2008;17(3):215-222. doi: 10.1111/j.1447-0349.2008.00526.x. Nevertheless, Pértega suggests at the same time one has the feeling of having become more defensive, less sure of oneself at work, believing that one must protect oneself, without ever having lost the feeling of estrangement and questioning of one’s work.

Experiences of conflict

Lastly, not all existing studies recover the professionals’ conflictive experiences with coercive measures. For example, coercive measures such as seclusion have been described by some professionals as “very necessary” and “highly therapeutic,” and they have suggested that they guarantee safety without being punitive.¹⁰⁸108. Meehan T, Bergen H, Fjeldsoe K. Staff and patient perceptions of seclusion: Has anything changed? Journal of Advanced Nursing . 2004;47(1):33-38. doi: 10.1111/j.1365-2648.2004.03062.x. Other researchers have found that the majority of professions see coercive measures as necessary to guarantee care and safety, putting in to doubt that significant moral conflicts exist.¹⁰⁹109. Molewijk B, Kok A, Husum T, Pedersen R, Aasland O. Staff’s normative attitudes towards coercion: The role of moral doubt and professional context: A cross-sectional survey study. BMC Medical Ethics. 2017;18(1):1-14. doi: 10.1186/s12910-017-0190-0. Nevertheless, the results of our work illustrate that the shared experience of the majority of residents in the context of Madrid can be characterized as presenting multiple contradictions that surface when they decide to indicate or carry out mechanical restraint. This difference might be owing to the fact that the denunciation of the consequences of mechanical restraint and the dilemmas surrounding its use have become much more present in the professional and public discourse in the last years. Considering mechanical restraint to be a necessary but damaging measure for the user and the therapeutic relationship puts residents before conflicts whose resolution depends on self-justification, negation of dissonance,⁹⁹99. Jacob JD, Holmes D, Corneau P, Macphee C. Convergence and divergence : An analysis of mechanical restraints. Nursing Ethics. 2019;26(4):1009-1026. doi: 10.1177/0969733017736923. and the acceptance of this contradiction as inherent to present-day psychiatry. This can be seen in the decision-making process,¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015. conflict with the professional role⁸⁹89. Bigwood S, Crowe M. ‘It’s part of the job, but it spoils the job’: A phenomenological study of physical restraint: Feature Article. International Journal of Mental Health Nursing. 2008;17(3):215-222. doi: 10.1111/j.1447-0349.2008.00526.x. or in the ethical dilemmas produced.³⁷37. Hem MH, Gjerberg E, Husum TL, Pedersen R. Ethical challenges when using coercion in mental healthcare: A systematic literature review. Nursing Ethics. 2016;25(1):92-110. doi: 10.1177/0969733016629770.

Strengths and weaknesses

One of the primary strengths of this study is the novel contribution it makes to the literature regarding mechanical restraint in Spain, where the lack of studies on the subject is noteworthy. It also differs from the majority of English-language publications, which tend to be particularly centered on nursing personnel. Having considered the experience of residents of different specialties enriches the understanding of the phenomenon and allows for comparisons with professionals with greater experience. Among the limitations, the controversy surrounding mechanical restraint renders it a topic of high social desirability, which can influence the narratives of the participants. Furthermore, although methodological tools were used to favor the representativity of the sample and the heterogeneity of discourses, it is possible that those with the greatest indifference toward these practices or those that might have felt threatened by the exposure decided not to take part in the study. On the other hand, the data collected should be understood in the context of a particular place and time, and therefore it is important to repeat this study in other environments in order to gain a deeper understanding of the phenomenon where it occurs. Lastly, regarding the analysis, the influence of the researchers’ history and subjectivity should be acknowledged; they have been in contact with the use of mechanical restraint in their professional practice, although this does not necessarily represent a limitation, as it was an element that enriched the design and development of the study.

CONCLUSION

The purpose of this work has been to explore in depth the experience of mental health residents with respect to the use of mechanical restraint and understand what aspects influence in what ways the process of deciding to apply restraints. Our results are similar to those presented by other authors¹⁹19. Pértega E. Health professionals’ decision making process about the use of physical restraints in inpatient pediatric psychiatric units in Madrid. New York University, Universidad Autónoma de Madrid; 2015.^,5252. Cocho Santalla C, Nocete Navarro L, López Álvarez I, Carballeira Carrera L, Fernández Liria A. Experiencia y actitudes de los profesionales de salud mental en torno a las prácticas coercitivas directas: revisión bibliográfica de estudios cualitativos. Revista de la Asociación Española de Neuropsiquiatría. 2018;38(134):419-449. doi: 10.4321/S0211-57352018000200005.^,8888. Riahi S, Thomson G, Duxbury J. An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint. Journal of Psychiatric and Mental Health Nursing. 2016;23:116-128. doi: 10.1111/jpm.12285.^,9393. Bowers L. Safewards: A new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing. 2014;21(6):499-508. doi: 10.1111/jpm.12129.^,9999. Jacob JD, Holmes D, Corneau P, Macphee C. Convergence and divergence : An analysis of mechanical restraints. Nursing Ethics. 2019;26(4):1009-1026. doi: 10.1177/0969733017736923.^,110110. Krieger E, Moritz S, Lincoln TM, Fischer R, Nagel M. Coercion in psychiatry: A cross-sectional study on staff views and emotions. Journal of Psychiatric and Mental Health Nursing. 2020;1-14. doi: 10.1111/jpm.12643.^,111111. Jacobsen TB. Involuntary treatment in Europe: different countries, different practices. Current opinion in psychiatry. 2012;25(4):307-310. doi: 10.1097/YCO.0b013e32835462e3. and suggest that the decision-making processes regarding the use of mechanical restraints are situated in a complex web of factors and experiences including elements of the sociocultural context and normative framework, relational dynamics and work environments, experiential, psychological and ethical processes, and others that stem from the interactions among these factors. A work culture based on coercion and the discourse of risk management especially stand out. Although they recognize the harmful impact stemming from their use, the professionals undergo an adaptation process through which they internalize and act upon these principles, justifying the need for mechanical restraint at the same time that they face conflicts with their professional role and ethical dilemmas.

Implications in clinical practice

The results of this research push us to demand radical change in the paradigm that promotes the metamorphosis of our practice. This implies that the transformations should transcend concrete areas of intervention and seek political, legislative, institutional and cultural changes, without ignoring the role of teams and professionals. The use of mechanical restraints, because of its implications, should be recognized as a failure in care and a measure to be eradicated. Our study suggests paths towards the elimination of restraints that take into account the complexity of the phenomenon.

CONFLICTS OF INTEREST

This project did not receive any type of funding. Researchers and participants did not receive any type of economic benefit or compensation, direct or indirect. No particular interests (economic, academic, or others) have been identified that could enter into conflict with the strictly scientific interest of the study.

ACKNOWLEDGMENTS

We thank all the residents that took part in the study. We thank Ana Moreno and Amalia Fariña for their advice, support, and comments

References

Publication Dates

History