to restraint globally is not very concrete. The reasons for restraint vary and
expectations in each case will also differ.
topic in this research is the subjective experience of nursing staff when using
mechanical restraints on adolescent inpatients in a child and adolescent psychiatric
The use of restraint affects nursing staff
personally, causing personal, professional and humanitarian inconveniences.
Therefore, social considerations, as well as subjective and personal experience,
have a bearing on the decision to use mechanical restraint.
considerations for using the method depend on the given interpretations. The
experiment may have something to do with them, since nursing staff often become
the executor of the legitimate authority. They deny responsibility for their
own behavior when accepting the establishment of an organized social hierarchy.
They also experience a fear of using cruelty when obeying treatment guidelines.
They question taking on board "mechanical restraint devices" and feel
obliged to think twice about their own behavior, controlling it and answering
for it. Thus, our initial consideration was that "nurses are ethically and
legally liable for the care they provide or should provide in the course of
their professional duty",2
which implies taking the opportunity and appropriateness of using mechanical
restraint into consideration.
silence surrounds mechanical restraint. In Spanish it is only mentioned in seven
in the CUIDEN database. The method is used in all hospitals, although there
are references of less. We have one reference from Greece9
and another on practice based on evidence in the magazine published by the Joanna
Briggs Institute in Australia.10
A few more can be found in the MEDLINE database.
under age who are admitted to a psychiatric unit in order to be mentally evaluated
feel great frustration, usually expressed through episodes of psychomotor agitation
and anger attacks when they realize that they will have to spend a few days
in hospital. Sometimes they have been tricked into coming and other times they
realize that they need to be hospitalized. Recurring to mechanical methods of
restraint is a painful resort in such situations11
but it may be of the essence and necessary to ensure a safe environment and
preserve them from physical harm, as well as their companions and the nursing
staff. Using restraints may leave a bitter aftertaste of having "trampled" on
a person's human rights. However, construing it as a tool may help to remove
"disastrous" emotional overtones.
The main theory
which we focus on is phenomenology, according to which subjective phenomena
can only be understood from the standpoint of individual experience.12
This paper seeks to learn about the experience of the members of the nursing
team in a Child and Adolescent Psychiatric Unit (CAPU) at the Basurto Hospital,
in Bilbao (Spain). The Unit was chosen for several reasons: it has easy access,
the author belongs to it, and it provides an opportunity to approach the topic
with inside knowledge. It is a new Unit, with two and a half years of experience.
The team is enthusiastic and highly motivated, in the process of cohesion, self-analysis,
self-criticism, and on-going improvement of daily practice, particularly in
the use of mechanical restraint and therapeutic alternatives to it. Currently,
the mentioned unit follows a protocol (Fernández, Vivanco and Marqués:
Protocolo de alteración de conducta. XIII Nacional de la Sociedad Española
de Psiquiatría Forense. Badajoz, April, 2005). Some opinions and experiences
have probably changed due to the method, since it is being used as a criterion
for unanimity. Likewise, the discussion that arose from this paper proved useful
in making group actions cohesive.
Participants and method
is descriptive-interpretative, based on qualitative methodology within the context
The sampling used was intentional.
All team members were asked to take part when the work began in March 2005,
in order to study the group's general feeling. In all, 12 members of the team,
six nurses and six auxiliaries nurses, took part. The only criterion for inclusion
was acceptance of the proposal to take part in the study.
ages were similar, around 45, with over fifteen years of hospital experience.
One nurse came from psychiatrics and the rest from several different hospital
units. Team members all began to work in the CAPU at the same time, with no
other experience with adolescents than their own children and family.
conversations, which were recorded, lasted from one to two hours, depending
on the characteristics of each staff member, and were transcribed literally,
in full. The conversations sought controversial and opposite opinions on common
topics, in order to validate the outcomes of the dialogue when it was already
saturated. An in-depth interview was used to gather data, trying to keep it
spontaneous, loosely structured and based on a brief initial script.
and sensations brought on by mechanical restraint was the initial question we
used to break the ice. Beyond doubt, subjectivity on the method used by the
Unit's nursing team emerged from the conversation.
add to the validity of the data, literal transcriptions of the interviews were
returned to each nurse participant so they could read, correct, add to or delete
any parts of the conversations that they considered to be wrongly interpreted
or private. The content was not analyzed until all of the material was returned
and the participants indicated that they fully accepted the manuscript.
procedure described by Colaizzi13
was used to analyze the content of the conversations. The last item, the meeting
to express their opinions, was changed due to fit the participants' schedule.
The steps followed were to:
1. Read the literal transcription corrected by
the participants, which gave an overall view of their experiences.
the aspects related to the study topic, and to key words and sentences.
Determine the meaning of each significant word and sentence.
of the topics considered to be important to the study into groups. These are
the researcher's interpretations13
which go beyond the literal discourse, are coherent with it, and exemplify its
5. Integrate the participants' ideas into an in-depth descriptive
and analytical report.
6. Deliver a written report on the outcome of the
research to the participants so they could write down their impressions on the
findings and on the way they were interpreted and return them.
flexibility of the entire process was a methodological requirement. It led us
to consider that another person could make a different classification and even
arrive at a different definition to the one given in this paper.
corrections were made to the literal quotes in order to make them easier to
read. In some cases, repetitions of concrete words, drawn-out syllables and
the tics inherent to any conversation were deleted to avoid disagreeable feelings
along the lines of "I don't express myself well".
the experience with mechanical restraint into three categories with their respective
sub-categories, as follows:
-The intervention: mechanical restraint:
It consists in any expression of conduct deployed during the restraining phenomenon.
The sub-categories we describe are: physical sensations, thoughts, feelings
-Questioning the intervention: The team makes a self-analysis
on how they acted before deciding to use restraint, without forgetting the method's
"disagreeable" emotional after-taste. The sub-categories are: individual assessment,
how the team is perceived, self-criticism for using restraint, the employment
of unanimous and objective criteria, differences in assessment.
of the method: Sometimes mechanical restraint can be useful as a constraint
that gives time to think and drain contained angry emotions. The sub-categories
are: timely restraint, taunting the milieu in a play to the limits, negative
reinforcement and last resort.
Intervention: mechanical restraint.
Behavior evidences one's emotional and cognitive reality. It goes beyond
what can be seen, as a result of the BEHAVIOURAL TRIAD: physical sensations
(physiological reality), thoughts (interpretation of reality), and performance
(what one does, based on what was felt and thought). The triad leads to one's
response. This process is automatic, irrational and immediate. Self-analysis
serves to gather information on the process. It makes one to stop to think,
remember what one did, enumerate the results and assess the usefulness of what
one achieved. With this information, changes can be made in one's behavior the
Descriptions of the physical sensations
caused by restraint evidence a deep-seated unease among the nursing staff
that use the method. This uneasiness has considerable impact on whether to use
it as a tool. Nurses feel compelled to seek justifications with clearly emotional
overtones when making their cognitive assessments. Although some nurses have
not had a bad experience, the general feeling is that it is quite disagreeable.
voice trembles and paleness. (E)
My heart is
in my throat. (F)
Thoughts refer to the force involved
in mechanical restraint, feelings of having used aggression, and the resulting
uneasiness among the nursing staff.
"If it is someone
strong, you get in a bad mood. I mean, you have to hurt them. It leaves you
with the feeling that you've been physically aggressive. (A)
feelings start the process of analyzing the experience. "Remorse" caused by
guilty feelings is also frequent, although it is often denied. To deny an experience
implies ignoring physical sensations. The literal expressions are quite significant.
maybe if I had taken a step back at the beginning it wouldn't have come to this.
Or maybe not, but you have this doubt and you say, well, maybe next time I'll
step back and see what happens. (E)
feel annoyed with myself because somehow I have this feeling, let's see, not
guilt but like you feel you could have avoided it and that maybe you could have
controlled them some other way. But then, when you think about it, you see it's
the only way, the best way for everyone, including them. (F)
Questioning the intervention.
An individual assessment of restraint also takes place. It depends mainly on
the personal emotional significance as well as the use of restraint. It determines
whether the situation will be judged as serious enough to justify the use of
restraint. The conviction that no other tools are available calms the disagreeable
feeling left by using it.
"It [restraint] is a failure.
A professional failure, although I'm not sure [that other strategies exist,
but] maybe I have the wrong idea about mechanical restraint when I shouldn't
have them. I think it's rude. (E)
goes deeper into how the team perceives the way restraint is carried out in
order to respect and defend the adolescents' rights at all times. Obviously,
it goes into the number of people needed, group unity, the allocation of tasks
to each member, approaching the patient, preparing the bed with the restraint
devices, and so on. However, it also goes into other aspects, such as quickness,
calmness, keeping silent to avoid refuting or answering the youngster's messages,
soothing words for the youngster and for the staff so they will not break down
once the decision to use restraint has been taken.
and during restraint [the aim] is to control the situation and hurt the kid
as little as possible. It's not all a matter of strength. I think a lot of other
factors enter into it, like doing it as quickly as possible and the rapport
between the staff who are restraining. I've learned, with children in particular,
to shut up because the patients tend to say the rudest things they can think
Self-criticism is an obligation and a necessity
when working with habits and behavior. It is used by the team to obtain feedback
that will allow them to improve the practice of restraint, change certain actions,
discharge emotions, revise criteria, and seek alternative means of approach.
true that next time I'm going to use more resources because I analyze whether
I have used every possibility or done all I could have done. (B)
we should study and reorganize our ability to endure, to listen, to be calm.
I don't want to answer back. (I)
No matter how clear
the restraint procedure is in general, it is obvious that there is still a lack
of criteria for some aspects of restraint. For instance, why it should be done,
how long should it last, and which aspects of interaction and communication
with the youngster determine when restraint should be removed. All this could
become a reason for confrontation, particularly when restraint is no longer
seen as an external means of control when internal means cannot be used. Even
when the procedure is straightforward, issues still arise regarding how to use
restraint and staff attitudes.
"Within the lack of
strict rules that I apply, they can pull a lot of shit on me and fool around
because nothing happens, but when they push it to the limit, well, some people
don't allow it and others aren't affected, even when they do the same as I do.
The differences in judging whether or not a situation
requires restraint are worth mentioning. There may be personal differences when
it comes to evaluating a circumstance, depending on a particular skill for holding
without having to use a restraint, or for using restraint as an initial resort
that subsequently becomes a problem. Or to use avoidance as an alternative,
that is, to not do anything, thereby solving the problem by avoiding confrontation
with the patient. Any strategy may be appropriate, controversial or unnecessary.
However, constant questioning of daily practice is useful in that it provides
feedback on professional decisions and performance. Besides self-criticism,
hetero-criticism on how to improve is also employed in an open, trusting and
safe environment so no one will feel personally called into question in the
"You work better when you feel complicity
than when you're on the defensive, you know? I like it [complicity] much more,
but you don't always feel that way, right? (C)
Usefulness of the method.
The method enables us to learn where the limits are. Sometimes, timely restraint
can prevent uncontrolled agitation. When youngsters become worried, impulsive
and out of control, verbal control may provide them with different references
to reality than the ones that moved them to act: most often, attributions to
external, stable circumstances beyond their control. When they feel unable to
control themselves, an invitation to isolation with the possibility of restraint
is usually accepted, even asked for. It is of the essence to understand provocation,
without giving in to it, as a means for drawing attention in order to discharge
unease and purge guilty feelings along the lines of "I deserve it". Thus, adolescents
show that they are completely unable to ask verbally for what they really need
or are used to getting, without becoming agitated and provocative.
remember one restraint that we expected to be very violent and then, well, I
did ask for advice but I took the initiative, right? So I called everyone, we
took him to his room and so on. And, well, in the end I felt good because we
managed to talk and restraint wasn't needed. So then you feel fine, which is
what I mean that, when you are sure that you have to use restraint and then
even so you manage to reach the kid, you feel great. (C)
the milieu is sometimes a way of obtaining from the outside what cannot be tolerated
in one's interior:
1) Punishment to atone for guilt
2) Control one's lack of control.
Stop feelings of impotence by fighting against the restraint as a way of diminishing
the physiological responses that are triggered by the anger caused by frustration
or a feeling of being abandoned. Through mechanical restraint, they realize
that the only thing they can do is think, after their hyper-activity has been
stopped, along with their impulsiveness, opposition and negative feelings, and
open or veiled attacks against their peers and staff, taunting, insults, and
spoiled behavior. From this point of view, restraint could be seen as a way
of providing instruction, guidance, models and molds, attention, restriction
and exemplification that allow them to learn. Rules are made so they will learn
to govern themselves by external references, and be able to govern their moral
The ones working here, we have to know
what to say, "Well, not now, not now". You have your reasons for saying no,
and on top of that for the kid to say, "That's true, today is not about what
I want. What can we do, yesterday it was my turn but not today". Generally,
most of us can do that now. And that's good. We retain the authority we're supposed
to have. (E)
This is restraint as a negative reinforcement,
not a punishment. It frees the adolescents from their anxiety over their situation.
It calms them down by allowing them a "catharsis" that normally they cannot
do. When their movements are restricted by restraint, they can let go. They
do so with a feeling of belonging, without feeling ashamed of yelling and kicking,
without group repression. It is the need of the youngsters and of the nursing
staff. Subsequently, staff members help the youngsters to interpret their feelings,
find the best ways to express unwanted and disagreeable ones, and to analyze
their behavior. From that point of view, restraint can be useful to adolescents
as an analytical tool.
For one reason or another,
you feel that they are asking for it. It's a way to draw attention. (A)
any case, in our Unit we tend to use mechanical restraint on adolescents as
a last resort. The team uses every strategy known to them to delay or avoid
the need for restraint, and gives youngsters every possible opportunity to think
of the consequences of their behavior.
we are tolerant with them until we are overwhelmed, until we get to the point
where of exhaustion. I think we also become more tolerant as we learn how to
control our own insecurity. I find that when we have to restrain is when they
have gone beyond the emergency and when they have gone so far that there is
no way of bringing them down. (A)
derived from applying restraint is based on a learned, blind and automatic cognitive
It is the result of a classification process and personal attributes and has
an impact on how restraint is experienced. It conditions subsequent approaches
and decision-making on the issue.
the need to use restraint in certain situations, one must ask: Is this a first
choice method or a last resort? What should I assess in a restraint and how
can I assess it? How do I assess the decision: on the basis of an interpreted
attitude or on the description of concrete behavior? What does agitation mean
to me? In mental health care, proper use of any method requires discussion and
uniform criteria. When uneasiness determines decision-making, it is even more
important to exchange experiences.
cohesion and consensus provide a feeling of safety when one needs to intervene,
particularly when personal subjectivity plays a core role in interpreting behavior.
Analyzing restraint implies knowing how it can be
done and how to improve it, when it should be used and when it should end, how
to use it and what to do while it is being done, and then to analyze its usefulness,
assessing the outcomes with a person who has undergone it. Mechanical restraint
of adolescents with behavior disorders is probably one of the most complex methods
that can be used. Medical sessions are needed to pool existing data and personal
experiences that allow staff to "discharge" uneasy feelings about using the
Some people defend that restraints in psychiatry
should be exemplary15
in order to mold behavior: respect for others' rights, obey the limits, tolerate
frustration. However, methods16
that are more appropriate and didactic exist, based on active listening and
empathy, which allow adolescents to express important feelings, and confused,
mixed-up or wrong ideas. In short, so they can express their psychological constellation
and make decisions. Learning alternatives to restraint requires time and effort.
It means learning to read the milieu with the adolescent and other team members,
in terms of objective and contrasted behavior.
the mechanical restraint seems that it has an analytical utility when handling
itself like final alternative in behavioral alterations. After it the behavior
of the transgressors changes, beginning to respect the limits, at the moment
in the unit. It is an element more than it makes possible the reflection. Probably
because during the time of restraint, they cannot do more than to think, to
analyze, self-critic, to criticize, to plan and to decide.
during restraint is an ethical and professional imperative. To argue, explain
and answer back means reinforcing the arguments for continuing disruptive behavior
caused by the emotional turmoil that triggered the process. Adolescents, incapable
of tolerating frustration, express their anger inadequately, causing a physiological
that forces them to defend themselves by attacking. Professionals need to be
trained to identify their experience and, above all, their reactions.
symbology of NO is an aim that the team needs to be clear about in order to
guide the youngster. Difficulties in obeying that symbology may lead to confuse
the care of the adolescent. Saying no is a way to teach them to tolerate frustration
and to seek and deploy more appropriate options that adjust to their reality.
It enables them to learn from their mistakes,18
assuming changes and uncertainty.
On the other hand
the nurses are a referring one of adult different from the customary one. The
security that maintains the personnel with the adolescents with respect to certain
behaviors and the reflection of the possible consequences, allows to introduce
doubts that slant the security of the young person, making possible to start
up different facings.
To deny one's feelings is to
reject one's own experience. It is a way of being outside of reality. Communicating
paradoxical messages confuses the receptor, prevents group unity and encourages
unresolved issues to grow larger. It is the beginning of much-feared division
within the group.
acknowledgement of the support and collaboration of the nursing team at the
Child and Adolescent Unit of Basurto Hospital for sharing their opinions, experiences
and criticism. Their contribution makes this paper worthy of attention. Any
errors are only attributable to the author, for not knowing how to understand
the feelings they expressed.
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