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Table of Contents
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 96-102

Perception on physical restraints and its relationship to psychopathology

1 Junior Lecturer, College of Nursing, CMC, Vellore, India
2 Professor, College of Nursing, CMC, Vellore, India
3 Professor, CMC, Vellore, India
4 Senior Lecturer, ßiostatistics, CMC, Vellore, India

Date of Web Publication11-Jun-2020

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The use of restraints in the management of violent patients dates back to the origin of Psychiatry. Despite its use, very little is studied about the impact of restraints on patients. This study was conducted to assess the perception on physical restraints and its relationship to psychopathology of patients with psychiatric disorder. Forty patients who needed restraints were selected using total enumeration sampling technique. Coercion Experience Scale was used to assess the perception of patients on physical restraints and positive and negative symptom scale was used to assess the severity of symptoms. Participants were interviewed after the termination of restraints. The findings revealed that 67.5% of patients were males. The diagnosis of 45% of the patients was Schizophrenia, 47.5% of them were restrained to prevent harm to others, and 87.5% were placed under four point restraints. The mean duration of restraints was 64.25 minutes. Subjective distress was high among 47.5% of the patients on physical restraints. Severity of symptoms was moderate among 87.5% of patients. There was a significant association between perception of physical restraints and religion of patients (p=0.039). Eliminating the use ofrestraints may not be possible, but it is possible to change the patients’ perception by providing patient centered, holistic, quality nursing care.

Keywords: physical restraints, perception, psychopathology

How to cite this article:
Gnanapragasam A, Charles HS, Packirisamy T, Peravali V. Perception on physical restraints and its relationship to psychopathology. Indian J Cont Nsg Edn 2018;19:96-102

How to cite this URL:
Gnanapragasam A, Charles HS, Packirisamy T, Peravali V. Perception on physical restraints and its relationship to psychopathology. Indian J Cont Nsg Edn [serial online] 2018 [cited 2022 May 28];19:96-102. Available from: https://www.ijcne.org/text.asp?2018/19/1/96/286500

  Introduction Top

Restraints have been used as a method of management of violent patients in mental health practice since mental health care began. Restraints are physical or chemical resources used to control the physical or behavioral activity of a person or a portion of his/ her body (College of Nurses of Ontario, 2009). The prevalence of use of physical restraints varies among psychiatric hospitals, despite the efforts to reduce its use (Feng et al., 2009; Korkeila, Tuohimaki, Kaltiala-Heino , Lehtinen & Joukamaa, 2002).

People with mental disorders are more likely to be violent than community controls (Davison, 2005). Restraints are one method of management used when patients with violent behaviours are encountered. Various types of restraints used are 2 point restraints (upper limbs), 4 point restraints ( all 4 limbs ), mittens, jacket restraints, wrist-to- waist restraints, soft restraints, manual holds, body nets and leather restraints (The Commission, 2018). Physical restraint is used to prevent a person from causing harm to self or others or staff or to prevent absconding, or administer medication against their will (Victorian Government Department of Health, 2009).

The use of restraint is traumatic and humiliating (Macpherson, Dix, & Morgan 2005). Physical restraint techniques involve the deliberate use of pain (Davison, 2005), since the patients are held by the staff and are restrained using straps. Restraints may compromise safety if performed incorrectly or monitored inadequately (Recupero, Price, Garvey, Daly, & Xavier, 2011). If used with compassionate, humanistic approach it can achieve a therapeutic outcome for the patient while protecting the safety of others (Moylan, 2009).

The perspectives of patients regarding the use of physical restraints had been predominantly negative (Evans & Fitzgerald 2002). Patients have expressed feelings of isolation, shame, distress, fear of being restrained again, and reawakening of distressing memories of previous traumatic events with use of physical restraints (Bonner, Lowe, Rawcliffe & Wellman, 2002). Patients also have denied the necessity and the beneficence of restraints (Soininen et al., 2013). On the other hand positive perception of feelings of safety and security have been reported by some patients (Chien, Chan, Lam, & Kam, 2005).

Research in to the area of legal and ethical controversies regarding use of restraints is few. Psychiatric patients’ experiences of physical restraints are still not completely known. This highlights the need to know patients perception on the therapeutic use of physical restraints which will help in improving the nursing care when coercive measure ought to be performed.

Therefore this study was done with the following objectives

  • To assess the perception on physical restraints of patients with psychiatric disorders
  • To assess the psychopathology of patients on physical restraints with psychiatric disorders
  • To determine the relationship between perception and psychopathology of patients on physical restraints with psychiatric disorders
  • To determine the association between perception on physical restraints and psychopathology of patients with psychiatric disorders and selected socio-demographic and clinical variables

  Methods Top

The study was conducted in the Acute Care Room (ACR), Department of Psychiatry, in a multispecialty teaching hospital in South India. A cross sectional design was used and 40 patients who were restrained were selected as study subjects using total enumeration sampling method. Subjects above 18 years of age, who were also able to verbalize and comprehend Tamil or English and gave written consent, were included in the study. Subjects with severe language, hearing, cognitive impairment or intellectual disability were excluded from the study.

Data collection instruments

The Coercion Experience Scale (CES) (Bergk, Flammer & Steinert 2010) was used to collect data on patient’s perception on physical restraints. The instrument has 2 visual analogue scales and a 5 point Likert scale. It assesses six factors such as “Humiliation”, “Physical adverse effects”, “Separation”, “Negative environment”, “Fear” and “Coercion”. Mean scores for the factors and overall score was calculated. The possible overall total score is 116. It was interpreted as higher the mean score the higher the level of subjective distress. Cronbach’s alpha reported in the literature for the scale is 0.67 to 0.93.

Positive and Negative Symptoms Scale (PANSS) (Kay, Fiszbein, & Opler, 1987) was used to assess the severity of symptoms in subjects. It is a 7 point Likert scale with 30 items. The range of possible score is 30-210. Cronbach’s score reported in the literature for this scale was 0.80. The score was interpreted as follows Absence of symptoms: 30, mildly ill: 31-74, moderately ill: 75-119, markedly ill: 120164, severely ill: 165-210.

Data collection procedure

The patients who were restrained and admitted in ACR were recruited for the study. After introducing and explaining the purpose of the study, a written consent was obtained from the subjects. The instruments were administered by the investigator in either of the two languages, English or Tamil according to the patients’ preferences. Data was collected after terminating the restraints, within 12- 48 hours or as soon as the subjects settled down. Each interview was conducted for 30-45 minutes in a separate room.

The study was conducted after getting approval from the College ofNursing Research Committee and the Institutional Review Board. Written informed consent was obtained from the subjects prior to the data collection. The data obtained from the participants were kept confidential.

  Results and Discussion Top

The descriptive analysis of the socio-demographic and clinical variables (see Table 1) revealed that the mean age of patients was 32.9 years, majority (67.5%) were male patients. Similar findings were reported in Zun’s (2003) study, that the mean age of restrained patients was 36.5years and 68% were men.
Table 1: Description of Clinical Variables

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Forty five percent of patients on restraints had the diagnosis of Schizophrenia and 40% of them had the diagnosis of Mania. The positive symptoms of Schizophrenia like delusions and hallucinations increase the risk of minor and serious violence (Swanson et al., 2006), and aggressive behaviours in mania is also found to be related to positive psychotic symptoms (González-Ortega, Mosquera, Echeburúa, & González-Pinto, 2010). A literature review by Beghi, Peroni, Gabola, Rossetti, and Cornaggia (2013) revealed that young adult men with the diagnosis of Schizophrenia were subjected to more coercive measures which support the current study findings.

The common indication for restraining the patients was (47.5%) harm to others. Similarly in Australia 52% of patients were restrained due to violence and threatened violence (Cannon, Cannon, Sprivulis, & Mccarthy, 2001). Tranquilizing agents were administered to 75% of the subjects who were restrained in this study. Physical restraints are usually accompanied with tranquilizers, since it takes 2030 minutes to reach the peak effect (Harwood 2017). According to the protocol for managing violent patients in the setting where this study was conducted, de-escalation techniques were attempted first to manage the violent behaviours, followed by chemical restraints. Physical restraints are used as a least preferred option. However Knutzen_ et al, (2013) reports that only 35% patients were restrained with physical and chemical restraints. The present study revealed that 55% of patients had prior experience of hospitalization. This is in line with the study done by Knutson et al.(2011) which states that history of several admissions was common among restrained patients, probably due to poor insight and poor treatment and negative experience with mental health. Similarly 76.25% of the restrained patients have been hospitalized several times in the study done by Kamel, Maximos and Gaafar (2007).

The current study revealed that 30 % of the patients had prior experience of physical restraints. This finding is in line with a study which demonstrates that history of violence is one of the important predictor of future violence (Iozzino, Ferrari, Large, Nielssen, & de Girolamo, 2015). The mean duration of restraints was 64.25 minutes or one hour and 4.25 minutes (range10-180 minutes). Standards on restraints and seclusion an order to restraint an adult patient should be renewed within 4 hours (Joint Commission on Accreditation of Healthcare Organizations, 2005). In the present study the duration was on restraints was less, since tranquilising agents (chemical restraints) were adminstered to most of the patients which helped the patients to calm down or sleep. The patients were un-restrained after they calmed down or fell asleep. In a study by Guedj, Raynaud, Braitman and Vanderschooten (2004) the average duration of physical restraints was 2 hours but in another literature review by Stewart, Bowers, Simpson, Ryan, and Tziggili (2009) reveals that the episode of restraints to be lasting for about 10 minutes.

In the current study, 87.5% were able to recollect 75100% of the restraints situation. On the contrary only 40 % of the patients have remembered some aspects of being restrained in a study done by Minnick, Mion, Johnson, Catrambone, and Leipzig, (2007). The global burden of restraint is 100% among 47.5% of patients. The global burden indicates the perception of the patient regarding the use of restraints from the time of initiation of restraints till the time of un-restraining. This finding is in line with the findings of Bergk, Einsiedler, Flammer and Steinert (2011) that found high global burden for patients on physical restraints.

In the current study half of the patients (50%) felt highly humiliated due to restraints. Patients mentioned that they were not treated like human beings but like animals. Some of them said they lost their dignity and self-respect. Some physical adverse effects such as pain and the restriction in the ability to use the toilet were perceived by 42.5% of patients. Restraints are considered unnecessary by patients and want to be off restraints. In their effort to fight against the restraints patients try to take off the restraints, causing pain at the restraint site. General body aches were reported by 68% patients in a study by Kamel et al. (2007). The feeling of separation was less among 57.5% of the patients in this study. When a patient is restrained, a relative is allowed to stay with them in this setting, thus reducing the feelings of separation. Fear was high among 30% of patients, which is in line with the findings of Wynn (2004) who found that patients felt fearful on physical restraints. Majority (55%) of the patients felt physical restraints as a coercive measure. Most patients refused physical restraints, which makes the process of restraining difficult and increased the number of people required to restraint. This might have made them feel subjected to coercion. The negative pressures (threats and force) used while initiating physical restraints strongly affect the amount of coercion experienced by the individual (Shah & Basu, 2010). Less than half (42.5%) of the patients perceived the environment as negative (see Table 2).
Table 2: Distribution of Subjects based on Perception on Physical Restraints

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Overall, the subjective distress was high among 47.5% of the patients. This is supported by the findings of Steinert, Birk, Flammer, and Bergk (2013) which revealed significantly high subjective distress among patients who were restrained (see Table 2).

In the current study, the severity of psychiatric symptoms is moderate in most (87.5%) of the participants (see Figure 1). Studies have reported greater clinical severity on PANSS score among the patients who required restraints (Pascual et al., 2006).
Figure 1: Distribution of subjects based on the severity of symptoms

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The current study showed that there was no significant relationship between the psychopathology of physically restrained patients and their perception on physical restraints.

Similar findings were reported by Anestis et al. (2012) that severity of psychiatric symptoms were unrelated to perceived coercion during hospitalization. On the contrary, a study done by Noda et al., (2012) had a significant negative correlation between overall perception about restraint/seclusion and severity of symptoms. In this study there was statistically significant association between perception on physical restraints and religion of subjects (p=0.039*) was noticed. However, females, younger patients, first admission, short duration of illness (Elgamal, 2006) have been found to be associated with the perception of patients on physical restraints.


Assessment of perception on physical restraints and its relationship to psychopathology of patients was a one-time assessment.


Nurses need to be sensitive to the patients’ perspectives of physical restraints. A person centered caring attitude and behavior by the restraint provider would cause positive feelings in the patient on physical restraints. This necessitates the need for nurses to be aware of their own attitude towards physical restraints. Providing a comfortable, safe environment and communication would support and maintain human dignity. A systematic debriefing session post restraint may help patients to understand why restraint was used. Further research in this area involving large samples and qualitative approach would help in exploring patients’ perception on physical restraints and its correlates.

  Conclusion Top

Patients may be at their lowest point of functioning when they are restrained, whereby their sense of reality is grossly impaired, and they are being forced into treatment. While it may not be possible to eliminate the incidents of restraint, nurses can render quality patient care focusing on the psychological and emotional needs of patients on physical restraints. This would help the patients to undergo the very unpleasant experience as a therapeutic experience.

Conflicts of Interest: The authors have declared no conflicts of interest.

  References Top

Anestis, A., Daffern, M., Thomas, S. D. M., Podubinski, T., Hollander, Y., Lee, S., Kulkarni, J. (2012). Predictors of perceived coercion in patients admitted for psychiatric hospitalization and the Stability of these Perceptions over Time. Psychiatry, Psychology and Law, 20(4), 492503. doi:10.1080/13218719.2012.712833  Back to cited text no. 1
Beghi, M., Peroni, F., Gabola, P., Rossetti, A., & Cornaggia, C. M. (2013). Prevalence and risk factors for the use of restraint in psychiatry: A systematic review. Rivista di psichiatria, 48(1), 10-22. doi.org/10.1708/1228.13611  Back to cited text no. 2
Bergk, J., Flammer, E., & Steinert, T. (2010). Coercion Experience Scale(CES)-validation of a questionnaire on coercive measures. BMC psychiatry, 10(1), 5. doi:10.1186/1471-244X-10-5  Back to cited text no. 3
Bergk, J., Einsiedler, B., Flammer, E., & Steinert, T. (2011). A randomized controlled comparison of seclusion and mechanical restraint in inpatient settings. Psychiatric Services, 62(11), 1310-1317. doi:10.1176/ appi. ps.62. 11.1310  Back to cited text no. 4
Bonner, G., Lowe, T., Rawcliffe, D., & Wellman, N. (2002). Trauma for all: A pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9(4), 465-473.  Back to cited text no. 5
Cannon, M. E., Cannon, M. E., Sprivulis, P., & Mccarthy, J. (2001). Restraint Practices in Australasian Emergency Departments. Australian and New Zealand Journal of Psychiatry, 35(4), 464467. doi:10.1046/j.1440- 1614.2001.00925.x  Back to cited text no. 6
Chien, W. T., Chan, C. W., Lam, L. W., & Kam, C. W. (2005). Psychiatric inpatients’ perceptions of positive and negative aspects of physical restraint. Patient Education and Counseling, 59(1), 80-86. doi:10.1016 /j.pec. 2004.10.003  Back to cited text no. 7
College of Nurses of Ontario. (2009). Practice Standards: Restraints. Retrieved from https://www.cno.org/ globalassets/ docs/prac/41043_restraints.pdf  Back to cited text no. 8
Davison, S. E. (2005). The management of violence in general psychiatry. Advances in Psychiatric Treatment, 11 (5), 362370. doi: 10.1192/apt. 11.5.362  Back to cited text no. 9
Elgamal, M. (2006). Patients and staff attitudes toward physical restraint. Current Psychiatry, 13(3), 474.  Back to cited text no. 10
Evans, D., & Fitzgerald, M. (2002). The experience of physical restraint: A systematic review of qualitative research. Contemporary Nurse, 13(2-3), 126135. doi:10.5172/conu.13.2-3.126  Back to cited text no. 11
Feng, Z., Hirdes, J., Smith, T., Finne-Soveri, H., Chi, I., Du Pasquier, J., … Mor, V. (2009). Use of physical restraints and antipsychotic medications in nursing homes: A cross-national study. International Journal of Geriatric Psychiatry, 24(10), 11101118. doi:10.1002/gps.2232  Back to cited text no. 12
González-Ortega, I., Mosquera, F., Echeburúa, E., & González-Pinto, A. (2010). Insight, psychosis and aggressive behaviour in mania. The European Journal of Psychiatry, 24(2), 7077.  Back to cited text no. 13
Guedj, M. J., Raynaud, P., Braitman, A., & Vanderschooten, D. (2004). The practice of restraint in a psychiatric emergency unit]. L’Encéphale, 30(1), 3239.  Back to cited text no. 14
Harwood, R. H. (2017). How to deal with violent and aggressive patients in acute medical settings. The Journal of the Royal College of Physicians of Edinburgh, 4 7(2), 94-101. doi: 10.4997/JrCPe.2017.218  Back to cited text no. 15
Iozzino, L., Ferrari, C., Large, M., Nielssen, O., & de Girolamo, G. (2015). Prevalence and risk factors of violence by psychiatric acute inpatients: A systematic Review and Meta-Analysis. PLoS ONE, 10(6). https://doi.org/10.1371/journal.pone.0128536  Back to cited text no. 16
Joint Commission on Accreditation of Healthcare Organizations. (2005). Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oak Brook, Ill: JCAHO; 2005. Retrieved from www.jcaho.org/ accredited+organizations/ hospitals/ standards/ hospital+ faqs/faq+index.htm.  Back to cited text no. 17
Kamel, N.M.F., Maximos, M.H.F., & Gaafar, M.M., (2007). Reactions of Patients and Psychiatric Hospital Staff About Physical Restraint. Archives of Psychiatry Nursing, 6(2). Retrieved from http://applications.emro. who.int/imemrf/asnj/2007_6_2_1.pdf.  Back to cited text no. 18
Kay, S. R., Fiszbein, A., & Opfer, L. A. (1987). The positive and negative syndrome scale (PANSS) for Schizophrenia. Schizophrenia Bulletin, 13(2), 261.  Back to cited text no. 19
Knutzen, M., Bj0rkly, S., Eidhammer, G., Lorentzen, S., Mj0sund, N. H., Opjordsmoen, S., … & Friis, S. (2013). Mechanical and pharmacological restraints in acute psychiatric wards. Why and how are they used?. Psychiatry Research, 209(1), 91-97. doi:10.1016/ j.psychres.2012.11.017  Back to cited text no. 20
Knutzen, M., Mjosund, N. H., Eidhammer, G., Lorentzen, S., Opjordsmoen, S., Sandvik, L., & Friis, S. (2011). Characteristics of psychiatric inpatients who experienced restraint and those who did not: a case- control study. Psychiatric Services, 62(5), 492-497.  Back to cited text no. 21
Korkeila, J.K., Tuohimaki, C., Kaltiala-Heino, R., Lehtinen, V., Joukamaa, M., (2002), Predicting use of coercive measures in Finland. Nordic Journal of Psychiatry, 56(5), 339-345. doi:10.1080/080394802760322105  Back to cited text no. 22
Macpherson, R., Dix, R., & Morgan, S. (2005). A growing evidence base for management guidelines Revisiting guidelines for the management of acutely disturbed psychiatric patients. Advances in Psychiatric Treatment, 11 (6), 404415. doi:10.1192/apt. 11.6.404  Back to cited text no. 23
Minnick, A. F., Mion, L. C., Johnson, M. E., Catrambone, C., & Leipzig, R. (2007). Prevalence and variation of physical restraint use in acute care settings in the US. Journal of Nursing Scholarship, 39(1), 30-37.  Back to cited text no. 24
Moylan, L. B. (2009). Physical restraint in acute care psychiatry: A humanistic and realistic nursing approach. Journal of Psychosocial Nursing and Mental Health Services, 47(3), 41-47.  Back to cited text no. 25
Noda, T., Sugiyama, N., Ito, H., Soininen, P., Putkonen, H., Sailas, E., & Joffe, G. (2012). Secluded/restrained patients’ perceptions of their treatment: Validity and reliability of a new questionnaire. Psychiatry and Clinical Neurosciences, 66(5), 397404. doi:10.1111/j. 1440-1819.2012.02350.x  Back to cited text no. 26
Pascual, J. C., Madre, M., Puigdemont, D., Oller, S., Corripio, I., Diaz, A., … & Alvarez, E. (2006). A naturalistic study: 100 consecutive episodes of acute agitation in a psychiatric emergency department. Actas Espanolas de Psiquiatria, 34(4), 239-244.  Back to cited text no. 27
Recupero, P. R., Price, M., Garvey, K. A., Daly, B., & Xavier, S. L. (2011). Restraint and seclusion in psychiatric treatment settings: regulation, case law, and risk management. The Journal of the American Academy of Psychiatry and the Law, 39(4), 465476.  Back to cited text no. 28
Shah, R., & Basu, D. (2010). Coercion in psychiatric care: Global and Indian perspective. Indian Journal of Psychiatry, 52(3), 203. doi:10.4103/0019-5545.70971  Back to cited text no. 29
Soininen, P., Välimäki, M., Noda, T., Puukka, P., Korkeila, J., Joffe, G., & Putkonen, H. (2013). Secluded and restrained patients’ perceptions of their treatment. International Journal of Mental Health Nursing, 22(1), 4755. doi:10.1111/j.1447-0349.2012.00838.x  Back to cited text no. 30
Steinert, T., Birk, M., Flammer, E., & Bergk, J. (2013). Subjective distress after seclusion or mechanical restraint: One-year follow-up of a randomized controlled study. Psychiatric Services, 64(10), 10121017. doi:10.1176/appi.ps.201200315.  Back to cited text no. 31
Stewart, D., Bowers, L., Simpson, A., Ryan, C., & Tziggili, M. (2009). Manual restraint of adult psychiatric inpatients: A literature review. Journal of Psychiatric andMentalHealth Nursing, 16(8), 749-757.  Back to cited text no. 32
Swanson, J. W., Swartz, M. S., Van Dorn, R. A., Volavka, J., Monahan, J., Stroup, T. S., McEvoy, J. P., Wagner, H. R., Elbogen, E. B., & Lieberman, J. A. (2008). Comparison of antipsychotic medication effects on reducing violence in people with Schizophrenia, The British Journal of Psychiatry, 193, 37- 43.  Back to cited text no. 33
The Joint Commission. (2018). Specifications Manual for Joint Commission National Quality Measures. Retrieved from http: // www. jointcommission. org/specifications _manual_joint _commission_national _ quality _ core_measures.aspx.  Back to cited text no. 34
Victorian Government Department of Health. (2009). A literature review and policy analysis on the practice of restrictive interventions in Victoria. Retrieved from http://www.health.vic.gov.au/chiefpsychiatrist/docume nts/creatingsafety/creating_safety_project_report.pdf  Back to cited text no. 35
Wynn, R. (2006). Coercion in psychiatric care: clinical, legal, and ethical controversies. International Journal of Psychiatry in Clinical Practice, 10(4), 247-251.  Back to cited text no. 36
Zun, L. S. (2003). A prospective study of the complication rate of use of patient restraint in the emergency department. Journal of Emergency Medicine, 24(2), 119124.  Back to cited text no. 37


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  [Table 1], [Table 2]


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