Patients with violent behavior can harm themselves, others and environment. It can be an indicator for mental health hospital admission. Violent behaviors can be characterized by verbal and physical attacks demonstrated by the individuals intensively. Management of violent behaviors in hospital often uses restraint, but it has physical and psychological effects. This study aimed to explore experience of restraint use among patients with violent behaviors in mental health hospital.
MethodTo gain deep understanding related to the patients' experiences, this study used a qualitative design with a phenomenological approach. Purposive sampling was employed to find patients who were restrained during their hospitalization. The number of participants in this study was 8 participants. The data were analyzed with Colaizzi's method.
ResultsPatients with violent behavior, specifically with physical restraint during their hospital-ization had negative impacts on patients. The results of this study were described in three themes: 1) aggressive behavior as one of the main reason of restraint; 2) professional healthcare supports during the restraint use, and 3) physical and psychosocial impact of the restraint use.
ConclusionsThe impact of restraint is related to human right violations and ethical dilemma. The process of decision-making for employing restraint, especially in relation to violent behavior management, requires a consideration of the rights of the patient. Every individual has the right of self-determination, liberty, security and physical integrity.
Mental health is a condition of emotion, behavior and socialization, so that the individual is able to perform their best functions1. The disturbance of thoughts, behaviors and emotions that lead to obstacles in functioning of human being is called as mental disorders2.
WHO estimated that 450 million people in the world are people with mental illness, 10% of adults experienced mental illness at this time and 25% of the population will experience it at a certain age3. The prevalence of severe mental disorders in Indonesia is 1.7 per a thousand of the population or 400 thousand people with the highest prevalence are located in the provinces of Aceh and Yogyakarta by 2.7 per thousand inhabitants. The prevalence of severe mental disorders in the province of Central Java poses the third rank by 2.3 per mil4. The most often mental disorder identified in the province is schizophrenia3.
Schizophrenia is one of the psychiatric disorders that affects brain functions and often characterized as severe and persistent. Schizophrenia is a group of symptoms or the disease process that affects all aspects of a person, including emotional, behavioral and social3. Schizophrenia has two main symptoms, namely positive and negative symptoms. One of the positive symptoms that appears, is violent behaviors. Violent behaviors have been one of main reasons of why people with schizophrenia are admitted to mental hospital2. Violent behavior can be demonstrated individuals verbally and physically. Verbal violent behavior can be in the forms of spoken words, physical threats and sexual harassment. Physical violent behavior can be in the form of damaging environment, surrounding people and the individual that cause mild or severe injury3.
The management of violent behavior can be performed in three strategies including prevention, anticipation and restraint strategy5. The prevention strategies are carried out through a set of trainings and education related to self-awareness and assertiveness. The anticipation strategies involve skill enhancement in areas of non-aggressive communication, education about environmental changes, and service provision such as behavior therapy and other treatment program. Aggressive behavior cannot be only dealt with anticipation and prevention management; but, it is necessary conduct the next strategy of crisis management through the actions of seclusion (confinement) and restraint4,6.
The restraint strategy is still in controversy among health professionals because it may violate the patients' rights7. The restraint use is viewed as an act with no therapeutic value8. Physical restraint has impact on the patient's psychological conditions such as helplessness, tension, anger, fear, and trauma9. The restraint action also leads to physical effects such as dehydration, choking, asphyxia, aspiration, urinary incontinence, injuries and even deaths10.
Studies related to violent behavior and restraint are scarce, thus the researchers were interested to investigate the topic through a phenomenological study to gain a better understanding from the experience of the patients.
MethodThis study used a qualitative research design with a phe-nomenological approach aimed to examine the experience of restraint use among individuals with violent behavior in mental health hospital.
The study was conducted in three districts in Central Java Province starting from January 2016 to June 2016. Eight participants were selected by using purposive sampling with the criteria: 1) 30- 45 years old; 2) patients with violent behaviors during hospitalization; 3) patients were restrained three times or more and occurred in the last year, and 4) able to speak Indonesian.
Method of data collection was in-depth interviews where the researchers as the main instrument11. The main researcher as the main instrument of the study was assessed for her interviewing competences by the research supervisors. The data collection began with the search of patient with restraint at one referral mental health hospital in Indonesia. From the initial search, there were 309 patients with restraint and 169 of them had violent behaviors. The researchers gave the explanation to participants about the purpose of the research, the research process and their rights. The interview process began when they consented for participation.
The researchers used Colaizzi's method to analyze data because it is suitable for the process of data analysis in the study of phenomenology and it had data validations steps12. In the course of analysis of the sixth participant, there was no new theme which means the data were saturated. The researchers interviewed the seventh and eighth participant to make sure the data were saturated. This study received ethics approval from the Faculty of Nursing, Universitas Indonesia.
ResultsThe participants in this study were eight patients diagnosed with a mental disorder and being or had experiences restrained. Participants of this study ranged from 31 to 45 years of age. They had varied level of education, from elementary to senior high school. From the data analysis, three themes were identified: 1) aggressive behavior as one of the main reasons of restraint; 2) professional healthcare supports during the restraint use, and 3) physical and psychoso-cial impact of the restraint use.
Aggressive behavior as one of the main reason of restraintAggressive behavior as the main reason of restraint is a theme that describes the patients' experiences when they were hospitalized. In details, these reasons included controlling of violent behaviors, punishment and threats. Threats and violence perpetrated by patients in psychiatric emergency inpatient units were quite common, and these were prevalent factors concerning the application of physical restraints. Restrained patients were more likely than nonrestrained patients to be diagnosed with schizophrenia but were less likely to be diagnosed with a mood disorder. Participants described that the reasons of the restraint were to control the behaviors of anger, kicking, spitting, hitting and damaging property. Violent behaviors could damage oneself, others and the environment. This statement was illustrated as follows:
“I was emotional, yelling, disrupting people around, did not want to listen to others and threw people with stones. My brain was chaotic at that moment; I was not able to control it” (Su).
“I wanted to run away, run out of the hospital; I was against the nurse who prevented me from running, keeping me tied up. I tried to remove the bond and little by little, I could escape and run, but, I was arrested again” (Re).
Another result under this theme is that punishment as the reason of restraint. Some participants perceived that restraint as punishment. This was illustrated in the following statement:
“I didn't know how they put in restraint and what I was doing but they punished me with physical restraint” (Tm).
“So sad, I had a punishment from them because I kicked the door and hit the other patient” (Ab).
They had been restrained because they refused to follow staff directions. They did not obey what staff asked and they refused treatment. It was disclosed in the statement below:
“I didn't do their orders, I didn't take medicine and I didn't join activities. I rejected all because they didn't understand me” (Si).
Internal factors were the cause of restraint that sourced from the patients such as yelling, threatening others, kicking, hitting and damaging property. The external factors were the cause sourced from environment such as being restrained when the patients got electroconvulsive therapy. The patients believed that they got restraint because it is the consequences of their behavior.
Professional healthcare supports during the restraint useThe theme of positive support of professionals during restraint was supported by physical and psychological support. The psychological support was including information, attention, and gaining a sense of security. The physical support was including feeling assisted in the need to eat and drink, toileting and personal hygiene.
Participants said that nurses gave information about the purpose and duration of restraint, asked whether any complaints, helped when in need to eat and drink. This statement was illustrated as follows:
“The nurse explained the purpose of restraint, told me the duration, asked my complaints, provided food and drink and bathing” (Sm).
“The nurse accompanied me during restraint, looked at my condition, gave me advice so I was not angry anymore, and told me if I had been more calm down, I would be released” (Tm).
“When tied up, I was full of eating and drinking, rice, side dishes, vegetables and fruit” (Ro).
Physical and psychosocial impact of the restraint useParticipants experienced negative feelings including discomfort, fear, trauma, anger, helplessness and self-blame. This was reflected on the statements of participants:
“I saw people on TV as I used to be” (Re).
“I feel sorry because being tied up was very painful... so tortured. I also got annoyed, sad, angry and vengeful because the restraint was very strong, as a result, I felt so sick over my body” (Su).
“Restraint makes me frustrated, when having restraint I just surrendered; I feel a lonely and anxious” (Ab).
Participants expressed feelings of loneliness and not being treated humanely. This was illustrated in the following statement:
“I felt the loss of my rights as a human being because they did not let me free to do what I want. I felt physical limitations, limitations in thinking, and being isolated. When in restraint, nobody was beside me; they abandoned me, and as the person, I was being punished” (Su).
All of participants expressed that they felt hurt of the body. This was reflected from the participant as follows:
“The restraint left a mark on the hands and feet. Having tied the feet, hands and body hurts; I feel so sore and stiff' (Sw).
“My head was dizzy, heavy and dark vision. My body was limp, powerless” (Si).
“All of the body felt stiff [...] I couldn't move freely while being tied up and not given a chance to tilt right and left, I was so tormented” (Re).
As described earlier some participants reported feelings of safety and trust in their nurses, caring and concern from nurses while they were restrained, and feelings of being respected. Nevertheless, the participants in this study reported negative experiences more than positive experiences.
DiscussionThis study aimed to explore the experiences of restraint use among people with violent behaviors in mental health hospitals. This study identified themes that describe the experiences of patients and the meaning of restraint use.
The experiences felt by the patients were aggressive behaviors as one of the main reason of being restrained. The restraint aimed to avoid outbursts of aggression, to minimize risk of injury, to reduce the need for restrictive coercive measures, and to help them to control their behavior. Participants of this study stated that they being punished having been placed in physical restraints.
This study showed that the participants' perception about restraint is divided into two. Three participants agreed with restraint because they needed help to control their aggression. But, five participants stated that they did not need restraint because it could produce painful experiences. The result of the study are consistent with previous studies showing that the restraint has a goal to manage and control the clients, manage maladaptive behaviors and control high-risk aggressive behaviors of patients13. The previous study stated that the people with mental illness rejected restraint because they did not have freedom in psysical and psycho-social aspects of life14. In addition, participants stated that nurses employed restraint when they were being angry, ballistic, yelling, hitting and breaking thing. The reason of the restraint use was for security of the patient, others and the environment. This is consistent with previous studies which stated that nurses make decisions to restrain due to the safety of patient and environment15.
Having knowledge about what was happening and what was going to happen gave the participants a sense of control, calm and security. In this study, one of the participants revealed that nurses gave clear information during the physical restraints situation. Clear information was described by participants as being the most important aspect of quality care in a physical restraints situation. The participants also revealed the physical presence of staff was crucial for their positive experience during their time in physical restraints. Previous study showed that informing the procedure about the restraint process could generate the patient peaceful condition16. Caring of nurses during the restraint process can make the patients more stable17. Nurses need to assess the needs of patients with restraint, monitor them continuously, evaluate every hour and, if already stable, the restraint is immediately terminated18.
Three participants said they were helped by staff during eating and drinking and eliminating. One of participant stated that in the morning and afternoon a nurse bathed her in the condition of being restrained. The quality of caring and attitude of staff towards patients during restraint procedure should be maintained. During restraint process, the staff remains calm, act stably, and succeed to deal with the emotion. The attitude of nurses during the restraint therapy provided a positive experience for the patients, so patients would have a sense of security and calm19. Indicators of the success of restraints are the creation of security for patients, other patients and professionals the patients dignity, humane treatment and the provision of comfort through restraints procedures20.
Restraint which is not in with the standard operating procedure brings negative impact. The experiences felt by patients were the physical and psychosocial impact. All of participants had injuries like blisters, bruises, stiff, and bloody. Three participants felt dizzy, nausea, vomitus, and contracture. The physical injuries included physical discomfort, blisters on the restrained area, an increase in urinary incontinence, ineffectiveness circulation, risk of contrac-tures, and the occurrence of skin irritation21,22. Previous studies indicated that the staff who acted unprofessionally, cold, rough, angry and emotional would create a negative experience for the client23. Participants revealed they were suffered psychological injuries. Five participants expressed feeling of anger, depression, fear, sad, and anxiety during restraint time. The previous study stated that restraint can cause emotional trauma or psychological effects such as fear, anger and anxiety24. Other effects are a sense of humiliation, resentment, sadness and despair, unfairness, and guilty25.
The experience of 3 participants at the time of restraint, they felt emotional, upset, trauma, painful, and hostile. Two participants felt that they were treated like animals and criminals. The previous study explained that negative psychological impact of restraint included anger, fear, humiliation, demoralization, dehumanization, degradation, powerlessness, distress, embarrassment, and feeling that their integrity as a person had been violated9,26. Some participants also expressed they could not socialize, such as playing and joining activities with another patients. They also tended to be more silent and did not have many friends at hospital because they afraid that their friends would know they are harmful. Participants in previous studies also felt the same impact. Social impact of restraint use was received stigmatizing attitudes from the environment, and shunned by others and health professionals27.
AcknowledgmentFinancial support was provided by Directorate of Research and Community Service of Universitas Indonesia.
Conflicts of interestThe authors declare no conflicts of interest.
