Background

The use of control and containment measures as an intervention to manage violent and

aggressive behaviours in psychiatric patients dates back decades in the field of psychiatry (Power

et al., 2020). However, it is considered one of the most challenging questions among mental

health care providers and is regarded as a moral argument (Hawsawi et al., 2020). Some of the

common interventions include physical restraint i.e. devices used to limit a patient’s physical

movements such as safety vests, limb holders and bandages, as well as seclusion and sedation of

high-risk patients who could potentially harm others (Vedana et al., 2018). Seclusion involves

placing a patient with possible dangerous behaviour in a locked room where the free exit is not

allowed and is thought to provide isolation, containment and reduction in sensory stimuli (Power

et al., 2020). These interventions are commonly used to manage severe mental disorders that are

manifested in maladaptive behaviours and agitation (Riahi et al., 2016).

Restraints and seclusion are inherently designed to manage and protect patients from harm to

others and themselves but are fraught with risks of several adverse effects ranging from patients’

own deaths to deleterious psychological and physical effects on the nursing staff and patients

themselves (Vedana et al., 2018). Evidence has shown the negative long-term effects of using

these controlling interventions on nurses who struggle with their ethical and moral values

(Hawsawi et al., 2020). Research not only discovers damage to the therapeutic alliance between

the nursing staff and the patients due to these interventions but also the risk of physical and

emotional damage to self (Korkeila et al., 2016). Despite the literature on the potential

challenges of using physical restraints, their use is still considered an effective and permanent

intervention in psychiatric wards. It is found previously that frequent use of these methods is

associated with staff’s negative feelings, fear for their safety, and internal conflict with the
patient’s autonomy and the practice of care (Power et al., 2020). However, the literature on this

topic is limited and several other variables that may affect their use of restraints could be a poor

level of education, inadequate training and hospital management and limited treatment programs

(Riahi et al., 2016).

Studies have previously focused on investigating the use of restraints and seclusion in psychiatric

wards, nurses’ knowledge and practice but remained unsuccessful in exploring their own

experiences and perceptions in relation to using these interventions to manage the aggressive and

agitated behaviour of patients. (Riahi et al., 2016). According to the literature, nurses’ personal

thoughts may affect their decisions on using restraints and seclusion methods (Korkeila et al.,

2016). Knowing how they see these practices are important, as they are in the position to make

such decisions. Moreover, nurses’ psychological factors while making such decisions in the ward

such as feeling negative and viewing these practices as unethical are presumed to lead to job

dissatisfaction and burnout (Power et al., 2020). To explore these concepts in detail, the aim of

this qualitative study is to capture richer data on nurses’ own experiences and perceptions in

using containment measures and restraints with high-risk psychiatric patients within psychiatric

wards.

Research question

The research question which will guide the objectives of this study is as follow:

What are the experiences and perceptions of mental health nurses in relation to seclusion and

restraints for psychiatric patients in psychiatric wards?

Method
A qualitative descriptive research design is used to explore the experiences and perceptions of

mental health nurses regarding the phenomenon. A qualitative descriptive design is ideal when

an uncomplicated description is needed to focus on the details of the experience or event (Doyle

et al., 2020). Most researchers use qualitative descriptive research due to its nature to remain true

to the accounts of participants and ensure that the researcher’s interpretations are transparent.

1. Study population

The study population for this research is registered mental health nurses working in psychiatric

wards and managing behaviours of complex patients. The study will be carried out in a

psychiatric ward at Grayland hospital (pseudonym) where nurse participants will give interviews

during the data collection process. Psychiatric nurses from wards will be those who use seclusion

and restraints as a containment measure to control aggressive and agitated patients. The

eligibility criteria for this research are psychiatric nurses working professionally within the

mental health care setting for the last 4 years at least. Moreover, these nurses work actively with

those individuals who are at high-risk and have previously been subjected to physical restraints

and seclusion by them.

2. Sample of the study

The sample size for the study will be 25 nurses which will depend on their willingness to

participate in the study. All the nurses will be informed of the purpose of the study and will

assure their participation based on the eligibility criteria. The demographics of nurses’ education,

training and incidents of seclusion/restraints will be collected from the clinical documentation to

eliminate those meeting the exclusion criteria.

3. Sampling method
A purposive sampling will be used to collect information from the nurses who have employed

restraints and seclusion during their practice of care. According to the literature, purposive

sampling enables the selection of participants for the research who are more likely to experience

and understand the phenomenon under study (Campbell et al., 2020). It is also beneficial in

saving time and resources as the researcher only collects data from those who understand the

purpose of the study and possess the knowledge.

4. Recruitment method

A descriptive form explaining the purpose of the study along with informed consent for

participation will be provided to the hospital and ultimately to the nurse manager after approval

from the hospital management. Those nurses who met the eligibility criteria and will be open to

participating in the study will be sent an invitation along with a form to consent their

participation and a form of data release. Upon approval from the nurses, they will be recruited

for the study and interviews will be taken within the setting. Moreover, all the nurses will be

briefed on the purpose and benefits of the study and in case of any confusion, they could contact

the researcher.

5. Data collection method

Data will be collected from the sample by using a semi-structured interview guide. A semi-

structured interview is the most suited data collection method that involves asking the nurses a

set of open-ended questions, often followed up with a probe question, to explore the experiences

and perspective of using restraints and seclusion on mental health patients in the ward (Barrett &

Twycross, 2018). Researchers with professional backgrounds with qualitative research,

interviewing and psychiatric nursing will conduct one on one interviews with the nurses, either
in a meeting room or the hospital room in the ward. An interview guide will be developed using

the literature from past studies and a set of open-ended questions will be asked of each

participant in depth. All the interviews will be audio-taped after getting participants’ permission

and later on, will be transcribed one by one. The researcher will ask questions about the

experience of using physical restraints on patients and their opinions about their use. For

instance, ‘how do you view the use of physical restraint on patients to manage risky behaviours?’

All the verbatim will be used exactly as it is to analyze the data.

A thematic analysis will be used to analyze the interviews which will be held in private. All the

interviews will be transcribed immediately afterwards with any additional information such as

nonverbal data i.e. changes in emotions, posture and body language. A thematic analysis is

commonly used in qualitative research which focuses on examining the patterns and themes

within the data to draw meaning to it (Castleberry & Nolen, 2018). This analysis is opted for

examining the rich description of data, organizing it and theoretically informed meaning. The

researcher will use Braun and Clarke’s steps of thematic analysis by becoming familiar with the

data, generating initial meaningful codes, searching for the potential themes, reviewing those

themes, defining them accurately and the write-up (Terry et al., 2017). In doing so, the researcher

will answer the research question of the study and provide comprehensive information on all

aspects of nurses’ experiences and perceptions regarding the use of seclusion and restraints to

manage psychiatric patients. Moreover, to overcome any bias from the researcher’s side, two

expert researchers analyzed the same data independently to compare and verify the themes.

Study limitations and rigour

There are some limitations of this study. The research will be conducted at one acute psychiatric

unit, therefore, the results cannot be generalized to other nurses’ opinions and experiences. Due
to purposive sampling, the limited sample size in qualitative research precludes broad

generalization of the findings, thus not accurately representing the perspectives of all psychiatric

nurses. In addition to that, the interviews will be conducted at the hospital where nurses are

employed which could affect their motivation to share their unfiltered thoughts. They may feel

intimidated and concerned to answer in accordance with the perceived explanations. However,

these limitations can be managed adequately (Munthe-Kaas et al., 2019).

The rigour of the study is measured by its transferability, credibility, confirmability and

dependability. As one-to-one interviews using open-ended questions were conducted by a trained

researcher with experience in nursing, the credibility of the research is assured. As for

transferability, a detailed brief of research settings and participants’ characteristics will be

provided so, the research can be replicated. Furthermore, codes and themes will be independently

analyzed and agreed upon by the authors to establish dependability (Johnson et al., 2020).

Ethical considerations

Formal agreements to conduct the research will be obtained from the research ethics committee

at the university. All the ethical principles will be met and following the evaluation of eligibility

criteria by the hospital manager and health care providers, permission and access to carry out the

research at the psychiatric unit will be given. All the nurses will be given written, informed

consent forms and assurance of confidentiality and anonymity will be provided. Their right to

withdraw from the research without prejudice in dealing with the sensitive issue will be informed

of (Artal & Rubenfeld, 2017).

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