Perspectives in Psychiatric Care ISSN 0031-5990

Physical Restraints in an Italian Psychiatric Ward: Clinical

Reasons and Staff Organization Problems ppc_308 95..107

Rosaria Di Lorenzo, MD, Sara Baraldi, MD, Maria Ferrara, MD, Stefano Mimmi, PhD, and
Marco Rigatelli, MD
Rosaria Di Lorenzo, MD, is a Psychiatrist, Department of Mental Health, Az-USL Modena, Servizio Psichiatrico di Diagnosi e Cura 1, NOCSAE,
Baggiovara (Modena), Italy; Sara Baraldi, MD, is a Resident in Psychiatry, Department of Mental Health of Modena, Department of Neuroscience,
Section of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy; Maria Ferrara, MD, is a Resident in Psychiatry, Department of Mental
Health of Modena, Department of Neuroscience, Section of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy; Stefano Mimmi, PhD,
is a Statistics Analyst, Department of Mental Health Az-USL, Modena, Italy; and Marco Rigatelli, MD, is a Professor of Psychiatry, University of Modena
and Reggio Emilia, Chairman of Department of Psychiatry, Modena, Italy.

Search terms:
Acute psychiatric ward, aggressiveness,
physical restraint, staff organization
Author contact:
saradilorenzo1@alice.it, with a copy to the
Editor: gpearson@uchc.edu
Conflict of Interest Statement
The authors report no actual or potential
conflicts of interest. No external or intramural
funding was received.
First received May 23, 2010; Final revision
received March 9, 2011; Accepted for
publication March 10, 2011.
PURPOSE: To analyze physical restraint use in an Italian acute psychiatric ward,
where mechanical restraint by belt is highly discouraged but allowed.
DESIGN AND METHODS: Data were retrospectively collected from medical and
nursing charts, from January 1, 2005, to December 31, 2008. Physical restraint
rate and relationships between restraints and selected variables were statistically
analyzed.
FINDINGS: Restraints were statistically significantly more frequent in compulsory
or voluntary admissions of patients with an altered state of consciousness, at night,
to control aggressive behavior, and in patients with Schizophrenia and other Psy-
chotic Disorders during the first 72 hr of hospitalization.
PRACTICAL IMPLICATIONS: Analysis of clinical and organizational factors con-
ditioning restraints may limit its use.

doi: 10.1111/j.1744-6163.2011.00308.x

Summary. The use of physical restraint is an old challenging

Physical Restraints in Psychiatry: Legal Aspects
Since Pinel and Esquirol (Winship, 2006), the use of coercive
measures in psychiatry has been considered a barometer of
the ethical nature of psychiatric treatments (Stubbs et al.,
2009). Today, the practice of coercive measures is still a con-
troversial issue concerning ethical, medical, and legal
problems. In Italy, as in other countries (Kaltiala-Heino, Tuo-
himaki, Korkeila, & Lehtinen, 2003; Steinert & Lepping,
2009), coercive measures, such as physical restraint, are not
clearly regulated. They can be indirectly justified in the case of
psychiatric compulsory admission, which is adopted accord-
ing to the criteria of Italian Law 180 (Legge 13 Maggio,
1978) (acute psychiatric symptoms that need urgent hospital-
ization refused by patient) or can be applied in the so-called
state of necessity,regulated by Art. 54 of the Italian Criminal
Code (people who commit illegal actions with the aim of res-
cuing somebody from an acute risk of life are not punished).
In these cases, the Italian law requires the physician and all
other health professionals to preserve health, which repre-
sents the supreme good of the person (Position of Guaran-
tee, Art.40 of the Italian Criminal Code); otherwise
practitioners could be accused of a crime of omission.
psychiatric question that raises conflicting legal problems,
not exhaustively regulated by law, concerning both the right
of individual freedom and the professional duty to ensure
patient safety.
Physical Restraints: Definition
All handling, physical, and mechanical methods applied to
the patient in order to reduce his or her freedom of movement
or access to his or her own body were defined as physical
restraints by Health Care Financing Administration in 1992
(Weick, 1992). This could range from isolation of the patient
in an enclosed space, the so-called seclusion room, to immo-
bilization of the patient by the staff, physically restraining him
or her or applying mechanical restraints, such as handcuffs or
cotton or leather ties.
In Italy, physical restraint (especially mechanical restraint)
is allowed as an extreme safety procedure, although its use is
discouraged by the Mental Health Department since it is not
considered a therapeutic instrument. In our country, after the
closure of psychiatric hospitals mandated by the 180 Law,
the so-called seclusion room has never been used. This is

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Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems
probably because, according to the spirit of this law, which
identified coercive procedures as potential inducers of wors-
ening illness and regressive behavior, the seclusion room has
been interpreted as a sort of bad practice related to psychia-
trys past.
According to the literature from several decades ago, the
aim of physical restraint should be limited to preventing self-
injuring behavior and violent behavior directed at others, as
well as to promoting control of symptoms such as anxiety,
delusion, and aggressiveness (Fisher, 1994; Gutheil, 1987).
Today, this procedure is widely accepted only when all thera-
peutic restrictive measures for the patient who is a danger to
himself or herself or others have failed (Kallert, 2008).
According to the White Paper of the Council of Europe
(Steering Committee on Bioethics of the Council of Europe
2005) . . . the use of short periods of physical restraint and of
seclusion should be in due proportion to the benefits and the
risks . . . . The response to violent behaviour by the patient
should be graduated . . . . and only in a last resort by
mechanical restraint, . . . prolonged only in exceptional
cases.
Summary. Physical restraint can be defined differently
according to how it is used, which, in turn, reflects the local
culture. However, its significance as a limitation of individual
freedom and its restriction as a last resort in extreme danger
situations are universally recognized in accordance with a
growing culture of protecting human rights and the dignity of
people.
Physical Restraints: Containment of Aggressive Behavior
In most cases, the need to contain a patient is strictly related
to his or her aggressive behavior, which may be considered a
very common trans-category symptom of many psychiatric
diseases (Monahan, 2003). For many years, there has been
evidence that psychopathology is associated with a high inci-
dence of violence (Link & Stueve, 1995). Thought disorders,
alcohol intoxication, and schizophrenia combined with sub-
stance abuse can be more frequently associated with aggres-
sive behavior (Duxbury & Whittington, 2005). According to
another study, only young patients (under 25 years old)
rather than those with a single diagnosis were more likely to
be assaultive (Biancosino et al., 2009; Duxbury & Whitting-
ton, 2005). A recent Brazilian study suggested that youth and
substance abuse or psychosis are the variables that can
predict the use of physical containment (Mignon et al.,
2008).
In a psychiatric ward, the control of aggressiveness can be
obtained by different patterns of intervention: institutional
containment, represented by the rules and organization of
the ward (Correale, 2006; Jervis, 2001); psychological or rela-
tional containment, aimed at understanding the psychologi-
96
cal meaning of aggressive behavior through an empathic
approach to the patient; pharmacological restraint, carried
out when psychological containment is no longer possible or
effective; and physical restraint, applied whenever all previ-
ous approaches have failed, in order to guarantee patient and
staff safety. Although physical restraint can be interpreted as
an extreme safety procedure and not a medical instrument, it
has to have a therapeutic significance since it is applied in a
healthcare setting. In psychiatry, all spatial and temporal
aspects of the context where therapy takes place (the psychi-
atric setting) are an integral part of therapy since they form
the frame of the therapeutic relationship with the patient.
So, also, physical containment can assume therapeutic
effects, such as communicating a message of reality to the
patient submitted to this procedure or providing him or her
shared attention and limiting his or her aggressiveness; all
these nonverbal messages represent a crucial moment of
therapy.
Summary. Aggressive behavior is associated with many psy-
chiatric disorders; the need to contain a violent patient can be
a common event in a psychiatric ward. Physical restraint rep-
resents a last resort when institutional, psychological, and
pharmacological containments are insufficient to guarantee
patient and environment safety, but it has to have a therapeu-
tic and ethical significance since it is applied in a healthcare
setting.
Physical Restraints: Aggressiveness and Ward Environment
Much research (Flannery, Rachlin, & Walker, 2002; Nijman,
2002; Steinert, 2002; Winstanley & Whittington, 2002) has
shown that the variables that increase aggressiveness during
hospitalization can be related not only to clinical and per-
sonal characteristics of the patient but also to staff attitude
and to ward organization.
Theoretical Framework. A number of theories have been
developed to explain the causes of aggressiveness in mental
health inpatient settings (Gadon, Cooke, & Johnstone, 2006;
Whittington & Richter, 2005). Some authors (Nijman, Camp,
Ravelli, & Merckelbach, 1999) proposed a three-part model
constituted by internal, external, and situational/
interactional models: the internal model consists of the
association of aggression and mental illness, which has been
investigated by numerous studies so far; the external model
includes all environmental factors that contribute to the
incidence of aggression (e.g., space, location, type of regime,
number of patients admitted, etc.); the situational/
interactional model is represented by negative staff attitude
toward the patient because of poor communication, intoler-
ance, symmetric position, and punitive control methods.
According to this model, a combination of environmental
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 Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems
and interpersonal factors, associated with symptomatic
behavior, could lead to the inpatients aggressive behavior.
The ward environment can have a crucial role in lowering
the violence rate and, concomitantly, lowering coercive mea-
sures adopted as underlined by the Royal College of Psychia-
trists more than 10 years ago (Stubbs et al., 2009). The ward
environment has its structure and its rules, which form the
frame and the context in which therapy takes place and reflect
the relationship between psychiatric professionals and
patients (Jervis, 2001). The misuse of physical restraints can
be seen as an organization problem that reflects failures in
leadership, in communications, or in the therapeutic capacity
to manage aggressive patients (Stubbs et al., 2009). As recent
literature shows, a zero tolerance policy can encourage a strict
and intolerant attitude by staff, which induces an escalation of
violence inside the ward (Duxbury & Whittington, 2005).
Summary. Many observations indicate that aggressive behav-
ior and the need to contain a hospitalized patient are condi-
tioned not only by the intrinsic characteristics of the patient
and his or her disease but also by the ward climate and the
staff attitude, according to the logic of circular causality.
Physical Restraints: Frequency
The limited data available to date on the use of coercive inter-
ventions (Steinert & Lepping, 2009) show that the frequency
of physical, mechanical, and seclusion restraint in psychiatric
units is difficult to establish and changes in accordance with
the different cultures of treating aggressive patients: less than
5% in Great Britain (OGrady, 2007), where seclusion is rarely
used and mechanical restraint never used, 10% in Finland
(Kaltiala-Heino, Korkeila, Touhimaki, Tuori, & Lehtinen,
2000), 15% in Denmark (Ohlenschlaeger & Nordentoft,
2008), from 8.5% to 31% in the United States (Currier &
Allen, 2000; Swett, 1994), 14.2% in Israel (Porat, 1997),
between 8.5% and 18.5% in Australia (Irving, 2004), and
1.4% in a French psychiatric emergency unit (Guedj,
Reynaud, Brightman, & Vanderschooten, 2004). Whereas, in
Dutch hospitals, one in four admitted patients experienced a
seclusion episode (Janssen et al., 2008), and in an Italian psy-
chiatric acute ward, 19% of patients were mechanically
restrained (Grassi, Peron, Marangoni, Bianchi, & Vanni,
2001). Although the few literature data show a low rate of vio-
lence among Italian psychiatric inpatients (Grassi et al., 2006;
Raja & Azzoni, 2005), the mechanical restraint procedure is in
force in many psychiatric acute wards in Italy. In Europe, only
Iceland seems to be an interesting exception: seclusion and
restraint were abolished some decades ago and never used
again as reported by local experts (Steinert & Lepping, 2009).
There is a total lack of controlled trials about the beneficial
effects of coercive measures in patients with violent behavior
since this clinical practice procedure has not been investigated
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by means of well-designed randomized studies (Jarrett,
Bowers, & Simpson, 2008; Murilidharan & Fenton, 2006) as
evidenced by Cochranes systematic review of Sailas and
Fenton (2000).
Summary. According to the few data available, there are
noticeable national differences in the percentage of patients
submitted to physical, mechanical, and seclusion restraints
among countries, reflecting the strong influence of local
culture and psychiatric organization on the use of this
procedure.
Physical Restraints: Risks and Consequences
In 2005, the National Institute of Clinical Excellence (NICE)
guidelines announced that the effect of a rapid pharmaco-
logical tranquillization can be more life-threatening than
physical restraint and warned about the risk of death in the
co-occurrence of medication and physical restraint (NICE,
2005). Nevertheless, literature reviews show many possible
consequences of physical and mechanical restraints: deep
venous thrombosis and pulmonary diseases (Dickson, 2009),
sudden death (Parkers, 2008), accidental strangulation from
vest restraints (Pollanan, Chiasson, Cairns, & Young, 1998),
brachial plexus injury (Scott & Gross, 1989), injuries caused
by handcuffs, and staff injuries (Evans, Wood, & Lambert,
2002). In the United States (Food and Drug Administration,
1992) and in the United Kingdom (OGrady, 2007), the
increase of physical injuries and deaths imputable to restraint
methods has heavily influenced clinical practice, resulting in
the reduced use of physical restraints.
More recently, experiences of restrained patients and con-
sequences of coercive measures on the course of treatment
have also been objects of discussion (Kuosmanen, 2009;
Mayoral, Torres, & Group Eunomia, 2005). Some authors evi-
denced that staff and patients had different points of view on
whether physical restraint was used as a last resort (Fish &
Culshaw, 2005). In another study, patients perceived environ-
mental conditions characterized by poor communication as a
significant precursor of aggressive behavior, whereas staff
identified the mental illness of the patients as the main cause
of aggressiveness (Duxbury & Whittington, 2005).
Summary. The risk of physical and psychological conse-
quences of physical, mechanical, and seclusion restraint use as
well as the risk of pharmacological containment or multiple
containment procedures have been well-reported in many
studies. These risks have contributed to more rigorous appli-
cation of restraints.
Physical Restraints: Recent Debate
Considering the ethical issues and clinical consequences
of physical restraint, many studies have recently indicated
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Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems
strategies aimed at reducing the use of this procedure
(Barton, 2009; Downes, Healy, Page, Bryant, & Isbister 2009;
Hellerstein, Staub, & Lequesne, 2007; Paterson & Duxbury,
2007; Prinsen & Van Delden, 2009; Sclafani et al., 2008). Staff
debate and investigation about physical restraints alone can
contribute to reducing the use of this procedure in accor-
dance with many authors who evidenced that assault behav-
ior of patients decreased at the same time professionals
awareness of their own feelings toward aggressive patients
increased (Bowers et al., 2006; Forster, Cavness, & Phelps,
1999; Stratmann, Vinson, Magee, & Hardin, 1997). More
numerous and well-trained staff (Kontio et al., 2009) and
more attention by level-of-care staff were cited as the most
important strategies for reducing the use of seclusion and
restraints (Wynn, 2003). A recent Dutch study demonstrated
that today, restraint procedure remains a common practice
despite opposed public opinion and policy interventions
(Van Doeselaar, Sleegers, & Hutschemaekers, 2008).
In light of recent fatal consequences of physical restraints
(Norfolk, Suffolk and Cambridgeshire Strategic Health
Authority, 2004), professional and government guidelines
have paid greater attention to this procedure and to other
coercive measures in order to promote prevention of violence
in accordance with human rights (World Health Organiza-
tion, 2005). Today, the rate of restraint use in a mental health
setting can represent an important indicator of quality
(Stubbs et al., 2009). Nevertheless, according to most authors
of recent publications, physical restraints cannot be com-
pletely abolished at the present time (Steinert et al., 2010).
Summary. During the past 10 years, a major debate on the
use of physical restraint has taken place in Western countries,
especially after fatal accidents recorded in concomitance with
physical restraint use, and has favored the implementation of
many strategies aimed at reducing the use of this procedure.
Aims
This work was prompted by the need to better identify the
modality and the frequency of physical restraint use in an
Italian ward in order to promote a progressive reduction of
this procedure as recommended by our mental health depart-
ment. For the purpose of this investigation, we will be refer-
ring to mechanical containment by handcuffs, leg ties, and
vest to immobilize the patient in bed when we use the term
physical restraint.
The first aim of this study is to describe the use of mechani-
cal restraint in a determinate period of time and to examine
various indicators in order to provide comparable data.
The second aim is to analyze the relationship between
restraint use and selected variables related to patients, staff,
and ward in order to evidence the influence of clinical situa-
tions or environmental factors on the use of physical restraint.
98
Methods
This study was conducted in accordance with the principles of
the Declaration of Helsinki (World Medical Association Dec-
laration of Helsinki, 1964) and good clinical practice and was
not sponsored by any pharmaceutical company. It was
approved by the Institutional Review Board of our General
Hospital (NOCSAE of Az-USL-Modena).
This was a retrospective study that analyzed the rate of
physical restraints applied in an acute Italian psychiatric
15-bed inpatient ward, Servizio Psichiatrico di Diagnosi e
Cura 1 (SPDC1), and the clinical and environmental variables
related to this procedure during a period of 4 years.
Setting
SPDC1 is the public psychiatric ward at the General Univer-
sity Hospital in Modena (NOCSAE of Az-USL-Modena),
which receives all patients from Modena and Castelfranco
Emilia (population 250,000) affected by acute psychiatric dis-
eases, admitted in compulsory or voluntary state. According
to Italian Law 180, patients in psychiatric compulsory state
must be admitted only to the public psychiatric wards called
SPDC, which have to be located inside a general hospital.
During the 4-year period of this study, the ward and its orga-
nization and staff remained unchanged.
Physical Restraint Procedure
In SPDC1, mechanical restraint was applied according to
defined hospital procedures: (a) this procedure could be pre-
scribed only by a physician when other control measures had
failed after evaluation of the patients capacity to give his or
her consent to treatment, (b) all staff had to focus attention on
patient and staff safety, nurses had to continuously monitor
the restrained patient and the physician had to reevaluate
every half hour the necessity for containment, (c) in cases of
restraint use for a period exceeding 24 hr, it was necessary to
inform the magistrate and mental health department, who
could then organize an audit, (d) all aforementioned instruc-
tions and interventions had to be registered in the nurse
restraint form and medical charts with the signature of each
staff member, and (e) during restraint, the necessary pharma-
cologic therapy and/or psychological support were pre-
scribed with the aim of resolving the condition that had
necessitated this procedure.
Data Collection
Demographic and clinical data for all restrained inpatients
admitted to our ward from January 1, 2005, to December 31,
2008, were retrospectively collected from medical charts. Data
relative to physical restraints of inpatients were extrapolated
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 Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems
from nurse restraint forms. The period of observation was
limited by the availability of nurse restraint forms, which
came into use from January 1, 2005. All data were registered in
a computerized database in order to be statistically analyzed.
Sample
The sample was composed of all restrained patients admitted
(n = 268) to SPDC of Modena from January 1, 2005, to
December 31, 2008.
Variables
The following variables were examined with the aim of better
identifying the contributions of both mental illness and ward
environment to the use of physical restraints. These variables
represented the only clinical information available for all
restrained patients, which could be retrospectively collected
from medical charts and nurse restraint questionnaires
(Table 1):
Restrained patients: age, gender, nationality
Admissions with physical restraint: diagnosis according to
the International Classification of Diseases, 9th Revision,
Clinical Modification, Italian Version of 2007 (Ministero del
Lavoro, della Salute e delle Politiche Sociali, 2008); state of
admission (voluntary state admission, with normal or altered
state of consciousness due to intoxication or psycho-organic
syndrome, or compulsory state admission, according to
Table 1. Variables from the Period January 1, 2005, to December 31,
2008, Retrospectively Collected and Analyzed
Restrained patient Age
variables Gender
Nationality
Admission with Diagnosis (according to International
physical restraint Classification of Diseases, 9th Revision,
variables Clinical Modification)
State of admission: voluntary (with normal or
altered state of consciousness); compulsory
(according to Italian Law 180)
Day of restraint use during hospitalization
Length of hospitalization
Physical restraint Reason for use: control of dangerous, violent, or
variables aggressive behavior; prevention of damage or
necessity of urgent therapy
Frequency of restraint use in comparison to the
three nursing shifts: morning
(7:00 a.m.1:00 p.m.); afternoon
(1:00 p.m.8:00 p.m.); night
(8:00 p.m.7:00 a.m.)
Duration
Use of concomitant therapy
Ward condition Number of all admitted patients at the time of
variables restraint use
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Italian Law180); day of restraint use during hospitalization;
length of hospitalization
Physical restraints:
Reason for use of restraints divided into the following
categories according to the most frequent reasons
registered in our ward and the literature indications
(Kaltiala-Heino et al., 2003): control of dangerous,
violent, or aggressive behavior; prevention of damage or
necessity of urgent therapy
Frequency of restraint use in comparison with the three
nursing shifts (morning, from 7:00 a.m. to 1:00 p.m.;
afternoon, from 1:00 p.m. to 8:00 p.m.; night, from
8:00 p.m. to 7:00 a.m.)
Duration of restraints
Use of concomitant therapy (drugs, hydrating infusive
therapy, or any other therapy used during restraint)
Ward conditions: number of all admitted patients at the
time of restraint use.
Analysis
Statistical analysis was performed in order to determine the
proportion of patients put in physical restraints in compari-
son with the total number of patients admitted and to analyze
the variables related to restraint use during the 4-year period
(Tables 2 and 3) (KruskalWallis and chi-square tests) (Siegel
& Castellan, 1988). The correlation between restraint use and
the following variables was analyzed: the reasons, the diagno-
sis, the state of admission, the day of hospitalization, and the
time of day (chi-square and Fishers tests) (Siegel & Castellan,
1988). For the 4-year period of the study, the different fre-
quencies of restraints during the three nursing shifts were
analyzed (chi-square test) (Siegel & Castellan, 1988).The cor-
relation between the number of physical restraints and the
number of all admitted patients at the moment of this proce-
dure was analyzed (Pearsons correlation) (Armitage & Berry,
1996). The length of restrained patient hospitalization was
compared with that of all other patients admitted during the
same period (Wilcoxon test) (Siegel & Castellan, 1988).The
data was processed by the SAS program (version 9.1.3, SAS
Institute Inc., Cary, NC, USA).
Results
Physical Restraints: Analysis of 4-Year Period
The frequency of restrained patients was similar across the
4-year observation period, with a statistically significant
increase of this trend during the last 3 years of observation (p <
.027, chi-square; Table 2). The median age (p = .008, Kruskal
Wallis) and the age range of the patients (p = .028, chi-square)
were significantly lower at the end of the 4-year period. The
frequency of male patients restrained increased significantly
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Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems

Table 2. Analysis of Restrained Patient Demographic Data Year by Year (Statistical Comparison per Year)

2005 (%) 2006 (%) 2007 (%) 2008 (%) p Value (Test)
a
Restrained patients/all 49/385 (13) 61/394 (15) 78/380 (21) 80/451 (18) p = .027 (chi-square)
admitted patients (%)
Age of restrained patients 43 47 40.5 35.5a p = .008 (KruskalWallis)
(median) p = .009a
Age range of restrained
patients: n
30 years 9 (18.4)a 8 (13.1)a 27 (33.8) 29 (36.3) p = .028 (chi-square)
3140 years 13 (26.5) 16 (26.2) 13 (16.3) 20 (25.0)
4160 years 12 (24.5) 22 (36.1) 26 (32.5) 19 (23.8)
> 60 years 15 (30.6) 15 (24.6) 14 (17.5) 12 (15.0)
p = .0147a p = .0360a
Sex of restrained F = 23 (47)a F = 32 (52)a F = 32 (40) F = 24 (30) p = .045 (chi-square)
patients: n M = 26 (53) M = 29 (48) M = 48 (60) M = 56 (70)
p = .0285a p = .0209a
Nationality of restrained Italian = 43 (82) Italian = 57 (93)a Italian = 57 (73) Italian = 58 (73)a p < .001 (Fisher)
patients: n EU = 1 (2) EU = 2 (3) EU = 4 (5) EU = 2 (3)
Extra-EU = 5 (10) Extra-EU = 2 (3) Extra-EU = 17 (22) Extra-EU = 20 (25)
p = .0151a p = .0267a
a
Statistically significantly different from all others.
M = male; F = female; EU = European Union.

during the 4 years (p = .045, chi-square; Table 2) and the
number of non-Italian restrained patients became statistically
significantly more frequent in the last 2 years of the observa-
tion period (p < .001, Fishers test).As shown in Figure 1, non-
Italian patients more frequently belonged to the youngest age
range. During the 4-year period, the duration of restraints was
6 hr (standard deviation [SD] = 4.09) on average, the fre-
quency of admissions with mechanical containment appeared
significantly different across the 4 years (p = .006, chi-square),
but the mean of restraints both per patient and per admission
was not significantly different (Table 3).
Restraints were more frequent during compulsory admis-
sions or voluntary admissions of patients with altered state of
consciousness. The state of admission with restraints was sig-
nificantly different across the 4-year period (p < .001, chi-
square; Table 3).
This procedure was applied especially during the first 3
days of hospitalization and was statistically significantly less
frequent during the morning and afternoon day shifts in
comparison to the night shift (p < .0001; Table 3).
The voluntary admissions with physical restraints pre-
sented a statistically significant superior length of hospitaliza-
tion to ones without restraints for the whole observation
period (2005: p = .002; 2006: p = .015; 2007: p = .0003; 2008: p
= .003; Wilcoxon test).
In 50% of the restraints in the 4-year period, a supplemen-
tary therapy was prescribed: sedative therapy in 42% of cases
and hydrating infusive therapy or antidote drugs or extrabuc-
cal feeding in 8%. The sedative therapy included the following
drugs: benzodiapenes (13%), antipsychotic drugs such as
haloperidol, chlorpromazine, clotiapine, promazine, or olan-
zapine (40%), and promethazine (5.5%) in monotherapy or
in combination (41.5%). The therapies for the restrained
patients were administered orally (11%), intramuscularly
(78%), or intravenously (11%).
Physical Restraints: Psychiatric Diagnosis, Reasons,
Nurse Shifts
During the 4-year observation period, the diagnosis of
schizophrenia and other psychotic disorders was the most
frequent among the restrained patients followed by the diag-
nosis of alcohol- and substance-related disorders (alcohol
dependence syndrome, drug dependence, nondependent
abuse of drugs, alcohol- and drug-induced mental disor-
ders). The acute and chronic psycho-organic syndromes
(dementias,transient or persistent mental disorders due to
conditions classified elsewhere) presented a frequency of
17% in our sample (Table 4).
The most frequent reason for restraint application during
the 4-year period was control of aggressive behavior com-
pared with prevention of damage or necessity of therapy
(Table 4). Analysis of the statistical relationship between the
reasons for restraints and the diagnosis of restrained patients
showed a statistically significant difference between the two
categories: reason A (control of aggressive behavior) repre-
sented the most frequent reason for restraint ( 70%) in
adjustment reaction, dementias, personality disorders,
schizophrenia and other psychotic disorders (Table 4).
The restraints were more frequent during the night shift for
each diagnosis (p < .001, chi-square). The frequency of
restraint reasons related to the day of hospitalization was the

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 Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems

Table 3. Analysis of Physical Restraint Characteristics Year by Year (Statistical Comparison per Year)

2005 (%) 2006 (%) 2007 (%) 2008 (%) p Value (Test)
Restraints: n 229 243 310 200
Restraint admissions/all 60/540a (11) 68/501 (14) 89/503a (18) 86/581 (15) p = .006
admissions (chi-Square)
p = .0341a p = .0305a
Restraints per patient (mean) 4.7 4.0 4.0 2.5
Restraints per admission (mean) 3.8 3.6 3.5 2.3
Restraints in compulsory 107 (47) 70 (30) 136 (43) 79 (39) p < .001
admissions: n (chi-Square)
Restraints in voluntary admissions 67 (29) 91 (38)a 53 (17)a 50 (25)
(altered state of consciousness
due to intoxication or
psycho-organic syndrome): n
Restraints in voluntary admissions 55 (24)a 79 (33) 125 (40) 72 (36)
(normal state of
p < .0001a p = .0351a
consciousness): n
Restraints applied up to 72 hr of 72a (31.3) 98 (40.8) 129 (41.1) 108a (53.7) p < .001
admission: n (chi-Square)
p = .0005a p < .0001a
Restraints distributed in day shiftsb: n
Morning (from 7:00 a.m. to Morning: 37 (17.8) Morning: 51 (21.9) Morning: 68 (22.1) Morning: 49 (25.3)
1:00 p.m.)
Afternoon (from 1:00 p.m. to Afternoon: 65 (31.2) Afternoon: 74 (31.8) Afternoon: 78 (25.3) Afternoon: 39 (20.1)a
8:00 p.m.)
Night (from 8:00 p.m. to Night: 106 (51.0) Night: 108 (46.3) Night: 162 (52.6) Night: 106 (54.6)
7:00 a.m.)
p = .0398a
a
Statistically significantly different from all others.
b
Thirty-nine restraints > 12 hr were not included.

following (Figure 2): reason A (control of violent or aggres-
sive behavior), statistically significantly more frequent
during the first 3 days (p < .0001 chi-square) and the last
period (> 20 days; p < .0001 chi-square) of hospitalization;
reason B (prevention of damage or necessity of therapy),
statistically significantly more frequent during the intermedi-
ate periods of hospitalization (410 days; p > .001, chi-
square). Moreover, reason A (control of violent or aggressive
behavior) was the most statistically significantly frequent
Figure 1. Age and Nationality of Restrained Patients
reason for restraint during the night shift in comparison with
the afternoon shift (p = .007, chi-square).
In our study, it was not possible to find any statistically sig-
nificant correlation between the number of patients in the
ward and the frequency of physical restraints.
Discussion of Findings
Physical Restraints in Our Ward
The data from our analysis of the 4-year period overlap those
in the literature: physical restraint was most frequently
applied in order to control the aggressive behavior of indi-
viduals experiencing an episode of psychosis (Flannery et al.,
2002; Mignon et al., 2008; Monahan, 2003; Nijman, 2002;
Steinert, 2002; Winstanley & Whittington, 2002) with a rate
(15%) similar to other psychiatric units (Grassi et al., 2001;
Irving, 2004; Ohlenschlaeger & Nordentoft, 2008; Porat,
1997).
The increased frequency of restraint use we observed in
young non-Italian patients during the last 2 years could indi-
rectly represent our social environment, characterized by a
growing number of immigrants (Charitas/Migrantes, 2009).

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Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems

Table 4. Number and Frequency of Restrained Patient: Psychiatric Diagnosis and Restraint Reasons During the 4-Year Period (Statistical Comparison of
the Two-Restraint Reasons)
Restraint Reasons
Psychiatric Diagnosis of Restrained Patients A. Control of Dangerous B. Prevention of
(According to International Classification of Violent or Aggressive Damage or Necessity
Diseases, 9th Revision, Clinical Modification) Behavior n (%) of Urgent Therapy n (%) Total n (%)
Dementias 68 (70.10) 29 (29.90) 97 (10)
Transient and persistent mental disorders due to 32 (45.07) 39 (54.93) 71 (7)
conditions classified elsewhere
Alcohol dependence syndrome 48 (54) 41 (46) 89 (9)
Drug dependence
Nondependent abuse of drugs
Alcohol- and drug-induced mental disorders
Schizophrenia and other psychotic disorders 242 (80.94) 57 (19.06) 299 (30)
Manic episode 64 (48.48) 68 (51.52) 132 (13)
Major depressive disorder and dysthymic disorder 17 (65.38) 9 (34.62) 26 (3)
Personality disorders 99 (72.79) 37 (27.21) 136 (14)
Adjustment reaction 42 (70) 18 (30) 60 (6)
Mental retardation 31 (67.39) 15 (32.61) 46 (5)
Others 18 (69) 8 (31) 26 (3)
Total 661 (67) 321 (33) 982 (100)

Reason A vs. reason B, p < .0001, chi-square, Fishers test.

Since physical restraint was more frequently applied
during the first days following admission and its rate
remained similar across the observation period, we can
presume that in our ward, it was regularly used in order to
deal with dangerous and acute situations.
As shown by the analysis of restraint reasons, its principle
aim was to control extreme situations of aggressive or danger-
ous behavior in seriously ill patients, who, in most cases, were
not able to give a valid consent to treatment (40% of
restrained patients had been compulsorily admitted and 27%
presented an altered state of consciousness). The percentage
of voluntarily admitted patients restrained was justified by
the state of necessity (Art. 54 of the Italian Criminal Code)
to avoid an imminent risk to the life of patient and/or others.
Restraint was associated with a sedative therapy in order to
resolve the clinical situation, which had required restraint
application in 42% of cases; in the other cases, this procedure
was adopted as a safety measure to avoid the risk of excessive
drug therapy or of combined pharmacological and physical
restraints as the NICE guidelines suggest (NICE, 2005).
The Variables Related to Physical Restraints
The Psychiatric Diagnosis. In our study, patients with the
diagnosis of schizophrenia and other psychotic disorders,
alcohol and drug abuse or dependence, and alcohol and
drug-induced mental disorders were more frequently
restrained than others in order to control aggressive behavior.
These data, similar to data found in the literature (Duxbury &
Whittington, 2005), indirectly show that psychotic dimen-
sion or intoxication state are the most frequent clinical situa-
tions that induce behavior so dangerous that mechanical
containment can often be required in order to avoid harm to
others or the patient himself or herself.
The restraint reason relative to control of aggressive
behavior was also prevalent in the patients diagnosed with
personality disorders and adjustment reaction, and
dementias, suggesting to us that aggressiveness is a common
trans-category symptom of many psychiatric disorders
(Mignon et al., 2008).

The Time of Restraints Following Admission. During the first

Figure 2. Physical Restraints: Reasons for Physical Restraint Use per Day days after admission, the necessity of controlling an aggres-
of Hospitalization sive behavior was the prevalent reason for restraining prob-

102 Perspectives in Psychiatric Care 48 (2012) 95107

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 Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems
ably because the aggressiveness itself, which characterizes a
wide range of psychiatric disorders, represented the prevalent
reason for admission (Biancosino et al., 2009). Otherwise,
the need to prevent a harmful behavior and/or the need to
prescribe an urgent therapy were the more frequent reasons
for restraining during the days following admission, indicat-
ing the need for continuous assistance for chronic and severe
diseases. In our sample, the restrained patients admitted vol-
untarily had a longer hospitalization than the patients never
restrained during hospitalization, data that can suggest a
more severe course of illness in these patients, who, although
admitted in a voluntary state, needed long and intensive
treatment.
The Ward Conditions. During night shifts, physical restraints
were more frequently applied in order to contain aggressive
behavior. These data suggest that a clinical variable, such as
different circadian rhythms, could favor agitation at night
(Wulff, Gatti, Wettstein, & Foster, 2010). In addition, environ-
mental factors, such as a lower intensity treatment and/or dif-
ferent staff organization, could impact the application of this
procedure at night.
Otherwise, it could suggest that larger numbers of staff, as
found in the day shifts, could by itself be sufficient to contain
patients without applying physical restraints as noted by
other authors (Wynn, 2003).
Finally, in our ward, this procedure was not influenced by
overcrowding since its frequency did not change in accor-
dance with the number of patients admitted. These data, dif-
ferent from the literature (Ng, Kumar, Ranclaud, & Robinson,
2001; Nijman, 2002; Steinert, 2002; Virtanen et al., 2011;
Winstanley & Whittington, 2002), could suggest that apply-
ing physical restraint in our ward was not apparently influ-
enced by overwhelming conditions such as an excessive
number of patients. Otherwise, these data indirectly suggest
that overcrowding is an environmental factor not sufficient in
itself to increase the aggressiveness of patients and physical
restraint use.
Conclusions
We can suggest that in our ward, physical restraint was fre-
quently adopted as an extreme tool in order to deal with dan-
gerous and acute situations, and its use was conditioned by
both clinical factors and staff organization. Regarding clinical
factors, we can underline that aggressive behavior was the
most frequent reason for restraint use, especially in the first
days of hospitalization, in compulsory admissions and in
patients affected by various psychiatric disorders. These data
lead us to presume that aggressiveness is a clinical transnoso-
graphic dimension, difficult to treat, with ethical and legal
implications, which often represents the reason for hospital-
ization. So we suggest that physical restraint use cannot be
Perspectives in Psychiatric Care 48 (2012) 95107
2011 Wiley Periodicals, Inc.
considered an indicator of a specific psychiatric disorder but
only of an acute and severe condition.
Regarding ward and staff organization, we put in evidence
that this procedure was frequently adopted at night probably
not only because of biological causes (different circadian con-
ditions, exacerbation of confusion, etc.) but also of organiza-
tional aspects (different daily activity, reduced number of
staff, different physicians on duty, etc.).
Limits of Our Study
The first limit of this study is its retrospective method, which
could have underestimated many elements such as the
complex relationship between patient and staff. A more
detailed analysis could have better evaluated the risk related to
each physical restraint variable (e.g., odds ratio). Another
limit is its short observation period because a longer time
(e.g., 10 years) could have more reliably established which
variable most influenced the use of this procedure. Prospec-
tive studies are needed to assess the causal link between clini-
cal and environmental factors and physical containment.
This study evidences a real clinical situation, often not
clearly described, by means of some indicators that can be
compared over time and with other similar groups. It
showed some elements relative to clinical and environmen-
tal factors that can influence the use of this extraordinary
procedure.
Thanks to this study, we could observe that in our ward,
although mechanical restraint was adopted according to our
ward procedure, only in acute and extreme clinical situa-
tions and in a safe way (we did not report any patient or
staff incidents), its frequency was still too high. In fact, the
policy recommendations of our mental health department
suggest a progressive reduction of this procedure up to its
elimination.
Final Comments
In Italy (Bersani, 2009), as in other countries (Foster, Bowers,
& Nijman, 2007), a community-based approach to mental
health services has led to a decrease in the number of psychi-
atric beds, resulting in a potentially higher concentrations of
people with more severe forms of illness in the acute public
wards (in our SPDC, almost 20% of patients were compulso-
rily admitted during the period of this study). So inside these
acute psychiatric wards, the environment can be character-
ized by conflicting relationships between patients and staff,
which could require many interventions of containment.
Although the Italian psychiatric reform following the 180
Lawhas permitted the growth of a community-based culture
that is innovative and a guarantor of human rights, until now,
many safety and organizational aspects of psychiatric services
may have been underestimated.
103
Physical Restraints in an Italian Psychiatric Ward: Clinical Reasons and Staff Organization Problems
According to our study, which evidenced that restraints
were more frequent at night to control aggressive behavior, we
can suggest that better ward organization and staff training in
dealing with hostile and dangerous patients could have
reduced physical restraints by means of reassuring both the
patient and the staff according to circular causality logic.
In our opinion and in accordance with other authors
(Stubbs et al., 2009), staff training should be based not only
on self-confidence in managing dangerous situations but
on a good awareness of ones own reactive feelings toward
violent patients in order to reduce the symmetric attitude
that induces an escalation of aggressiveness. Only a deep
knowledge of ones own reactive feeling toward aggres-
sive patients and a clear identification with ones own profes-
sional role can permit an empathic approach to patients,
which is necessary to reduce aggressiveness. As indicated by
literature (Stubbs et al., 2009), a well-run staff with good
leadership can be really efficacious in containing an aggressive
patient.
Finally, we can presume that more careful investigation and
more in-depth debate among the staff about physical inter-
vention could have reduced its use and promoted alternative
approaches as noted by other authors (Flannery et al., 2002;
Stratmann et al., 1997).
Implications for Nursing Practice
Our study analyzed the clinical and organizational factors
related to the use of coercive procedures by means of
observing daily clinical practice in an acute psychiatric ward
to promote a deeper knowledge of clinical practice. This has
to be the first instrument used to improve heath care for
people with mental illness. All healthcare professionals,
especially nurses, have a central role to play in this pursuit of
achieving better outcomes. Our analysis of reasons and cir-
cumstances that induce the applying of physical restraints
may promote a limited and more accurate use of this proce-
dure in clinical practice and permit a comparison of differ-
ent clinical and assistance procedures worldwide. Moreover,
this report favors a reflection on the therapeutic and ethical
meanings of physical containment. Such a reflection must
necessarily precede all professional interventions in health-
care settings.
We can suggest that the first resources needed to reduce the
use of physical restraints may be human resources them-
selves. Only a well-trained staff that is able to communicate
and debate about physical interventions and to emphatically
approach to patients can promote alternative procedures to
physical restraints. The latter should be the key to all thera-
peutic interventions. In any case, these human resources
should be supported by a well-organized mental health
service that takes into account both the needs of patients and
the challenges of the team.
104
Finally, we stress that a good quality of service index should
be the use of this procedure only for extreme and acute situa-
tions. In fact, repeated use of physical restraints during hospi-
talization could potentially induce a sort of dependence in the
patient as some tragic cases have taught us and as usually hap-
pened in the old lunatic asylum.
Ethical Issues
As clinical experience teaches, only if the application of physi-
cal restraint can be justified by an extreme and otherwise
unmanageable situation could it be accepted by the patient
afterward. Otherwise, if its use is only to control behavior
without any therapeutic aim, it can only assume a punish-
ment significance for the patient, who can increase his or her
aggressiveness in a sort of escalation spiral. So we can
presume that in this instance, ethical and therapeutic aims
overlap since such an extreme intervention as physical
restraint can have a therapeutic significance only if it has been
applied in an ethical way in accordance with human rights
and therapeutic needs.
Implications for the Future
Recent debates on physical interventions in psychiatry have
permitted a deeper knowledge of institutional capacity to
manage difficult patients, and some studies have shown
accurate descriptions of these procedures. Despite its limita-
tions, this study contributes to better identifying the factors
that can influence the use of physical restraints in an acute
psychiatric ward. In doing so, it favors overcoming the
taboo related to all highly emotive situations such as those
connoted by violence and danger. More study is necessary to
throw light on this controversial issue and to improve our
professional practice.
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