Introduction
Physical restraint is any device or equipment applied to or near a patient’s body that the patient cannot control or remove. Wrist and ankle braces, a chair for the elderly [1-3] and a magnetic belt, restraint band [4]. In some cases, the full use of bed rails is considered a form of physical restraint [1-3]. It is used to limit and control the patient’s movements [5]. Physical restraint is an extreme measure to prevent self-harm, injury to others and damage to the physical environment [2, 4]. Studies in Europe show that physical restraint is commonly used in psychiatric hospitals, ranging from 15% to 55%. Variations in usage across countries are influenced by cultural, social, and legal factors. Numerous studies indicate that restraint is frequently used as a method in psychiatric hospitals [1].

Methods
This was a descriptive cross-sectional study conducted at Shafa Psychiatric Hospital in Rasht City, Iran, in 2022. The sample size was determined to be at least 324 hospitalized patients, based on a study by Kohangi et al. [15], which reported a 22.9% frequency of physical restraint use among patients at Isfahan Hospital. This calculation considered a type I error rate of 0.05 and a precision of 20%. Data analysis was conducted using the STATA software, version 14. Mean±SD were utilized for quantitative variables, while frequency and percentage were used for qualitative variables.

Results
The records of 2912 hospitalized patients were evaluated. Based on the results, 295 physical restraints were performed on 214 patients. In total, physical restraint was performed in 10.13% of the total patients studied. Physical restraint was used in 106 cases (49.5%) in men’s wards, 66 cases (30.8%) in women’s wards and 42 cases (19.6%) in the emergency ward. The age range of patients was 18-84 years and the mean age of them was 36.7±12.5 years. 147 patients (69%) were male and 67(31.30%) were female. Meanwhile, 91(51.1%) had less than a high school diploma and 115(60.3%) were unemployed. The number of times of physical restraint was more than once in some cases, so 295 times of physical restraint were performed in 214 patients. The lowest frequency of physical restraint was once and the highest was 10 times for each patient. The mean duration of physical restraint was 18.5±7.6 min. The lowest duration of physical restraint was 2 min, and the highest was 70 min. The highest frequency of physical restraint was performed in patients diagnosed with substance psychosis (61 patients, 15.5%), followed by patients diagnosed with bipolar disorder (58 patients, 11.6%) and patients diagnosed with schizophrenia (47 patients, 5.1%), respectively. The mean duration of physical restraint in minutes in patients diagnosed with substance psychosis was 18.2±8.5, bipolar disorder was 19.6±6, and schizophrenia was 19.9±7. Among the participants, 50(23.5%) were physically restrained in the morning shift, 87(40.9%) in the evening shift, and 76(35.7%) in the night shift, with the highest frequency of physical restraint occurring in the evening shift. The most common reasons for physical restraint in patients were aggression in 81 cases (32%), irritability in 52 cases (20.6%), and assault and verbal abuse in 41 cases (16.2%). According to the findings of this study, no complications were recorded or reported following physical restraint.

Conclusion
The current study assessed the frequency of physical restraint and its associated factors in the inpatient wards of Shafa Psychiatric Hospital in Rasht City, Iran, in 2022. Despite global policies to reduce the number of physical restraints [3, 6], their use is sometimes considered unavoidable in psychiatry [6]. Fernández et al. (2020) conducted a review, entitled “Alternatives to the Use of Mechanical Restraints in the Management of Psychomotor Agitation and Aggression in Psychiatric Patients,” and concluded that training staff in the use of verbal and nonverbal de-escalation techniques is recommended as an alternative to physical restraint [7]. According to the results of the present study, physical restraint was more common in men, which is consistent with the results of the studies by Jørn Lykke [8], Andrea Aguglia et al. [5], Jose Guzman-Parra et al. [9] and Reitan et al. [10]. Based on the hours of physical restraint, more physical restraint was performed between 3 pm and 5 pm (evening shift). The presence of a physician, psychologist, occupational therapist, and support worker in the morning shift effectively reduces physical restraint in this shift. According to the results obtained, it is suggested that anger management and relaxation techniques be included in the patient education program and that non-competitive exercise and walking be used in patients, especially those diagnosed with substance-induced psychosis. It is also recommended to do activities and entertainment, such as watching television in the afternoons.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by Ethics Committee of  Guilan University of Medical Sciences, Rasht, Iran (Code: IR.GUMS.REC.1401.313). 

Funding
This article is taken from Alaleh Ahmad's thesis for a doctorate in general medicine from the Faculty of Medicine, Guilan University of Medical Sciences-Bandar Anzali Campus. The research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors contributions
Methodology: Robabeh Soleimani, Samin Khoshnoud Espili, and Alalah Ahmad; data analysis: Mir Mohammad Jalali; Writing: Robabeh Soleimani and Samin Khoshnoud Espili; Conceptualization, validation, and investigation: All authors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all participants in this study, and the staff of Shafa Hospital in Rasht for their cooperation in this research.



 

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