Bakgrund: Fastspänning är en intervention för att som sista utväg hantera hotfulla och våldsamma patienter i svensk psykiatrisk heldygnsvård. Dock är dess effekt bristande vetenskapligt utvärderad. Patientens perspektiv visar på en komplex upplevelse med risk för fysiska och psykiska skador. Sjuksköterskan prövas i sin yrkesroll gällande etik, beslutsfattande och sin egen säkerhet. Samtidigt är sjuksköterskans perspektiv på fastspänning relativt vetenskapligt outforskat. Syfte: Att belysa sjuksköterskors erfarenheter av fastspänning i psykiatrisk heldygnsvård. Metod: En empirisk, kvalitativ intervjustudie genomfördes med tio informanter och materialet analyserades med kvalitativ innehållsanalys inspirerad av Burnards metod för innehållsanalys. Resultat: Analysen resulterade i tre rubriker: fastspänning som del i omvårdnaden och dess svårigheter, sjuksköterskerollen i relation till fastspänning samt många faktorer påverkar utförandet. Slutsats: Fastspänning upplevdes som nödvändigt för att återskapa kontroll i hotfulla och våldsamma situationer samt skydda alla inblandade från skada. Patientens bästa prioriterades vilket kunde skapa etiska dilemman gällande eget beslutstagande och att följa beslut om fastspänning. Ledarskap, samarbete och förberedelse var nyckelfaktorer för att utföra fastspänning på ett bra sätt. / Background: Mechanical restraint is a common last resort intervention to handle threats and violence in Swedish psychiatric inpatient care. Its effect is lacking scientific evaluation. The patients’ perspective shows a complex experience with risk of physical and psychological injuries. Nurses are tested in their professional role regarding ethics, decision making and their own safety. At the same time the nurse’s perspective on mechanical restraint is relatively unexplored. Objective: To hightlight nurses’ experiences of mechanical restraint in psychiatric inpatient care. Method: An empirical, qualitative interview study with ten informants was conducted and the material was analysed with qualitative content analysis inspired by Burnard’s method of content analysis. Results: The analysis resulted in three headings: mechanical restraint as a part of nursing and its difficulties, the nurse’s professional role in relation to mechanical restraint, many factors affect the outcome. Conclusion: Mechanical restraint was perceived as necessary to regain control in threatening and violent situations in addition to protecting everyone involved from harm. The patient’s best interest was prioritized which could create ethical dilemmas regarding the nurse’s own decision or to follow other’s decision to perform mechanical restraint. Leadership, teamwork and preparation were key factors to performing mechanical restraint successfully.

The use of mechanical restraint is a common practice in psychiatric care, often defended by medical necessity but seldom questioned from a human rights perspective. The purpose of this thesis has been to investigate under which circumstances mechanical restraint by bed through belt fixation could amount to torture and other cruel, inhuman or degrading treatment or punishment. Persons with psychosocial disabilities are in a particularly vulnerable situation and as the International Convention on the Rights of Persons with Disabilities (CRPD) is the most comprehensive rights framework for this group, it has been discussed whether the CRPD sets out additional safeguards in relation to restraint.  A legal doctrinal approach is the basic methodology used in order to outline the current international and European legal framework on torture and other ill-treatment and disability rights. A survivor-controlled research methodology has been applied and to amplify other voices of persons with firsthand experience of being mechanically restrained, interviews have been conducted with persons from Sweden and Spain. Healthcare professionals have also been interviewed. A feminist perspective on the law is applied.  Different international conventions and bodies of the United Nations have diverse interpretations on what acts or omissions that amount to torture and other cruel, inhuman or degrading treatment or punishment, although there is an aim and will to streamline the conventions. It is clear that the use of mechanical restraint can create such intense mental or physical suffering required to reach the common criterion of seriousness. However, some people do not experience the required levels of suffering for it to be considered torture, meaning that it might not amount to torture but rather other ill-treatment. The threshold for being considered torture according to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT) seems to be somewhat higher than that of the International Covenant on Civil and Political Rights (ICCPR) and the European Convention of Human Rights (ECHR). In this thesis it was found that the most critical element for this is the requirement of intent. Intent can however be implied under certain circumstances if the practice is of discriminatory nature. If a person has a psychosocial disability, intent might be presumed if States do not provide appropriate health care. In the case of girls and women, intent might also be presumed since they seem to have a higher risk of getting restrained for unlawful reasons.  The main conclusion in this thesis is that mechanical restraint by bed through belt fixation could amount to torture or other cruel, inhuman or degrading treatment or punishment according to the UNCAT, ICCPR and ECHR.

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L’utilisation des mesures de contrôle pour la gestion des comportements violents constitue une préoccupation majeure pour les infirmières qui pratiquent dans les unités de soins de santé mentale adulte. Le recours à ces mesures engendre des conséquences physiques et des traumatismes psychologiques chez les patients et tout le personnel soignant. Par conséquent, la prévention et la réduction de leur utilisation deviennent une priorité. De par l’aspect multifactoriel de cette problématique, la connaissance des facteurs qui influencent l’utilisation de ces mesures est primordiale pour cibler les interventions qui permettent de les prévenir ou les réduire. Les facteurs reliés aux caractéristiques cliniques des patients et au personnel soignant sont bien décrits dans la littérature. Toutefois, les facteurs reliés à l’environnement du patient ne sont pas attribués à l’ensemble des dimensions qui le constituent. Ceci est dû à la rareté des modèles conceptuels qui donnent une représentation structurée et globale de cet environnement. L’absence de cette représentation laisse les facteurs associés à l’environnement circonscrits seulement dans sa dimension physique, alors que d’autres facteurs reliés à ses autres dimensions sont rapportés dans la littérature sans être définis comme des facteurs environnementaux. Le but de cette revue de la portée a donc été d’explorer l’étendue des connaissances et d’identifier les facteurs de l’environnement qui sont associés à l’utilisation des mesures de contrôle chez les patients atteints de troubles mentaux. Afin d'intégrer une représentation globale de l’environnement, le cadre de référence du modèle de l’environnement thérapeutique optimal a été retenu (Optimal healing environment, ETO) (Jonas et al. , 2014). Les étapes de la revue de la portée selon Peters et al. (2020) ont été suivis, ce qui a donné lieu à l'inclusion de 35 écrits. L’analyse thématique des données extraites a permis d'identifier deux dimensions, à savoir l’environnement interpersonnel et l’environnement externe du patient. L’environnement interpersonnel décrit le développement et le maintien d’une relation thérapeutique à travers l’amélioration des compétences de communication du personnel soignant, l’utilisation des stratégies de prévention de crise d’agressivité, l’implication du patient, le retour post-évènement d’isolement et/ou contention et le sentiment d’appartenance à la communauté de l’unité de soins. Il décrit également la création d’organisations thérapeutiques via l’exercice du leadership organisationnel, les initiatives d’améliorations de l’organisation des soins, et la gestion des ressources humaines et technologiques. Pour sa part, l’environnement externe décrit la conception architecturale et le design intérieur des unités de soins où le patient est hospitalisé. Finalement, on pourrait conclure que des trois dimensions de l’ETO qui ont été incluses dans ce travail, les dimensions de l’environnement interpersonnel et l’environnement externe sont les plus représentées dans la littérature des cinq dernières années. De plus, les interventions de prévention de crise d’agressivité et le leadership organisationnel se sont montrés des facteurs clés d'un environnement thérapeutique favorisant la réduction de l’utilisation des mesures de contrôle. / The use of coercive measures (seclusion and restraints) to manage violent behaviors is a major preoccupation for adult mental health nurses. The use of these measures results in physical consequences and psychological trauma for patients and all caregivers. Therefore, prevention and reduction of their use becomes a priority. Due to the multifactorial aspect of this problem, understanding of the factors influencing this measures use is essential in order to target interventions to reduce them. Factors related to the clinical characteristics of patients and caregivers are well described in the literature. However, factors related to the patient's environment are not attributed to all of its dimensions. This is due to the scarcity of conceptual models that provide a structured, global representation of this environment. The absence of such a representation leaves the factors associated with the environment circumscribed only within its physical dimension, while other factors related to its other dimensions are reported in the literature without being defined as environmental factors. The aim of this scope review was therefore to explore the extent of knowledge and identify the environmental factors associated with reduced use of coercive measures in patients with mental disorders. In order to incorporate a holistic representation of the environment, the framework of the Optimal healing environment (ETO) model was selected (Jonas et al., 2014). The scope review steps according to Peters et al. (2020) were followed, resulting in the inclusion of 35 literatures. Thematic analysis of the extracted data identified two dimensions, namely the patient's interpersonal environment and external environment. The interpersonal environment describes the development and maintenance of a therapeutic relationship through the improvement of caregivers' communication skills, the use of aggressive crisis prevention strategies, patient involvement, the post-event return from isolation and/or restraint, and the sense of belonging to the care community. It also describes the creation of therapeutic organizations through the exercise of organizational leadership, initiatives to improve the organization of care, and the management of human and technological resources. For its part, the external environment describes the architectural and interior design of the care units where the patient is hospitalized. Finally, we may conclude that of the ETO three dimensions included in this work, interpersonal environment and external environment are the most represented in the literature of the last five years. In addition, aggression crisis prevention interventions and organizational leadership have been shown to be key factors in a therapeutic environment conducive to reducing the use of coercive measures.