La cultura de la contención física en el paciente geriátricoperspectiva de los profesionales sanitarios de los hospitales de atención intermedia en Mallorca

Abstract

Introduction: The use of physical restraints is a common practice in the care of hospitalized and institutionalized elderly. However, this practice is currently being questioned because of the physical, psychological, moral, ethical, legal and social repercussions that its use entails. The use of physical restraints is influenced by both the patient himself and his family, as well as the health professionals and the institution. Specifically, the literature indicates that professionals show a lack of knowledge regarding physical restraints and have attitudes favourable to their use, which is related to a worse practice. Theoretical framework: The study is framed in the critical-social paradigm. Specifically, it has been decided to use Foucault's theoretical framework, especially, the conceptual framework related to safety, discipline, normalization, and resistance. The theory of Haslam's dehumanization has been chosen as a middle-range theory, meaning dehumanizing the act of stripping the person of certain qualities that are characteristic of humans. Objectives: To explore the culture of physical restraint of geriatric patients among health professionals of intermediate care hospitals in Mallorca. Specifically, it is intended to describe the knowledge, attitudes and practices of professionals regarding the use of physical restraints, to describe the institutional factors that influence it and to analyse its ethical impact, identifying the similarities and differences in the discourse of healthcare professionals according to their discipline and professional category. Methodology: Qualitative design with an ethnomethodological approach through critical discourse analysis. The study was conducted in intermediate care hospitals in Mallorca. Twenty-two semi-structured interviews were conducted with physicians, nurses, and nursing assistants, selected through theoretical-intentional sampling. Methodological rigour was guaranteed through data saturation, triangulation, and reflexivity. The study was approved by the Research Commission of the centres included and was positively evaluated by the Research Ethics Committee of the Balearic Islands (IB 4026/19 PI). All participants gave their informed consent and their data were treated confidentially. Results: The professionals have a lack of knowledge about physical restraints, the legal framework that regulates them and the principles of care without restraints. The restraints are valued as necessary, protective, and even therapeutic elements in the care of the elderly and constitute a standardized practice when they are used in an automated, routine, preventive, and prolonged manner. In addition, architectural and institutional deficits encourage their use, which is maintained due to the lack of control by the organization over its application. The practice of restraint responds thus to the culture of safety and discipline in health institutions and to a dehumanized view of the elderly. Professionals present ethical conflicts arising from the debate between patient autonomy and non-maleficence (understood only from the physical sphere). To deal with these conflicts, professionals deploy strategies such as rationalization based on physical security or their professional role. The practice of physical restraint differs depending on the professional category, in such a way that nursing assistants assume a technical function; nurses prescribe and coordinate the process; and doctors become legal guarantors of the prescription. Conclusions: Physical restraint is a standardized, dehumanizing, and dehumanized practice in the care of the elderly, justified by and for the geriatric patient's physical security and developed in the presence of a permissive attitude of the institutions. Professionals and institutions must commit to person centred care and free from physical restraints.