Le retour de l’usage des contentions en psychiatrie pose de nombreux problèmes éthiques aux soignants. Pourtant leur vécu est peu exploré dans la littérature. Notre objectif était d’étudier le vécu des soignants confrontés à cette pratique au regard d’une perspective éthique et de dégager des pistes d’amélioration. Entre novembre 2011 et février 2012 a été réalisée une étude épidémiologique descriptive transversale dans deux services d’urgences psychiatriques et deux unités fermées dans lesquels les médecins et les infirmiers étaient interrogés à l’aide de questionnaires semi-dirigés au cours d’entretiens individuels. Vingt infirmiers et neuf psychiatres, en majorité de sexe féminin, ont été recrutés. Ils avaient tous participé à des expériences de mise sous contention. Leur vécu était riche, intense et majoritairement négatif à type de frustration (35 % des infirmiers ; 66,7 % des médecins), de colère (30 et 33,3 %) et d’absence de ressenti (35 et 44,4 %). Il s’agissait pour eux d’une expérience difficile mais nécessaire (82,75 %), d’un acte de soin et de sécurité (68,9 %). La frustration pouvait concerner le manque de moyens mais aussi être dirigée envers un patient ou un soignant. Nous avons dégagé trois perspectives pour réduire l’utilisation de la contention et modifier le vécu des soignants.

The return of restraint in psychiatry raises many ethical issues for caregivers. However their experience is little explored in literature.

Our objective was to study the feelings of caregivers facing restraint with regard to an ethical perspective and to identify areas for improvement.

Between November 2011 and February 2012 a descriptive cross-sectional epidemiological study was performed in two psychiatric emergency services and two closed units in which doctors and nurses were individually interviewed using semi-structured questionnaires. Five topics were explored: indications and contexts, impact on the patient, caregiver–patient relationship, perspective on the practice and feelings of caregivers on which we insist particularly. Results were presented in tables with percentages and possibly diagrams. The notable responses of caregivers were also cited.

Twenty nurses and nine psychiatrists, mostly female, were recruited. They all had participated in experiments of restraint. The self-aggressiveness, the aggressiveness against other persons and agitation were the most frequent indications. In the patients, caregivers identified misunderstanding (79.3%) and anger (75.9%). The majority of nurses (75%) felt that there was an improvement in the caregiver–patient relationship after the episode of restraint compared to what it had been in the moments preceding this measure. The emotional experience of caregivers was rich, intense and predominantly negative type of frustration (35% of nurses; 66.7% of doctors), anger (30 and 33.3%) and lack of feeling (35 and 44.4%). The feelings of doctors and nurses were not completely similar. For caregivers it was “a difficult but necessary experience” (82.75%), “an act of care and safety” (68.9%). All psychiatrists and almost half of the nurses (45%) said they did not feel the same when they used seclusion. In their opinion, seclusion entailed a less painful experience because of its therapeutic properties. More than half of the caregivers thought that there were alternatives to restraint: the strengthening of containing function in the hours before the use of restraint; the use of seclusion at the time of the decision to restrain. They identified contexts (80%) encouraging the use of restraints, not only related to the patient, the lack of resources but also institutional contexts, in particular conflicts or divisions in the health care team.

The misunderstanding of the patient led us to wonder about the quality of the information he/she received: it was sometimes too formal and did not take into account the uniqueness of the patient. The frustration of caregivers could concern the lack of resources but also be directed towards a patient or caregiver. In addition, there were often cleavages between doctors and nurses that stemmed from a misunderstanding, also with rivalries and power struggles.

From the literature and caregivers’ reflections we identified three prospects to reduce the use of restraint and modify feelings of caregivers: 1) develop better crisis management upstream through increasing resources and improving training; 2) promote patients support in using ethical principles of autonomy and beneficence by showing them solicitude, inviting them to tell themselves and helping them to regain their own experience; 3) develop an afterthought in setting up institutional reflection time by restoring a central role in clinical team meetings in psychiatry, possibly supplemented by supervision, but also through regional ethical spaces.

In our investigation, we found that caregivers had a predominantly negative experience with frustration, anger and a lack of feeling. Among caregivers we also identified awareness of ethical issues that may be for the first time for a change.