The use of both physical and chemical restraint is widely extended in the Spanish care system. This is something cultural, not only circumscribed, as we have been led to believe, to nursing homes. Its use has been known throughout the history of Psychiatry, where it might seem more justified in order to face clinical problems, even though it should not be so. With population ageing and an increase in the prevalence of dementia, restraint is becoming widely used in psychogeriatrics. But it is commonly used not only in nursing homes for old people, but throughout the care system. This patient profile will typically use restraints in all levels of care they go through, both in medium and long stay hospitals, and in sociosanitary centres, emergency services and, most of all, acute care hospitals. Besides, restraints can be observed in centres for persons with physical and/or intellectual disability, and even at Intensive Care Units; all this shows that restraining “is country culture”.

Faced with this situation, some entities considered that restraints “indignify” the patient, and their use is unnecessary in order to solve clinical problems which could be addressed with a change of model towards person-centred care; we advocate for the discontinuation of their use in our care system, both in the healthcare and the social settings. In the last ten years, it has been demonstrated that the etiology of the use of restraints is not clinical but organizational, because the problem is not the patient and their clinical presentation, the problem lies in the set of deficient care processes which prioritize organizational needs over the needs of patients, and in the pro-restraint culture of care that has been built by all those involved. In this scenario, clinical decisions are “uncentered” on the patient. Restraints are used for management problems and not for clinical reasons.

Faced with this situation, legislators on “social” matters in their different regional decrees have gone from creating laws that limited the use of restraints, to acknowledging the right of the person not to be restrained. The first laws regulating social services acknowledged the right to not being subject to physical or pharmacological restraint WITHOUT medical prescription and supervision. Lawmakers did not consider acknowledging the right of the person not to be restrained, even when this represented a violation of essential rights. Laws accepted the use of physical and pharmacological restraints as long as there were medical prescription and supervision. This way, restraints were legitimised. Subsequently, with higher awareness of the essential rights violated (freedom, physical integrity, etc.), in regional legislations it was not enough to guarantee a good use of restraints granted by medical prescription and supervision, and the right of the person NOT to be object of restraints was openly acknowledged, while this was only legitimised in exceptional scenarios. The idea was no longer to apply restraints under medical prescription, but NOT to apply them. However, this approach is not shared by all autonomous communities, and there is still a lot of work to do in this matter.

There has been a growing sensitivity about not using restraints. This fact has been shown in the recent approval of  Preliminary Investigation 1/2022 by the State Prosecutor’s Office, on the use of mechanical or pharmacological means of restraint in Psychiatric or Mental Health Units or Residential and/or Sociosanitary Centres for the elderly and/or disabled  (1); as well as on the Resolution dated July 28th, 2022, by the State Secretariat for Social Rights, which collects the common criteria for accreditation and quality for centres and services within the System for Promoting the Autonomy and Care of Dependent Persons (2), with requirements for centers to be “restraint-free”. It is worth pointing out that the regulatory advances mentioned are essentially focused on sociosanitary centres, ignoring the realities circumscribed to the healthcare setting. To this date, there are data available on the use of restraints in the sociosanitary setting; however, there are limited data on the use of restraints at acute care hospitals, regardless of whether focused on hospitalization units, stays at the Emergency Unit, or during admissions at the ICU. There is a concerning lack of data, because it seems that the problem of restraints is not a reality in the hospital setting. However, this perception is quite far from reality.

There is a high use of restraints in Spanish hospitals. Even though there are no updated data regarding the use of restraints in the healthcare setting, it is known that Spain is one of the countries within the Organisation for Economic Co-operation and Development (OECD) where these are used in all settings, and a prevalence of 10-20% has been described (3,4). All experts on restraints coincide in the idea that prevalence studies not always show the perception of reality by professionals; in fact, the perception by most professionals is that there is a higher use of restraints than what appears in the different published studies. The causes for this dissonance seem varied; but among other reasons, the data source used is pointed at (observation   records, knowing that there are many cases in the hospital setting where the use of restraints is not entered into the Clinical Record), or what the centres / professionals consider restraints (beyond current formal and consensual definitions).

If we interviewed healthcare professionals from different care services, from different healthcare centres, from different autonomous communities, they would all coincide in acknowledging there is a routine use of restraints and, in most cases, it is not adapted to minimum standards in order to reduce malpractice as much as possible. In Spain, patients are restrained in healthcare centres without exploring in depth the cause for the agitation that leads to restraint (pain, delirium, sensory deprivation, etc.), without using up all alternative approaches to restraint, without comprehensive monitoring for adverse effects, without an agreement for implementation, maintenance and withdrawal from a multidisciplinary perspective, without an informed consent signed by the patient, without medical prescription, etc.

Comparing the healthcare reality with the social reality, we can guess there is a discrepancy by years. The first laws trying to restrict the use of restraints in the social sector seem to still be emerging in the healthcare sector. It would be a good starting point that there always was medical prescription at hospital, without being concerned about the severity of the measure itself or the essential rights violated. However, society moves forward, and it is our duty as managers of care, in the social or healthcare settings, to move forward with it and, of course, to learn from those who have already initiated their road towards respecting the right of the person to NOT being subject to restraints, regardless of their clinical situation, the moment in their life cycle, or the level of care where they are.

Therefore, once legislation in the social setting is advanced, a question comes up, should it not be possible to advance in the legislation for restraints in the healthcare setting? Some jurists believe that Spain should protect better the right not to be restrained, that the indignity of this practice should disappear from our healthcare system, and it is necessary to create an organic law. Others believe that the Spanish legal system already includes what is needed so that those currently restraining stopped doing it, that the responsibility lies in care providers. The legal discussion is open, but the ethical mandate of respecting the right of the person NOT to be restrained is universal.