Understanding Healthcare Professionals’ Decision-Making Regarding Physical Restraint in Acute Psychiatric Wards: A Grounded Theory Study

Background: Physical restraint remains a controversial intervention in psychiatric settings, raising complex clinical, ethical, and emotional challenges. In Italy, where mental healthcare is grounded in a community-based model, restraint use continues to spark debate, but the perspectives of healthcare professionals involved in these decisions remain underexplored. Aim: This study aims to contribute further by comparing psychiatrists' and nurses' perspectives and decision-making processes, offering valuable insights into the interplay of roles within multidisciplinary teams. Methods: A qualitative study using a constructivist grounded theory approach. Semi-structured interviews were held with 89 professionals (64 nurses, 25 physicians). Data were analysed through open, focused, and theoretical coding. Rigour was ensured through triangulation, memo-writing, and external validation. Results: Four key themes and 16 categories were identified. Restraint decisions were primarily driven by fear of violence and the need to ensure safety, especially for nurses. While professionals emphasized alternatives, restraint was often seen as unavoidable. Physicians reported external pressures and ethical dilemmas, while nurses expressed emotional burden and moral conflict. Communication barriers and interprofessional tensions affected decision-making. Restraint was often initiated collaboratively but managed under ambiguous guidelines. Both professions emphasized better training, clearer protocols, and emotional support. Conclusions: This study reveals the multifaceted nature of restraint decision-making and its moral and professional implications. Findings highlight the need for systemic, cultural, and educational interventions to reduce reliance on restraint and foster more ethical, patient-centred care, offering lessons applicable across diverse international mental health systems.