Experiences of Individuals Who Were Physically Restrained in the Emergency Department

IMPORTANCE Individuals with behavioral disorders are increasingly presenting to the emergency department(ED),andassociatedepisodesofagitationcancausesignificantsafetythreatstopatients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED. OBJECTIVE To characterize how individuals experience episodes of physical restraint during their ED visits. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast city between March 2016 and February 2018. Data analysis occurred between July 2017 and June 2018. RESULTS Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic).Thetimebetweenthepatient’slastrestraintandtheinterviewrangedfromlessthan 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illnessand/orsubstanceuseascontributingtotheirrestraintexperience.Mostpatients(20[80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, found a different set of experiences among their participants, with many positive sentiments of respect, dignity, and trusting relationships with staff members. our interviewees described overall negative experiences and emotional consequences, with some even perceiving overt antagonistic and unprofessional behavior from staff members during their restraint process and associated ED visit. findings may be because of disparate geographic and clinical practice conditions, pathways to the ED, or differences in focus between sedative use vs restraint use.


Introduction
Visits to the emergency department (ED) related to behavioral disorders are rapidly increasing in the United States, 1 with 1.7 million episodes of associated patient agitation occurring annually in emergency settings. 2 A recent study performed at a large urban county health care facility 3 estimated that agitation was associated with 2.6% of all ED visits. Unfortunately, treatment of these agitation episodes may lead to potential harm among patients. When deescalation attempts fail, ED staff commonly use physical restraints, which are associated with lasting physical injuries and cardiac arrest. [4][5][6] Efforts to reduce threats to patient safety during agitation management have led to calls for early detection and intervention to prevent escalating agitation and to minimize the use of restraints. 7 However, use of deescalation is often challenging in the emergency setting, where the acuity of agitation may be higher and the nature of patient presentations is more varied. 8 Behavioral techniques rely on building a strong rapport and therapeutic relationship with the patient, but ED staff have reported that their insight into patients' perspectives during agitation events is very limited. 9 This is compounded by the fact that agitated patients may often experience coercion, defined as actions performed on a patient that cause loss of self-determination, ranging from involuntary detention or seclusion to use of forcible treatment with restraints. 10 A recent observational study 11 found that 61% of agitated patients felt coerced by police or prehospital staff before ED arrival. Experiences of coercion may limit the ability of ED clinical staff to engage in a dialogue and create a therapeutic bond. 12 Unfortunately, studies that are drawn directly from the perceptions and experiences of patients who experienced agitation episodes in the ED are rare. Having a better understanding of patient wishes during and experiences of ED agitation care may assist staff in practicing the use of noncoercive techniques at the bedside. This study aimed to explore the experiences, backgrounds, and health care system interactions of individuals who were physically restrained during an ED visit.
In giving these patients a voice, we hope to inform future research, policy, and clinical practice for the use of restraints and management of agitation in the ED.

Study Design
This was a qualitative study using a grounded theory approach, seeking to describe how individuals experience being physically restrained in the ED. 13 The research team consisted of an interprofessional group with expertise in clinical psychology, public health, psychiatry, systems engineering, and emergency medicine to provide a broad spectrum of perspectives, given the wide etiologies of agitation and reasons to use restraints in the emergency setting. Our study protocol was approval by the Yale University institutional review board. We followed the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline. 14

Participants and Setting
Our study sites consisted of a tertiary care academic referral center and a community-based teaching hospital with average annual adult ED volumes of 99 000 and 62 000 visits, respectively. Both institutions belong to a large regional health care network in the Northeast United States. Our previous work 15 identified approximately 1300 unique adult visits per year to these EDs that were associated with a physical restraint. Eligible individuals were adult ED patients who had been restrained during a visit to either hospital site. We identified these patients either through a convenience sample of visits that contained an ED restraint order between March 2016 and February 2018 or during a prospective cohort study 11 of agitation events that occurred in either study site ED between June 2017 and August 2017. Participants received $50 in compensation for completion of a survey and interview. We obtained verbal informed consent from our participants at the beginning of each session.

Study Protocol and Data Collection
To represent the breadth of classes and backgrounds of patients who may be restrained in the ED, we performed purposive sampling in an iterative fashion throughout the data collection period. We identified the demographic and clinical characteristics of patients restrained in the ED at our study sites over a previous 3-year period, as follows: a median age of 46 years, 68.3% men, 73.5% white individuals, and 22.1% homeless individuals. 15 We then used this data to recruit a sample with a similar representation of sex, race/ethnicity, reason for ED visits, and other relevant demographic characteristics. Experts have identified that patients' perceptions of coercion may differ depending on the interval between the restraint episode and data collection. 16 Thus, we also sampled for a range of periods between the date of last ED restraint episode and the date of interview. We contacted a total of 79 eligible individuals by telephone, with 45 (57%) either having telephone numbers that no longer functioned or not responding to our request to call back. A total of 4 individuals (5%) declined to participate.
We developed interview questions through a synthesis of previous literature on patients' experiences of coercion 16,17 and triangulation with perceived patient perspectives from qualitative data of ED staff regarding the use of restraints. 18 The interview guide explored participant experiences in the ED, associated health conditions, reflections on restraint episodes, and consequences on health outlook and interactions with health care. One member of the research team (A.R.), who was trained in qualitative data collection, conducted the in-person interviews.

Characteristics of Study Participants
We achieved data saturation after interviews with 25 patients (17 [68%] men) who had been physically restrained during an ED visit. Those interviewed were predominantly white (18 [72%]) and non-Hispanic (19 [76%]) individuals. The interval between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months, with 10 patients (40%) being interviewed between 2 weeks and 1 month after restraint. Characteristics and patient factors, including homelessness and rates of alcohol use, drug use, and mental illness, are detailed in Table 1.
A total of 22 participants (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. When asked questions from the MPCS-5, 19 17 (68%) responded false to the statement, "I chose to come into the hospital," while 20 (80%) responded false to the statement, "I had more influence than anyone else on whether I came into the hospital," indicating that most patients viewed entry to the ED as coercive ( Table 2).

Qualitative Results
Qualitative analysis of these interviews identified the 3 following primary themes characterizing the experiences of individuals restrained in the ED: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being. Table 3 provides a summary of each of these themes as well as their subthemes, concepts, and definitions. Alcohol or drug use and mental illness 6 (24) Confrontation with personnel or staff 3 (12) Patient quotes illustrating subthemes and concepts are presented in Table 4. These tables are designed to present a comprehensive review of our results, while the following sections highlight key findings from each theme.

Harmful Experiences of Restraint Use and Care Provision
In recalling the experience of restraint, patients described a loss of freedom and personal dignity associated with dehumanization, loss of self-determination, and even mistreatment. One patient Patients described the experience of not being heard or acknowledged by anyone around them, leading them to conclude that ED staff did not care about them or were even actively shunning them. "The people that take care of you on the other floors are considerate and care and talk to you, but the people in the ED ignore you. They don't care about you. They walk by you a hundred times. You can try to ask them a question every time they walk by and nobody will say anything, they'll just keep walking right by you as if they can't hear you."  "I'm in here probably for substance abuse and I'm homeless, so they look at me like, 'You are the least of our worries right now. You are not important enough to even talk to, right now. We'll get to you when we have time,' or something. There could be nothing really going on in the hospital but seeing how I'm in here for whatever reason, I'm the very last person to be seen because I'm homeless, or whatever the case may be." Emotional responses and consequences "I was intoxicated, so I was scared and I guess, I was too wild, and they had to stick me with the needle in my bottom part. The next minute, you know, I woke up with tubes down my nose, IV in my arm, and I was scared, I didn't know what happened, and the doctor just tells me to calm down. Obviously, there was a reason why they put the tube in my nose, maybe I wasn't breathing right or anything like that. I felt like I was knocked out for hours. They just told me that they had to restrain me because I was too wild at the moment in time when I was intoxicated. The only thing I really wanted was my credit card, I lost it at the club. I guess they was scared, so they had to put me to sleep. It was scary for me. I had no control over my body." "You have no clue what is going on. It's really confusing. When you are on a medication they inject into you, you don't know why you are acting like this. I was really lost. I didn't know anything and then when they restrain you they ignore you. If you took 2 minutes out and said, 'Listen, we put you this way for this reason. This is how long it's going to take. When this period is done we will release you or take you out of restraints.' It's just that I was automatically restrained and nobody tells you why." Consequences on outlook and future actions "I will live with this broken finger, they did that to me when they held me down like that. You will not break my finger again. I remember that pain and that pain didn't go away. I was in pain for a long, long time. I think that from the bone being jammed down, it's affecting this finger. This finger, when I bend it, it gets stuck. I have to physically push it back up because it hurts. I don't know. If the security can get away with breaking somebody's finger and nothing be done about that, then how can they call it a hospital?" "The social worker called DCF. They came 3 times already. I didn't drink. I peed in the cup at mental health. I've seen my counselor. All this stuff happened after I left the emergency room. I didn't even know my daughter got a phone call. 'DCF is comin'." "Once I'm in that emergency, oh, there ain't no way I'm leaving there and going home. That's why I already know. When my sisters call the paramedics. Oh it's going to be a while. I just go kiss my son, see you later. The experience in the emergency room, it's traumatic as hell and it makes me feel like a piece of sh-t." drug and alcohol use, mental health, or complex and chronic medical problems that were difficult to manage and significantly affected their daily lives. In addition, the perception of an unresponsive, unavailable, and inconsistent health care system led some patients to experience difficulty engaging with the health care system as a whole, despite sometimes serious medical conditions. One patient

Challenges in Resolving Their Restraint Experiences, Leading to Negative Consequences on Well-being
Interview analysis revealed that restraint experiences affected not only proximal relationships within a given visit but had lasting consequences on a patient's relationship with the health care system.
Reflecting on their experiences produced a range of reactions among the participants regarding the use of restraints in the ED, from a desire for personal freedom to self-reflection and understanding.
On one end of this spectrum patients described the desire to maintain free will, even in the setting of attempting to self-harm. These sentiments are often because of apprehension and skepticism of the

Discussion
Using a qualitative approach, we found that those who were physically restrained during their visits to the ED represented a marginalized population that desired compassion from and therapeutic engagement with the staff caring for them. These individuals frequently presented at times of crisis requesting or requiring emergency care. Our findings indicated that, of those interviewed, most did not enter the ED willingly, as indicated during their interviews and in their responses to the MPCS-5. 19 In addition, our participants felt violated and dehumanized, with a lack of connection to and understanding of the clinical decisions, process, and events leading up to the use of restraints. In fact, some perceived mistreatment and overt physical violence against them, leading to a range of negative responses both immediately and after discharge. These experiences were influenced by homelessness, drug and/or alcohol use, physical and mental illness, and inadequate or harmful system responses to these concerns, resulting in the repetition of agitation events during times of intense stress. Finally, their experiences of being restrained in the ED led to challenges in interpreting future outlook and implications, with many describing health care avoidance, mistrust of the public health system, and lasting consequences that they continued to struggle with as a result of being restrained in the ED. These new insights into the experiences and contexts of these patients may help inform future investigations and changes in clinical practice for the use of restraints and management of agitation in acute care settings.
Understanding and addressing the needs of individuals with drug and/or alcohol use disorder and mental illness is a pressing issue. However, there are limited primary sources that describe experiences of those patients during crisis and decompensation of their disease, leading to coercion and visits to the ED. Within similar contexts in psychiatry, patients with mental illness who experienced coercion during their inpatient psychiatric admissions reported negative feelings of helplessness, fear, and rage, with increased sentiments of isolation and despair among the cohort that was physically restrained. 20,21 In contrast, a previous study of ED patients who received sedatives in a large metropolitan Australian hospital 17 found a significantly different set of experiences among their participants, with many describing positive sentiments of respect, dignity, and trusting relationships with staff members. Unfortunately, our interviewees described overall negative experiences and emotional consequences, with some even perceiving overt antagonistic and unprofessional behavior from staff members during their restraint process and associated ED visit. These contrasting findings may be because of disparate geographic and clinical practice conditions, pathways to the ED, or differences in focus between sedative use vs restraint use.
Recent studies examining the experiences of ED health workers during the management of agitation have begun to shed light on potential reasons for our patients' descriptions of their restraint experiences. Staff members 18 reported that decompensation of mental illness and disinhibition from alcohol and/or drug use manifested as loud and boisterous behavior in agitated patients. This described behavior may have resulted in the need for a level of attention that was often unable to be met in the busy ED environment and led to feelings of neglect and abandonment in our participants.
In addition, our previous work found that staff sentiments of empathy and compassion for this patient population were sometimes overshadowed by fear and frustration because of verbal and physical assaults they encountered from the same patients they desired to care for. 9 These sentiments may have manifested as episodes of mistreatment or displays of aggression that our participants described during their experiences of being restrained. Thus, systems that address potential staff harm and patient safety together as part of the same problem would enable health care professionals at the bedside to make conscious, balanced, and evidence-based decisions to use physical restraints only as a last resort and minimize associated lasting negative consequences on the patients under their care.

Limitations
Our study contains several key limitations. First, a number of patients were identified as eligible who either did not respond to the study request (57% of those contacted) or declined to participate (5%).
It is possible that these patients had different experiences than those who chose to participate in our study. In addition, it is possible that the time between restraint and our interview could have affected the recollection of the restraint experience. Memory processing and memory decay over time could affect the recall of the event as well as the emotions surrounding the event. 22 In an attempt to control for this, we purposely sampled patients with a spectrum of intervals between restraint experience and the interview.

Conclusions
The participants in this study represented the most marginalized and disadvantaged population that presents to the ED. They overwhelmingly described a desire for dignity, respect, compassion, therapeutic engagement, and attempts by staff to explain actions performed on them, even if the therapeutic relationship has been fractured as a result of coercion and physical restraint during agitation events. Most participants did not present to the ED willingly and already felt threatened before arrival. Without psychological support from staff members during these restraint events, patients may begin a spiral of negative emotions with subsequent ED visits and instinctively escalate with short-term agitation and aggression as a protective shield based on prior experiences. Instead of providing care, we may inadvertently cause more harm to these individuals. Our findings suggest that patient-centered approaches to agitation management may be helpful to foster a therapeutic alliance, which may include documentation of specific behavioral health care plans 23 tailored for patients and described in their electronic health records or case-management programs 24,25 that link with outpatient and social services for patients with complex mental health conditions and histories of violent behavior. Future work may include partnering with patient advocates or community members to develop better behavioral care processes and adapt agitation-reduction techniques that reduce coercion to fit with the needs of emergency care.