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Wong AH, Ray JM, Rosenberg A, et al. Experiences of Individuals Who Were Physically Restrained in the Emergency Department. JAMA Netw Open. 2020;3(1):e1919381. doi:10.1001/jamanetworkopen.2019.19381
How do individuals interpret experiences of physical restraint in the emergency department?
This qualitative study of 25 patients who were physically restrained in the emergency department found the 3 following major themes: harmful experiences of restraint use and care provision, diverse and complex personal contexts affecting visits to the emergency department, and challenges in resolving their restraint experiences, leading to negative consequences on well-being.
Results of this study suggest that the participants in this study desired compassion and therapeutic engagement during physical restraint, warranting further attention to patient-centered approaches and coercion-reduction techniques that fit with the needs of emergency care.
Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients 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.
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.
Main Outcomes and Measures
Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED.
Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic). The time between the patient’s last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (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, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being.
Conclusions and Relevance
In this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm.
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 facility3 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.4-6 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 study11 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.
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
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 work15 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 study11 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.
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 coercion16,17 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. A second team member (J.P. or C.M.) made field notes during the sessions. Discussions lasted between 40 and 60 minutes and were audio recorded on digital equipment, professionally transcribed verbatim, deidentified, and entered into qualitative data management software (Dedoose version 8.2.27; SocioCultural Research Consultants).
At the end of each interview, we conducted a brief survey to collect anonymized sociodemographic information and responses to the MacArthur Perceived Coercion Scale (MPCS-5),19 a brief 5-question instrument used in the psychiatric literature to measure perceived coercion and represent patients’ sense of empowerment, choice, and personal influence associated with health care visits.
A 5-member coding team (A.H.W., A.R., C.M., A.J.P., and J.P.) used Dedoose for thematic analysis and organization of the qualitative data. The coding team created and refined the code book through masked open coding of initial transcripts, identifying additional codes through iterative rounds of group discussion, and integrating existing codes. After all transcripts were analyzed, the team summarized codes into major themes and subthemes. We conducted descriptive statistics for the sociodemographic and MPCS-5 data using SPSS statistical software version 21.0 (IBM Corp).
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 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. 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.
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 said, “You took all my clothes off, you had me laying on the bed strapped down with no clothes, no cover, no nothing. My privates are wide open, people just walking by, and you won’t give me no clothes or shut the curtain.” The patient experience of restraint ranged from descriptions of being treated like an animal to being handled roughly both physically and verbally by staff, even including displays of overt antagonism and profanities. One participant reported, “The lady who told me to shut up, one of the nurses, she pushed my face in like that. I say, ‘I can’t breathe; you’re hurting my neck. Let me go. You people are hateful the way you treat me.’ After I was tied up, she just gave me the finger. The policeman who was nice to me, he just looked at her like he knows she’s doing something wrong, but they don’t say anything.”
Emotional responses to the restraint experience included confusion, frustration, worry, and a sense of isolation. This may reflect the fact that most interviewed patients (17 [68%]) did not freely choose to enter the ED in which they were restrained. A frequent analogy when describing the restraint experience was that of being in prison. “I felt like nobody really cared. I felt like I was in prison, in the bed. I’ve never been to jail before, so my first experience of it was scary for me. I’d never been restrained before, I never had anyone hold me from my rights, you know? I cried, you know, I felt like I was alone in the bed with the straps on my wrists, my ankles.”
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.”
A number of medical and social factors were found to shape the individual contexts preceding and following restraint experiences. Participants described facing challenges and ongoing struggles with 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 explained, “The beginning of this year, I started doing dope because I been suffering through this pain for such a long time. It started out as a small leg issue and they messed up big time when they took me to surgery. Now it’s affected different areas of my body. It’s not just the physical part of it. I can’t really do what I want to do like play basketball or martial arts—the things that I would really like to do for my life. The doctor that initially did the surgery wasn’t qualified and caused all these problems, and then I kept being sent to a different doctor after another until I gave up.”
Social determinants, including psychosocial stressors, occupational and social backgrounds, and histories of being survivors of abuse, further shaped their visits to the ED and their interactions with staff during the restraint experience. In relating experiences of homelessness to an ED visit, a participant stated, “It just seemed like, almost every month I was ending up [in the ED]. My ankle was so bad I couldn’t get around, I couldn’t eat. They had to admit me because I couldn’t walk or really do anything. It was more like my social situation was really intense than it was a medical thing, but what else could I do?”
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 underlying intentions of health care professionals and society at large. “Honestly, I think if someone’s going to kill themselves, it’s their choice. They should be able to kill themselves. People should be left free to do what they want to do, even if it means it hurts them. The folks in the hospital, they don’t really care if you do it or not.” In contrast, other patients’ reflections describe an understanding of caregiver intent, usually when they view the role of their own state more strongly at the time of restraint. For example, a participant said, “The staff have got my best interest at heart. They’re trying to do the best that they can, but if it happens once, twice, that’s a different story. When it happens 6, 7 times, it’s like—they get sick of it. I don’t blame them. They have other things that they could be dealing with and helping other people.”
Patients described developing distrust and avoidance of health care interactions, perceiving the outcome of ED visits as inevitable, and leaving the ED with lasting physical and psychological consequences from their restraint experience. Repeated exposure to similar experiences led patients to a feeling of inevitability or futility in the path of their ED experience. One participant explained, “I already experienced so many times when they go right to the straps, to me it’s a ritual. It’s just what it is. There’s nothing I can do about it.” For some patients, these experiences led to a distrust of and disengagement from the health care system, especially when they were associated with adverse effects because of the use of restraints and sedatives. For example, a participant said, “I think they need to be a little more conscious about what they give people because obviously, they did something incorrect that I ended up in the ICU [intensive care unit]. I think they need to be a little more careful with the dosage of that strong stuff that they give you, I couldn’t even hold my head up, I was drooling. It’s terrible, and I still have flashbacks about that. I don’t want to go back to that again, ever.”
Other lasting consequences of restraint use and ED visits included the exacerbation of existing psychiatric conditions. One participant reported, “After all the times I’ve been restrained in the emergency room, it makes my PTSD and anxiety worse. My provider increases my anxiety medication for a few days until I can adjust to being back outside and get it out of my mind.”
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 hospital17 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 members18 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.
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.
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 plans23 tailored for patients and described in their electronic health records or case-management programs24,25 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.
Accepted for Publication: November 20, 2019.
Published: January 24, 2020. doi:10.1001/jamanetworkopen.2019.19381
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Wong AH et al. JAMA Network Open.
Corresponding Author: Ambrose H. Wong, MD, MSEd, Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave, Ste 260, New Haven, CT 06519 (email@example.com).
Author Contributions: Dr Wong had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Wong, Rosenberg, Iennaco, Bernstein.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Wong, Ray, Pavlo.
Critical revision of the manuscript for important intellectual content: Wong, Rosenberg, Crispino, Parker, McVaney, Iennaco, Bernstein, Pavlo.
Statistical analysis: Wong, Ray, Crispino, Parker.
Obtained funding: Wong.
Administrative, technical, or material support: Crispino, McVaney, Bernstein.
Supervision: Iennaco, Bernstein.
Conflict of Interest Disclosures: Dr Wong reported belonging to the Society for Academic Emergency Medicine, Simulation Academy. Dr Ray reported receiving grants from the National Institute on Drug Abuse, the Society of Academic Emergency Medicine Foundation, and the Yale School of Medicine Department of Emergency Medicine outside the submitted work. No other disclosures were reported.
Funding/Support: This study was supported by the Yale Emergency Medicine New Investigator Award and grant KL2 TR001862 from the National Center for Advancing Translational Science, components of the National Institutes of Health and the National Institutes of Health Roadmap for Medical Research.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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