A team of researchers recently investigated the experiences of those who were physically restrained in the emergency department (ED), an experience that is known to cause injuries and trauma in patients. The group conducted semi-structured, one-on-one interviews with 25 adults, and found that most patients felt coerced, that their experience was harmful, that there was a wide range of personal contexts that affected ED visits, and that there were challenges related to their restraint which had adverse effects on their well-being.

“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,” wrote the researchers. “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 any 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.”

As many as 2.6% of all ED visits are associated with ‘agitation,’ a number that continues to rise. Treatment of ‘agitation’ is often harmful and involves physical restraint. This has led to calls for de-escalation, though that requires strong rapport and a therapeutic relationship, which is difficult to achieve in an ED context. This is made more challenging due to the high volume of patients (61%, by one study) who feel coerced by police or hospital staff, which makes establishing a therapeutic relationship all the harder. Given the dearth of research on this population, the authors sought to explore the background of the individuals themselves as well as their experiences in the ED.

To do this, the team used a grounded theory approach to interview 25 individuals who had been restrained during a visit to either a tertiary care academic referral center or a community-based teaching hospital. They used the demographic profile of patients who were restrained at the ED to recruit a sample with similar demographic backgrounds as well as with a range of period between the last time they were restrained and the date of the interview. Interview questions were developed from a literature review on patient coercion and triangulation with perceived patient perspectives from data collected from ED staff on the use of restraints.

Patients were 68% male, 72% white, and had a range of 2 weeks to 6 months from last restraint. 88% reported that their ED visit and restraint resulted from a combination of mental illness and/or substance abuse, and the majority felt their entry to the ED was coercive. Three major themes emerged from interviews: (1) harmful experiences of restraint use and care provision, (2) complex personal contexts that affected ED visits, and (3) difficulty resolving their restraint experiences that led to negative consequences on well-being.

“I will live with this broken finger, they did that to me when they held me down like that,” said one participant. “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?”

Patients experienced a range of emotions, including confusion, frustration, worry, feeling shunned, and a sense of isolation, which may have stemmed from the fact that 68% of them did not voluntarily choose to enter the ED. Several contextual factors preceded individuals’ admission to the ED, including substance use, mental health, or chronic medical problems that were difficult to manage and significantly affected daily life.

Social determinants were a factor related to admission and included psychosocial stressors, occupational and social backgrounds, and histories of being survivors of abuse. The treatment from ED staff and the use of restraints had a range of effects on patients, including skepticism and distrust of the medical system, the worsening of existing psychiatric conditions, or healthcare avoidance.

“The participants in this study represented the most marginalized and disadvantaged population that presents to the ED,” the researchers concluded. “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.”

These results are contrasted to a similar study done in an Australian hospital, where researchers found positive sentiments of respect, dignity, and trusting relationships with staff members. The vastly different results may be from diverse geographic and cultural conditions underpinning ED care. The authors argue that boisterous behavior from patients that resulted from mental illness or disinhibition from substance use may have caused a need for attention that the busy ED was unable to accommodate. This compounds with staff sentiments of empathy and compassion being overwhelmed by fear or frustration of verbal or physical assault.

The authors propose that a system that addresses both potential staff harm and patient safety together collectively would allow health care professionals to make conscious, balanced, and evidence-based decisions to use physical restraints only as a last resort, which would minimize negative consequences on the patients under their care.

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Wong A.H., Ray J.M., Rosenberg A., et al. (2020). Experiences of individuals who were physically restrained in the emergency department. JAMA Network Open, 3(1):e1919381. DOI:10.1001/jamanetworkopen.2019.19381 (Link)