Patients who were physically restrained in the emergency department (ED) said they experienced a sense of dehumanization, loss of freedom and personal dignity, and even mistreatment, researchers found.
Ambrose Wong, MD, MSEd, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, and colleagues report their findings in an article published online January 24 in JAMA Network Open.
They interviewed 25 individuals from diverse socioeconomic backgrounds who had presented to the ED in an agitated state and were restrained.
Most subjects reported "harmful experiences of restraint use and care provision," a range of "diverse and complex person contacts" behind their visits to the ED, and challenges resolving their adverse restraint experiences, with ongoing negative consequences that continued to affect their well-being.
"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," the authors state.
Limited Insight
Visits to the ED related to behavioral disorders are "rapidly increasing" in the United States, with patients frequently presenting with agitation. ED staff are called upon to deescalate the situation, but when attempts to do so fail, they commonly use physical restraints, which are not only associated with lasting physical injuries but also with cardiac arrest.
ED staff have reported "limited" insight into patients' perspectives during agitation episodes and few studies have focused on the issue.
The current qualitative study used a "grounded theory approach" to describe the experience of patients who were physically restrained in the ED.
Patients were drawn from two study sites in a large regional healthcare network located in the Northeast United States: 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.
Approximately 1300 unique adult visits to these EDs annually were associated with a physical restraint.
The researchers identified demographic and clinical characteristics of patients restrained at these sites over a 3-year period, using the data to then recruit a sample with similar representation in sex, race/ethnicity, reason for the ED visit, and other characteristics.
Additionally, they sampled individuals at a range of time intervals between the last ED restraint visit and the date of the interview.
Of 79 eligible individuals who had been physically restrained in the ED and whom they contacted, the final sample consisted of 25 (17 [68%] male, 72% white, and 76% non-Hispanic) individuals. Roughly one third (32%) were homeless.
Close to half (40%) were interviewed between 2 weeks and 1 month after their last restraint, while the other interviews ranged from fewer than 2 weeks to more than 6 months after the last restraint.
Harmful Experiences
Patients reported "harmful experiences" when recalling their physical restraint, including "loss of freedom and personal dignity associated with dehumanization, loss of self-determination, and even mistreatment."
Examples included removal of clothing with no privacy in the ED during restraint and being "handled roughly, both physically and verbally by staff, even including displays of overt antagonism and profanities."
Patients reported experiencing "confusion, frustration, worry, sense of isolation" and being treated as if they were in prison — in contrast with experiences some of them had in other units of the hospital, where one participant reported being treated with more consideration and care.
Long-Lasting Effects
Most participants (88%) indicated that mental illness and/or substance use contributed to their restraint and most reported that they were not the ones who made the choice to go to the hospital and regarded their entry to the ED as coercive.
Patients reported chronic and complex medical problems and the "perception of an unresponsive, unavailable, and inconsistent healthcare system."
The researchers noted that social determinants (psychosocial stressors, occupational/social backgrounds, and history of being an abuse survivor) "further shaped their visits to the ED and their interactions with staff during the restraint experience."
The impact of physical restraint affected not only "proximal relationships within a given visit," but also had long-term repercussions on the patients' relationship with the overall healthcare system and exacerbated existing psychiatric conditions, such as posttraumatic stress disorder (PTSD) and anxiety.
Patient-Centered Approach
Some participants expressed the importance of autonomy and self-determination even when a patient is in the midst of engaging in attempted self-harm. In the words of one interviewee, "Honestly, I think if someone's going to kill themselves, it's their choice. . . . The folks in the hospital don't really care if you do it or not." By contrast, other patients felt that the caregivers did have their best interests at heart.
The sense of "distrust and avoidance of healthcare interactions" left many participants with "lasting physical and psychological consequences of their restraint experience" and a sense of futility that their ED experience could ever be different.
The researchers recognize the challenges faced by ED staff when confronted with agitation caused by loud and boisterous behavior due to decompensation in mental illness or substance-related disinhibition.
They also acknowledge that it might not be feasible to provide the level of attention demanded by this type of behavior in a busy ED environment; moreover, empathy and compassion may be "overshadowed by fear and frustration because of verbal and physical assaults they [ED staff] encountered from the same patients they desired to care for."
The researchers suggest that systems should "address potential staff harm and patient safety together as part of the same problems," thus enabling healthcare professionals to use physical restraints only as "a last resort" and "minimize associated lasting negative consequences in patients under their care."
They encourage a "patient-centered approach" to promote a therapeutic alliance, which may incorporate documentation of specific behavioral healthcare plans in the patient's electronic health records or case management programs and linking to outpatient and social services for patients.
They also recommend future research to develop these approaches.
"These patients' voices remind us that we can learn a great deal about clinical care and about ourselves by listening to the people we meet as patient," Abraham Nussbaum, MD, MTS, associate professor of psychiatry, University of Colorado School of Medicine, Aurora, and Matthew Wynia, MD, MPH, director of the Center for Bioethics and Humanities, University of Colorado, Aurora, write in an accompanying editorial.
Also important is asking ED staff members about their own experience of placing patients in restraints and whether they are aware of less coercive treatment options.
They recommend that further studies "should also seek out family and staff perspectives" regarding the experience of those with mental illness in the ED.
This study was supported by the Yale Emergency Medicine New Investigator Award and a grant 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. Wong reported belonging to the Society for Academic Emergency Medicine, Simulation Academy. The other study authors' and editorial authors' disclosures are listed on the original papers.
JAMA Netw Open. 2020;3:e1919381, e1919582. Full text, Editorial
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