Abstract for: Understanding Patients’ Experience of Agitation and Restraint Use in the Emergency Department: Toward a Comprehensive Model

Agitation is excessive psychomotor activity leading to aggressive and violent behavior in patients and is often due to exacerbation of underlying serious mental illnesses. Coercive measures like physical restraints are used routinely on agitated individuals in the emergency department (ED) but are associated with physical trauma, apnea, and sometimes death. At the same time, healthcare workers experience stress and burnout from episodes of workplace violence by agitated patients, leading to reinforcement of negative attitudes and biases. We used group model building (GMB) with key professional groups and patients to develop models of agitation care and identify modeling insights, in order to assist hospital leadership in decision-making around potential interventions. In this paper, we analyze GMB results and insights related to agitation management from the perspective of patients with lived experience of agitation and being restrained in the ED. The causal loop diagram and key feedback loops that emerged from GMB sessions with patients with lived experience of restraint in the ED highlight how, from the patient perspective, miscommunication, misunderstanding, and mistreatment in the ED (by hostile attitudes from clinicians and staff due to burnout) contribute to patient agitation and consequent use of restraints. Patients identified hostile clinician and staff behavior and attitudes, lack of updates from hospital staff, and other effects of clinician and staff burnout as contributors to mistreatment of patients, which reinforces agitation behavior among patients. Effective communication between clinicians and patients can mitigate patients’ feeling of neglect and resulting agitation in the ED. Mistreatment at the ED erodes trust over time, which makes the ED setting ineffective as a healing place from the patients’ perspective.