From De-escalation to Restraint: A Qualitative Study of Emergency Clinician Decision-Making in Patient Agitation.
7 affiliations
- 1Brown University Health, Department of Emergency Medicine, Providence, Rhode Island.
- 2Brown University, Warren Alpert School of Medicine, Providence, Rhode Island.
- 3Baylor College of Medicine, School of Medicine, Houston, Texas.
- 4University of Washington, Department of Internal Medicine, Seattle, Washington.
- 5Baylor College of Medicine, Department of Psychiatry, Houston, Texas.
- 6Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas.
- 7Baylor College of Medicine & Michael E. DeBakey VA Medical, Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas.
Abstract
Introduction
Managing agitation in the emergency department (ED) is challenging and frequently involves decisions about physical restraints and emergent medications. While institutional protocols and behavioral response teams exist, little is known about how individual clinicians make decisions about restraint use-decisions with significant implications for safety, ethics, and equity. The objective of the study was to explore how emergency physicians, residents, and nurses make decisions about physical restraint and emergent medication use during episodes of patient agitation in the ED.Methods
We conducted a qualitative study using semi-structured interviews with 35 emergency clinicians (18 attending physicians, 7 senior residents, and 10 nurses) at an urban academic ED. Interviews were transcribed and analyzed using inductive thematic analysis.Results
Clinicians described three key factors informing restraint decision-making: (1) commitment to patient-centered care through noncoercive de-escalation; (2) real-time assessment of threats to staff and patient safety; and (3) team-based collaboration in both the restraint decision and implementation process. Participants shared a common mental model that prioritized verbal de-escalation before moving to pharmacologic or physical restraint. Clinicians acknowledged that unconscious bias and identity-based dynamics, including age, gender and race, may influence perceptions of threat and decision-making.Conclusion
Emergency clinicians share a consistent framework for managing patient agitation, suggesting potential for a standardized, team-based algorithm. Future interventions should consider clinician and patient identities, aiming to reduce disparities and enhance safety while minimizing restraint use.
Related
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- Ensuring quality in research, 'Authorship Effect' & Conflict of Interest. Response submitted to BMJ Mental Health in response to 'Clinician perspectives on the utility and acceptability of OxSATS: a qualitative study of a novel structured suicide risk assessment tool
- Chest Pain Hospitalizations: How Varying Emergency Clinician Tendencies Impact Care, Outcomes, and Costs
BibTeX
@article{suh2026from,
title = {{From De-escalation to Restraint: A Qualitative Study of Emergency Clinician Decision-Making in Patient Agitation.}},
author = {Michelle Suh and Beatrice Torres and Elise Brickhouse and Datonye Charles and Ynhi Thomas and Anita Chary},
journal = {The western journal of emergency medicine},
year = {2026},
month = aug,
doi = {10.5811/westjem.53798},
url = {https://europepmc.org/article/MED/42900927},
note = {CC BY},
}
RIS
TY - JOUR
TI - From De-escalation to Restraint: A Qualitative Study of Emergency Clinician Decision-Making in Patient Agitation.
AU - Michelle Suh
AU - Beatrice Torres
AU - Elise Brickhouse
AU - Datonye Charles
AU - Ynhi Thomas
AU - Anita Chary
PY - 2026
DA - 2026/08/28
JO - The western journal of emergency medicine
DO - 10.5811/westjem.53798
UR - https://europepmc.org/article/MED/42900927
AB - Introduction Managing agitation in the emergency department (ED) is challenging and frequently involves decisions about physical restraints and emergent medications. While institutional protocols and behavioral response teams exist, little is known about how individual clinicians make decisions about restraint use-decisions with significant implications for safety, ethics, and equity. The objective of the study was to explore how emergency physicians, residents, and nurses make decisions about physical restraint and emergent medication use during episodes of patient agitation in the ED.Methods We conducted a qualitative study using semi-structured interviews with 35 emergency clinicians (18 attending physicians, 7 senior residents, and 10 nurses) at an urban academic ED. Interviews were transcribed and analyzed using inductive thematic analysis.Results Clinicians described three key factors informing restraint decision-making: (1) commitment to patient-centered care through noncoercive de-escalation; (2) real-time assessment of threats to staff and patient safety; and (3) team-based collaboration in both the restraint decision and implementation process. Participants shared a common mental model that prioritized verbal de-escalation before moving to pharmacologic or physical restraint. Clinicians acknowledged that unconscious bias and identity-based dynamics, including age, gender and race, may influence perceptions of threat and decision-making.Conclusion Emergency clinicians share a consistent framework for managing patient agitation, suggesting potential for a standardized, team-based algorithm. Future interventions should consider clinician and patient identities, aiming to reduce disparities and enhance safety while minimizing restraint use.
SN - 1936-900X
SN - 1936-9018
ER -